If your heart is failing, your chances of getting a new one might hang on whether your local transplant center concludes that you're too old, too fat or too sick to qualify for a precious donor heart.
If you're turned down, you can shop around and might get a more sympathetic hearing at a hospital in another city, or even across town.
Critics say the criteria that hospitals in Baltimore, across the country and around the world use to select patients for life-saving transplants are inconsistent and sometimes arbitrary - with too little foundation in current science.
"A center in the South can say, `We're going to transplant all diabetics,' while a center 400 miles up the coast says, `Absolutely not, we won't transplant any diabetics,'" said Dr. Mandeep Mehra, head of cardiology at the University of Maryland Medical Center. "If each center has this power ... is it truly ethical?"
That's why he agreed to lead a task force, assembled by the International Society for Heart and Lung Transplantation, to write the first set of uniform, science-based guidelines for selecting transplant patients.
Wherever they are adopted by hospitals and insurers, the proposed standards would make new hearts available to more patients over 65, and to more diabetics and cancer patients, among others.
The guidelines were published last month in the society's Journal of Heart and Lung Transplantation.
At the current level of heart donations, the new guidelines could allow doctors to save at least 300 more lives a year, Mehra said.
Dr. Stuart D. Russell, clinical chief of heart failure and transplantation at the Johns Hopkins Hospital who co-authored the guidelines, expects as many as 15 additional transplants per year in this region - which stretches from Northern Virginia to southeastern Pennsylvania.
Under the old standards, some centers might have rejected Tim Heffner as too sick for a heart transplant. The 56-year-old customer services manager from Westminster had heart failure linked to blocked coronary arteries and a heart attack he'd suffered at 41.
He also had blocked arteries and was disabled by a stroke in 2000, induced by a chronic heart arrhythmia.
When he sought help at the University of Maryland Medical Center for arrhythmia, doctors there told him he needed a new heart, and by early this year, they were giving him just six to eight months to live.
But the UM Medical Center already has a transplant policy close to the new guidelines. After extensive tests, the UM transplant team decided that if they could restore proper blood flow to his gut, fix the arrhythmia and get a better handle on his future stroke risk, he could become a good transplant candidate.
So they did.
"When they're at that end stage ... we want to do everything we possibly can to make them into better candidates, and that may mean pushing the envelope a little bit," said Dr. Erika D. Feller, UM medical director for heart transplantation.
In March, Heffner received a heart he believes is from a donor in his 20s. "I can do pretty much anything now," he said. "I don't get winded going up steps like I used to. I would say I'm fairly fit for a man my age."
Best of all, he said, he lived to see his first granddaughter, born last month.
The new, expanded guidelines aren't mandates. But Mehra expects the International Society for Heart and Lung Transplantation's influence in the medical community to lead to their adoption over the next three years by hospitals and - perhaps more importantly - by health insurers.
Not everyone agrees.
"Those are just guidelines," said Dr. David Vega, director of the heart transplant program at Emory University School of Medicine in Atlanta. "Each program is still going to go and do what they think is best for their patient population and their program."
Besides, he added, "I think most of those things are already common practice, to be honest." Emory, for example, increased its heart transplant age limit several years ago, from 65 to 68.
But Russell, who came to Hopkins recently from Duke University's transplant program, found Hopkins "a much more conservative place" than Duke in selecting transplant candidates. "There are other centers much more along the Hopkins mode that will expand their criteria based on this," he said.
And as word of the new guidelines gets out, he said, community hospitals and primary care physicians will begin to refer more patients for transplants.
How a hospital chooses patients can have legal as well as medical complications. For example, a center's decision on whether to follow such guidelines is sometimes cited in lawsuits when a transplant turns out badly, Mehra said.
But he noted that the guidelines are not legal mandates, merely suggestions to be weighed against other considerations. "They ... don't often turn out to be the sole clincher of a decision," he said.