By Nick Triggle
BBC News health reporter
Ever since Papworth Hospital carried out the first heart transplant in 1979 it has been at the forefront of the field.
All heart transplant surgery carries high risk
But following the Healthcare Commission's review into its practices after a rise in the number of deaths, patients could be forgiven for doubting the Cambridgeshire centre.
While inspectors concluded the quality of care was good, future patients have still had the brutal truth spelled out to them.
Those on the waiting list have been told that a hospital which previously had a below average death rate has seen it shoot up five fold to 35%.
Healthcare Commission head investigator Nigel Ellis acknowledged the "very difficult" decision the families and patients have faced in light of this information.
But, perhaps surprisingly to some, none of the patients currently on the waiting list has so far indicated they do not want to be treated at Papworth.
And this in many respects demonstrates the nature of heart transplant surgery.
Transport time crucial
The facts show that in the UK one in ten patients die within 30 days of surgery.
But these are after all extremely ill patients, who are having to live with the prospect of death day in day out.
Many patients also face the prospect of their new hearts being transported across the country - with every minute that ticks by raising concern.
Of the eight Papworth patients who died this year seven were cases where the heart was without blood for over 200 minutes.
Research shows the risk of death increases after 180 minutes.
But this is a situation all heart transplant centres face.
Differences in practice
The Healthcare Commission said the results were in line with other hospitals - and actually better than Papworth's times in previous years.
Nonetheless, the hospital was still told to reduce the times.
And it was also told to alter its practices in other areas.
During transportation it is important the heart is kept cold to preserve it.
This is done by surrounding the organ with ice in a transportation box.
To ensure the heart does not freeze though it is carried in three bags - an outer, an inner, and one in between.
Most hospitals fill each bag with fluid to prevent the heart coming into direct contact with the ice.
But Papworth only puts fluid in two bags, apparently believing the air in the outer bag would also protect the heart.
The problem is that as there are relatively few heart transplants - just over 150 a year in the UK - it is hard to establish good practice guidelines.
Hence differences in procedures do arise from time to time.
The Healthcare Commission did tell the hospital to do as others do, fill the outer bag with fluid.
But importantly it made no specific criticism of the pratice to date.
And then there are other factors to contend with.
For example, the age of donors is known to be getting older.
This, Mr Ellis said, is a challenge for all transplant units.
All in all it means there are no easy solutions for what is still the cutting edge of medicine.
Steven Tsui, clinical director of transplant services at Papworth, said: "We spend a lot of time explaing all the risks involved.
"We put it into context and then it is up to the patient to give their informed consent."