A heart transplant may be the most dramatic surgery done in the operating room. Each step takes great precision, from the quick, careful journey to retrieve the heart to the preparation of the recipient, who may be gravely ill and bedridden. The best part is the outcome soon after the transplant, when the patient goes home and starts returning to his or her life—whether that means getting married, having babies, running in marathons, or simply breathing massive sighs of relief while strolling around the neighborhood without having to periodically stop to catch a breath.
This is happening more frequently in Yale Medicine’s Heart Transplant & Left Ventricular Assist Device Program, which is one of the fastest-growing, highest volume programs in the country, and one of just a few in the United States willing to push the envelope on accepting donor hearts. Yale Medicine specialists performed 49 heart transplants in 2019, earning a spot among the top 10 programs in the country in volume. This year, the program continued to provide transplants even amid the COVID-19 pandemic.
For people who are considering a heart transplant or have a loved one who needs one, here are some things to know about getting an organ and other advances in transplant.
1. Each patient’s journey is different
Heart transplants are done in people of all ages, even children. “Heart failure can affect anyone; in fact, it is the number one cause of death and a leading cause of disability in the United States,” says Tariq Ahmad, MD, MPH, medical director of the Yale Heart Transplant and Left Ventricular Assist Device Program. “We've had people in their 20s, 30s, and 40s—and our oldest transplant patient last year was 73 years old. One of our patients later completed a 100-mile bike ride up in Maine, and he's doing incredibly well.”
“A routine heart transplant surgery can be performed in less than four hours, while some complex ones may take seven, eight, nine hours—or more, especially if we need to remove a heart pump or clean up scar tissue from previous surgeries,” says Arnar Geirsson, MD, chief of cardiac surgery. “Regardless, the basic procedure remains the same. The patient is given general anesthesia and connected to a bypass machine that takes over the heart’s function. Surgeons make an incision in the chest, divide the breastbone and remove the diseased heart. They sew the donor heart into place and connect it to the remnants of the old heart and the major blood vessels.”
One issue is that many people waiting for hearts are critically ill, says Sounok Sen, MD, an advanced heart failure specialist. “Historically, there's this concept that people would be at home waiting for the call that a heart was available, and then they would come in and have a very smooth experience—and that still happens in a lot of cases,” he says.
But given today’s shortage of available organs, the sickest patients are prioritized for transplants, so many patients waiting for a heart to become available are already in the hospital on various types of medicine or heart pumps, he says.
2. A practice called ‘donation after cardiac death’ may increase the number of heart transplants
United Network for Organ Sharing (UNOS), a private, non-profit organization under contract with the federal government to manage the organ transplant system in the U.S., allocates newly available hearts based on such priorities as medical urgency. Patients who are hospitalized or dependent on mechanical assist devices to help their heart function are at the top of the list.
About 3,500 people in the U.S. are waiting for a heart, and many will wait more than six months. But some will die before a heart becomes available to them. That’s why one of the greatest breakthroughs in heart transplantation may be the practice of accepting donor hearts that most other programs do not have the expertise to accept. This means that more sick patients who are eligible (based on strict criteria) may be able to receive one. A limited number of programs in the U.S. are starting to do this. Yale Medicine is one of them.
“I remember we said to ourselves as a team: ‘We're going to switch gears now. We can be more aggressive and take some risks,'” says Muhammad Anwer, MD, associate director of the Center for Advanced Heart Failure at Yale New Haven Hospital and a key cardiac surgeon for heart transplantation. “Now all the data that's coming in is showing that the outcomes may be just as good with the more aggressive approach.”
The vast majority of hearts used for transplant are retrieved as “donation after brain death,” or DBD. But Yale Medicine’s heart transplant surgeons are participating in a multi-site clinical trial that allows them to offer “donation after cardiac death,” or DCD, which is relatively new in the U.S., as a way to make more donated hearts usable.
“During DBD heart transplant, the heart is still beating, allowing for a controlled procurement,” says Christopher Maulion, MD, who is spearheading the DCD program at Yale Medicine.
DCD is a more intense process. DCD organs and recipients must meet strict eligibility criteria, and the process of retrieving the heart involves multiple doctors. “When you have a brain death donation, the heart is removed and simply transported on ice,” Dr. Maulion says. When a DCD heart becomes available, however, Drs. Maulion and Anwer, as well as two perfusionists are sent to retrieve it. Once the heart is removed, it is reanimated and preserved in a warm environment with circulating oxygenated blood. Nicknamed “heart in a box,” the technology for transporting a donated heart is called the Transmedics Organ Care System. Only a few transplant centers (those participating in the ongoing clinical trial) are able to use this system to procure and then transplant hearts.
While there is still more to learn, outcomes from DCD heart surgeries are proving to be comparable to those using organs from DBD donors. “DCD is the likely next chapter in cardiac transplantation,” Dr. Maulion says. “By being one of the few centers in the country that can offer DCD heart transplantation, Yale is in the position to offer transplants to more patients who may not have had the opportunity otherwise.”
3. Anti-rejection drugs are customized for each patient
Heart transplants wouldn’t be possible if it weren’t for the drugs that prevent people’s bodies from rejecting the transplanted organ. These drugs have vastly improved in the last 15 to 20 years. “Essentially, people are on two to three medicines for life,” says Dr. Ahmad. The drugs can have adverse effects, including high blood pressure, as well as blood sugar and kidney problems. “So, there’s a trade-off. But we’re very vigilant about monitoring for those types of things.”
One notable advance is that doctors can now tailor an immunosuppression strategy for each patient, says Dr. Ahmad. “So, it’s not only just whether or not we have novel drugs. It’s also making sure we have a personalized immunosuppression strategy to match each patient. We’ve taken a personalized approach in terms of looking at what the risk will be for a particular recipient as far as their potentially rejecting the heart, and then tailoring treatment to them.”
4. People can have multiple organ transplants
Yale Medicine doctors have performed almost 10 heart–kidney transplants in the past two years, which is significant for almost any center, says Dr. Sen. “Many patients who have heart failure over time also develop kidney dysfunction,” he says. “Sometimes that can be a limiting factor in terms of being able to get a heart transplant. But we’ve tried to think ‘outside the box’ and be open to multi-organ transplant for certain cases.”
Surgeons perform the heart transplant first and the kidney transplant a day or more later. The kidney surgeon must have expertise in performing kidney transplants in patients who are not stable, Dr. Ahmad says, explaining that heart transplant patients who have been in the intensive care unit have more complex needs than those who have been on dialysis and are otherwise healthy.
Heart transplant doctors work closely with Yale Medicine’s kidney transplant specialists on these patients. “Together, we’ve come up with pathways for how to manage patients before and after a heart–kidney transplant,” says Dr. Ahmad. “We are lucky to have some of the world's experts in organ transplantation at Yale, including Richard Formica, MD, president of the American Society of Transplantation and David Mulligan, MD, president of the Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS).”
5. You can survive with a heart from someone who had a serious disease
Another breakthrough in the past few years is the transplantation of hearts from donors who had hepatitis C, a viral disease that can cause fatal liver problems.
“Even though other organ systems for those donors were transplanted, traditionally these hearts would not have been utilized,” says Dr. Sen. There's been a cultural shift around that; hepatitis C is now not viewed as an insurmountable problem. “With the advent of new therapies for hepatitis C that have a 99% or greater cure rate, those organs are now available to individuals who are willing to undergo the treatment afterwards. That has expanded the donor pool quite a bit as well,” he says.
6. The outlook has improved for transplant survivors
Though a successful heart transplant was a major medical milestone, in the early days, patients with these new hearts didn’t live that long. Now many people live for decades, with a median survival of 14 years, according to Dr. Ahmad. The one-year survival rate after a heart transplant at Yale Medicine is 93%, which is higher than the national average, says Dr. Ahmad. He adds that a transplant team’s experience with heart transplant is an important predictor of outcome.
“It’s important for patients to know that physicians and surgeons at transplant programs are trained in centers that have lots of experience and large volumes, so they can be comfortable with the entire process, which is very complex,” says Daniel Jacoby, MD, director of the Comprehensive Heart Failure Program. “The need for expertise only begins with the surgery. Transplant patients have complex medical needs, but with the right care, they can do things once considered impossible. For instance, one of our transplant patients recently had a baby—a potentially high-risk and complicated medical situation. Our team has trained at the best programs in the country and brought the best of this experience to Yale. Such a set up only exists at a handful of places in the world. We're lucky to have it here.”
7. Follow-up care makes a difference
One reason patients can now live longer after transplantation is close monitoring and follow-up, especially in the several months after their surgery. “The thing about heart transplant is that you get rid of one disease, but you replace it with another,” Dr. Ahmad says. “Heart transplant patients become immuno-compromised. They can get infections and develop kidney problems.”
Follow-up care is most intense in the first six months after a transplant, when doctors see patients frequently, says Dr. Sen. “We adjust their medications and do heart biopsies to make sure there are no signs of rejection,” he says. “After the first six to eight months, the follow-up becomes every three months, every six months, every year.” Some patients may also need to see other sub-specialists, such as infectious disease specialists and nephrologists.
Anyone who has a heart transplant is at high risk for COVID-19 complications, so Yale Medicine doctors are in close contact with the 500 or so heart transplant patients they care for at Yale, advising them to be especially careful about taking measures to avoid the virus. “Our patients need to be incredibly careful about social distancing and not going out, especially during the first months following the procedure, because that's when you are most at risk for infections,” Dr. Ahmad says.
8. It takes a community to support a heart transplant patient
“In some ways, when you get a transplant, you become part of the transplant family. We plan to be with our patients all their lives,” says Dr. Ahmad.
In the hospital, this team includes cardiologists who work hand-in-glove with the cardiac surgeons, as well as other surgeons, anesthesiologists, transplant coordinators, electrophysiologists, infectious disease specialists, nephrologists, nurses, and social workers.
“The team supports patients not just medically, but also mentally, psychologically, and spiritually,” Dr. Jacoby says.
Since so much recovery happens at home, it’s helpful to seek care at a transplant center close to home. Patients benefit from being geographically close to family and friends, Dr. Sen says. “The journey after transplant is often an amazing thing. Before the operation patients are very sick. Seven days after the surgery, they're walking out of the hospital, and they feel completely different,” he says. At that point, many patients are happy to have their loved ones around them for support as they get back to the business of living a normal and healthy life.
[Read about Yale’s strategic changes in donor heart and recipient selection that, according to a recent study, “may significantly increase the number of heart transplants while maintaining short-term outcomes comparable with more conservative patient selection."]