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of drugs. The attraction of performance-enhancing drugs is simply that they permit the fulfillment of the mythical promise of boundless athletic performance1,4 the hubristic faster, higher, stronger motto of the Olympic Games. An ethically based medical science cannot compete. Thus, drug use in a subgroup of athletes who even in the absence of drugs are able to compete at an elite level causes their separation into a distinct athletic population, distanced from natural humans by a margin determined by the potency of the drug combinations that are used. These athletes, quite simply, have moved off the natural bell-shaped curve of normal human performance. In disclosing his own drug-enhanced performances, former Australian world discus champion Werner Reiterer, who chose to retire rather than risk winning a tainted medal in the 2000 Olympic Games in Sydney, has written, There was something pathetically wrong with the fact that a packed home arena an entire country would urge me

Tainted Glory Doping and Athletic Performance

on without any concept of the truth behind my ultimate athletic achievement, or of the sham of which they were unwittingly a part.1 Our burden is that no longer do we share this ignorance. We can no longer pretend that we do not know.
From the University of Cape Town/Medical Research Council Research Unit for Exercise Science and Sports Medicine, Department of Human Biology, University of Cape Town, and the Sports Science Institute of South Africa, Newlands, South Africa.
1. Reiterer W. Positive an Australian Olympian reveals the inside story of drugs and sport. Sydney: Pan Macmillan Australia, 2000. 2. Voet W. Breaking the chain: drugs and cycling; the true story. Fotheringham W, trans. London: Yellow Jersey, 2001. 3. Franke WW, Berendonk B. Hormonal doping and androgenization of athletes: a secret program of the German Democratic Republic government. Clin Chem 1997;43:1262-79. 4. Hoberman JM. Mortal engines: the science of performance and the dehumanization of sport. New York: Free Press, 1992. 5. Idem. How drug testing fails: the politics of doping control. In: Wilson W, Derse E, eds. Doping in elite sport: the politics of drugs in the Olympic movement. Champaign, Ill.: Human Kinetics, 2001:241-70.

Building a Bridge to Heart Transplantation

Dale G. Renlund, M.D.
Related article, page 859

He who saves one life, saves the world entire. Hebrew proverb, quoted in Thomas Keneally, Schindlers List End-stage heart failure, characterized by marked symptoms at rest or with minimal activity despite optimal therapy, is designated as stage D heart failure. Frequent, recurring exacerbations may often be treated successfully, but decline is inevitable and life expectancy with medical therapy alone is short (survival rates are below 50 percent at one to two years) (see Figure). The addition of palliative measures, such as continuous infusions of inotropic drugs and hospice-like care, may be considered. Cardiac transplantation or permanent mechanical circulatory support is possible only in a select few patients. When candidates for heart transplantation have hemodynamic deterioration, metabolic, cellular, and nutritional compromise follow, and the likelihood of survival after transplantation diminishes.

Even among patients with moderately compromised function, the likelihood of post-transplantation survival exceeds 80 percent at one year. However, as hemodynamic compromise progresses from moderate to severe, not only is there an increase in the risk of dying before transplantation can be performed, but the results after transplantation also worsen. The timely use of mechanical circulatory support halts further deterioration; decreases the likelihood of death before transplantation can occur; and reverses metabolic, cellular, and nutritional compromise. The temporary use of such support thus permits heart transplantation with a greater expectation of long-term survival and a better quality of life. The temporary use of mechanical circulatory support before transplantation, known as bridging, is not to be confused with mechanical circulatory support intended from the outset to be permanent treatment, known as destination therapy. Bridging is reserved for candidates for transplantation,

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Building a Bridge to Heart Transplantation

Figure. The Course of Stage D Heart Failure. As hemodynamic status deteriorates in a patient with stage D heart failure, metabolic, cellular, and nutritional health is compromised. The deterioration is marked by frequent exacerbations that may often be treated successfully. Although signs and symptoms of progressive heart failure predominate, the risk of sudden death is also present (dotted lines). Heart transplantation early in the course is associated with excellent results, whereas later transplantation is less successful. Mechanical circulatory support decreases the likelihood of death before transplantation can be performed; restores metabolic, cellular, and nutritional health; and improves the likelihood of successful transplantation in most candidates for heart transplantation. The optimal use of donor hearts is enhanced. Such support appears to be warranted when the patients health has deteriorated into the red zone, whereas patients with health in the green zone can safely undergo transplantation without prior mechanical circulatory support. NYHA denotes New York Heart Association.

and success is measured in terms of the proportion of patients surviving to successful heart transplantation. Since a variety of bridging devices are commercially available, the selection of a device depends on the type of heart failure, the size of the patient, the surgeons experience, and the institutional preference. Implantable left ventricular assist devices channel blood from the left ventricle to the pump, which then circulates blood to the aorta. The currently available implantable devices are too large for patients with a body-surface area of less than 1.5 m2, but investigations with smaller devices are ongoing. Meanwhile, paracorporeal devices, with the pump placed outside of the body, provide an alternative for the support of one or both ventricles. Left ventricular assist devices are generally inadequate for bridging to transplantation in patients with severe biventricular heart failure, which requires the use of two paracorporeal devices.

When left ventricular assist devices or paracorporeal devices are either difficult to use or contraindicated, the replacement of both ventricles with an implantable device such as a total artificial heart may be warranted. Such circumstances frequently arise in patients with severe aortic insufficiency, intractable ventricular arrhythmias, an aortic prosthesis, an acquired ventricular septal defect, or irreversible biventricular failure requiring a high pump output. In this issue of the Journal, Copeland and colleagues (pages 859867) show that the CardioWest artificial heart (SynCardia Systems) provides a successful bridge to transplantation in most severely compromised patients and that those whose cardiac function is so bridged do better than similarly compromised patients who instead undergo emergency transplantation. The use of the artificial heart studied by these investigators is generally restricted to patients with a body-surface area of at least 1.7 m2. Given the overwhelming and growing prevalence of heart failure, why does a report of a nonrandomized study demonstrating successful bridging to transplantation in relatively few patients warrant attention? Since the 1980s, more than 6 million people have died of heart failure in the United States alone. A mere fraction of that group fewer than 50,000 patients received transplants. An even smaller number have required mechanical circulatory support before transplantation a total artificial heart was used in fewer than 500 patients, and left ventricular assist devices in approximately 5000 patients. Some public health officials have derided heart transplantation as obscenely irrelevant; then how relevant is the use of an artificial heart as a bridge to transplantation? Others have argued that bridging to transplantation is much ado about very little, since suitable candidates are always available for transplantation. In short, why bother? Heres why. A 52-year-old entrepreneur, father of four, grandfather of one, lay dying in an intensive care unit with severe, end-stage, biventricular heart failure. He had been on the waiting list for transplantation for more than a year. Hemodynamic compromise led to incipient renal and hepatic failure. Just 12 hours previously, he had had a cardiac arrest and became obtunded. Cardiogenic shock persisted despite the use of an intraaortic balloon pump and high intravenous doses of inotropic drugs. This doomed man, typical of those whom Copeland and colleagues studied, then received an artificial heart. Had emergency transplantation been

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performed instead, the likelihood of post-transplantation survival would have been dismal (see Figure), and the donor heart, a very precious commodity, would most likely have been squandered. After the implantation, however, the patients metabolic, cellular, and nutritional abnormalities resolved. Four months later, he received a transplant. During the subsequent 10 years, he has been able to do all he chooses, living a vigorous and rewarding life. As is typical of heart-transplant recipients, the patient has medical follow-up visits two to four times each year. Joseph Lister did not need a randomized, controlled trial to prove that an antiseptic approach benefited patients with compound fractures. No more than one administration of ether inhalation by William Morton at an operation at the Massachusetts General Hospital in 1846 was necessary to convince skeptical surgeons about the potential of general

Building a Bridge to Heart Transplantation

anesthesia. Nor should it take more than this report regarding the use of the artificial heart as a bridge to transplantation in certain patients to convince us of the triumph of medical technology in helping patients in dire circumstances. Although not all patients with heart failure can currently be saved, the Hippocratic ideal holds: we are honor-bound to serve as advocates for individual patients. Therefore, we should not condemn the artificial heart for failing to save all patients with heart failure. Rather, we should embrace this technology because it increases our ability to help some patients, like the man described above. The artificial heart is not a bridge too far, but a triumph for the afflicted patient. Like Oskar Schindler, we may not be able to save all people in need, but one life is worth the effort.
From the Division of Cardiology, University of Utah School of Medicine, and LDS Hospital both in Salt Lake City.

Chronic Vulvovaginal Candidiasis

David A. Eschenbach, M.D.
Related article, page 876

Vulvovaginal symptoms are common, and they represent one of the most frequent reasons for visits to physicians by women in all age groups. Vulvovaginitis is rarely life-threatening, and it is therefore vastly understudied and poorly understood. However, it is associated with substantial, albeit poorly quantified, cumulative morbidity. It causes genital discomfort, loss of productivity, reduced sexual pleasure, and psychological distress and necessitates medical expenditures. Noninfectious vulvovaginitis is caused by a wide variety of inflammatory, hypersensitivity, and collagen vascular conditions.1 The most common cause of infectious vulvovaginitis is candidiasis, which accounts for 40 to 50 percent of all cases. Vulvovaginitis primarily affects the vulvar skin, the vagina, or a combination of the two. In candidiasis, both the vulvar skin and the vaginal epithelium are usually involved. In most patients, vulvovaginal candidiasis is uncomplicated (see Table). When properly diagnosed, uncomplicated candidiasis may be treated easily and reliably with any number of azole anticandidal medications, including short-course regimens. However, successful treatment is often delayed because the causes of vulvovaginitis, includ-

ing candidiasis, are commonly misdiagnosed both by patients and physicians2 mainly because the symptoms and signs may be nonspecific, but also because of the lack of inexpensive and accurate diagnostic tests and because of suboptimal medical training. Complicated candidiasis is much less common than uncomplicated disease (see Table). Severe symptoms usually require 7 to 14 days of therapy instead of the short course used for uncomplicated candidiasis. Candida species other than Candida albicans account for only about 10 percent of all infections, but only about half of these infections respond to either oral or vaginal azole therapy. Patients with chronic, recurrent candidiasis account for the remainder of cases of complicated candidiasis. Most cases of recurrent candidiasis are caused by C. albicans. The problem for both patients and physicians is that although complicated candida vulvovaginitis affects only a small proportion of cases of candidiasis, it leads to a substantial percentage of the total physician visits, because the symptoms and the disease usually clear only with very specific therapy or repeated treatment. In this issue of the Journal, Sobel et al. (pages

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