While patients awaiting a heart transplant grapple with complicated emotions, their doctors are focused on very practical matters—for instance, timing and logistics. Every transplant requires that a carefully orchestrated sequence of events occurs quickly and efficiently, often in locations that are miles apart. In the city where the transplant will happen, a transplant coordinator needs to deal with such details as getting the patient to the hospital, making sure his or her lab work and medical workup are in order, and booking the OR. At the same time, a retrieval surgeon may need to fly to a different state to evaluate whether the heart that has suddenly become available because a donor has passed away is right for the recipient. By the time the retrieval surgeon returns with the organ, the heart transplant patient is already under anesthesia and prepared to receive his or her new heart.
“In every situation, multiple things have to fall into place,” says Ayyaz Ali, MD, who arrived at Yale in June 2018 as the surgical director of the Yale Medicine Advanced Heart Failure, Heart Transplantation, and Mechanical Circulatory Support program. And time is of the essence. “The longer the preserved heart remains outside of the body, the more likely that heart is going to be dysfunctional after the transplant. So, we try to keep that time period—usually between two to five hours—as short as possible.”
Dr. Ali has a passion for, and lots of experience with, this highly precise routine. Internationally recognized as an innovator in heart transplant surgeries, he has performed more than 125 heart transplants (at Yale and elsewhere)—he has even done several in a given week, sometimes back to back, and on weekends. He has observed or assisted with hundreds more at some of the biggest heart transplant centers in the world.
Dr. Ali spoke to us about his work and how he feels about helping these patients get their lives back.
What are your plans for Yale Medicine’s heart transplant program?
We want to make sure no one in Connecticut has to leave the state for a heart transplant. It’s important to know that after a heart transplant, patients require complex medical therapy and must manage a lot of medications as they recover from their heart transplant. This allows people to live longer lives after heart transplants, and there's nothing more convenient than being able to get this continuing care at a center that is close to home.
It’s worth noting that last year we performed 30 heart transplants, 76 percent of which occurred after I arrived in July. Our clinical outcomes are the best in the United States with a 30-day survival of 100 percent. We established the record for the most heart transplants at Yale New Haven Hospital and the state of Connecticut. We also saw a 114 percent increase in our heart transplant volume compared to 2017—the largest growth of any program in the United States. I believe we will continue to grow at this rate and, within the next few years, rank among the top 10 centers in the United States for heart transplant volume.
What are the challenges for the surgeon?
One is that every heart is different. Sometimes a patient has congenital heart disease, and their anatomy is somewhat unusual. In other cases, disease has weakened and enlarged the heart muscle, causing it to become dilated and distended. But essentially, the basic process of a heart transplant remains the same. The patient is given general anesthesia and connected to a bypass machine that takes over the heart’s function. We make an incision in the chest, divide the breastbone and remove the diseased heart. Then, we sew the donor heart into place and connect it to the remnants of the old heart and the major blood vessels.
Some operations are more complicated because we're also removing a mechanical assist device that has allowed the patient to live with heart failure while they waited for a donor heart. Or a patient has already had multiple heart surgeries and there’s a lot of scar tissue to remove before we can do the transplant. A routine heart transplant can be done in under four hours. But complex surgery may take seven, eight, or nine hours—or even longer.
Heart transplantation must also be one of the most complex procedures a surgeon can do.
I would say it’s one of the most dramatic operations. We see an amazing turnaround in the patient's health after a successful transplant. Some had been dependent on mechanical devices and extensive support mechanisms for months or years. Many were essentially bedbound and in an intensive care unit, unable to move. After the heart transplant, they return to society.
But to the surgeon, heart transplants become routine—and that’s a good thing. In fact, I think it’s important that surgeons who choose to do this sort of surgery train in centers that have lots of experience and large volume, so they will become comfortable with the procedure and perform it well independently.
How successful are heart transplants these days?
When we started transplanting hearts in the late 1960s and early 1970s, the results were poor; often the body would reject another person’s heart or there were other issues. Now the median survival after a heart transplant is about 14 years. Many people survive for decades. Again, that’s because the surveillance patients undergo after a transplant is so rigorous. We monitor them closely, manage their immunosuppressive medications (which have vastly improved in the last few decades), and prevent infections. So, we don’t just do the transplant, then send people home. There is careful postoperative care over many years.
There is still the challenge of finding hearts to transplant.
That’s true. There are currently about 3,800 people in this country on the waiting list for a donor heart, and many will wait more than six months. United Network for Organ Sharing (UNOS), a private, nonprofit organization that manages the nation’s organ transplant system under contract with the federal government, allocates hearts to compatible donors based on such priorities as medical urgency. Those who are hospitalized or who are using mechanical assist devices are at the top of the list.
We are always waiting for suitable donor organs to become available for our patients on the waiting list. At the same time, almost every day I see there is a donor heart somewhere that's not being used for reasons I don’t really understand or agree with. What we try to do at Yale—and this has been a feature of my career—is to optimally utilize the organs that are available. I believe we need to work hard to make each donor heart count, because such a donation is a very precious gift.
Can you talk about the work you’ve done to make more hearts available?
I’ve done extensive work on what we call donation after circulatory death (DCD), a practice that could double the number of transplantable hearts. In most cases, a donor heart is harvested immediately upon a donor’s death—usually after they have suffered a severe brain injury and are designated brain dead. But some donors with severe brain injuries still have some brain function. Before we can remove their organs, their family must decide to withdraw life support, and then wait for the heart to stop or go into cardiac arrest. Once the heart stops, these patients still are not declared dead (and their organs cannot be removed) for several minutes—usually 10 or 15 minutes. It was always felt that the heart wasn't suitable for transplant after that much time without any blood supply.
I was awarded my PhD for this topic after undertaking comprehensive research at Stanford University and the University of Manitoba showing that you can resuscitate the heart after it has stopped beating under these circumstances and restore its blood supply using a perfusion machine. Then in England, at Royal Papworth Hospital in Cambridge, I helped develop a unique heart transplantation program using hearts from these DCD donors. We have undertaken the first 50 DCD heart transplants in the world there, with results comparable to conventional heart transplants. I expect to do this here at Yale as well.
What is it like to care for patients who may have thought they wouldn’t survive?
It’s fantastic to dedicate yourself to these patients. I see them before the transplant, when they're in very poor health, and then I’m on a journey with them to get them well again. That journey may take several months, or it can be very short, because they came to us very suddenly after a major heart attack or debilitating heart illness and urgently need a heart transplant. So, the massive transformation in their health and their well-being is quite impressive to see.
There are so many patients, and each one has family members, friends, and coworkers—all of whom are impacted by this one person’s transplant surgery. There are always people in the waiting room during the operation. One of the most satisfying things is that they send me letters, sometimes months later. I have lots of cards and letters, and I appreciate them all.