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Ron Falk: Hello, and welcome to the Chair鈥檚 Corner from the Department of Medicine at the University of North Carolina. This is our series for patients focused on organ transplant, and today we will talk about heart transplant. We welcome Dr. Patty Chang who is an Associate Professor of Medicine in our Division of Cardiology, and she directs the Heart Failure and Transplantation Program at 黑料网. Welcome, Dr. Chang.

Patty Chang, MD, MHS: Thank you.

Evaluation for Heart Transplant

Falk: Not too long ago we recorded an episode focused on heart failure with you, Dr. Chang, and we just barely touched on heart transplant. Today I want to provide a more in-depth conversation about what patients go through in the heart transplant process. The first question really is, how does a patient actually get on the heart transplant list?

Chang: Great question, because this process of evaluation can be quite confusing, both to the patient and local or referring providers. I think our first effort is really to make sure we encourage referring providers and patients to think, How soon should I think about other alternative therapies, like heart transplantation?

One of the things we really encourage is seeing the patients earlier rather than later. When we have a patient think about heart transplant and their referring physician thinks about the referral, we say, 鈥淭his is a process. Just because we meet you doesn鈥檛 mean you鈥檙e on the waiting list. It鈥檚 a true multidisciplinary evaluation of your candidacy for something as serious and as resource-intensive as heart transplantation.鈥�

We pride ourselves on the team approach. The team is not only the heart failure or transplant cardiologist seeing the patient, but all of the people involved to make sure that they can have a successful outcome. This includes nurse coordinators, often referred to as our heart transplant coordinators, and of course our heart surgeons who do the surgery itself.

As part of the evaluation, we want to vet out all of the important medical issues, and potential medical complications that could occur after transplant, but we also want to make sure that their social and mental well-being can withstand all of the things needed to undergo this process. Often, we think of this as a surgery, it鈥檚 more of a process than just the surgery. The evaluation process involves meeting the cardiologist, meeting the nurse coordinator, meeting the social worker, our psychologist, perhaps our psychiatrist as needed, our financial counselor, our dietician, and ultimately the surgeon as well.

Ventricular Assist Devices

Falk: Walk me through the process of deciding how a patient would have an artificial device, a ventricular assist device (VAD), or a heart transplant? When do you decide that somebody should have a VAD? How is that device sometimes thought of as a temporary device or as a bridge to transplant device, and then the actual possibility of getting a living organ from a deceased donor? How do you decide what a patient really needs?

Chang: Great question, because very often we are evaluating a patient for both transplant and a ventricular assist device. The process is very similar, the major difference is we don鈥檛 worry about suppressing the immune system in someone who gets a ventricular assist device. Otherwise, the evaluation process is the same. We often now think of the LVAD, or left ventricular assist device, as a bridge to transplant. In some patients, it is the alternative or destination therapy and that is all the patient will be eligible for. Very common now, we don鈥檛 have the luxury to wait for an organ transplant, which can happen in a short time, or very often, a long while for waiting for a transplant. So, we have to think about a patient needing a ventricular assist device before they can have a transplant. As a result, the process for evaluating a patient鈥檚 candidacy is very much the same for both.

Falk: How long can a patient live with an LVAD?

Chang: Many years. We are very excited that as technology has improved, patients can do very well and live very much a normal life on an LVAD. The only issue with this is that it is connected to an external power source, so a patient cannot submerge themself in water, or go swimming or take true bath, but they can certainly shower and go to the beach and put their legs in the water.

Falk: Because the power device is a battery that is carried externally.

Chang: Right, and we certainly don鈥檛 want to short-circuit any power source and have them lose power. That is then potentially life-threatening.

Falk: What鈥檚 the difference between a 鈥渄estination鈥� left-ventricular assist device, and a temporary one? Do they look different, do they feel differently?

Chang: Most of the time, if we鈥檙e talking about durable LVADs, they look the same, whether it鈥檚 as a bridge to transplant or as the destination, as the final therapy for that patient. There are more temporary support devices that we think about as temporizing the patient to a more permanent type of LVAD that they can leave the hospital with. When we think about a temporary support device, as bridge to transplant, or as destination, it鈥檚 really the same device that can let the patient leave the hospital and live a normal life at home.

Falk: If the destination LVAD works as well as you鈥檙e describing, other than the concern of the external battery pack, why would somebody then want a heart transplant if they鈥檙e not planning to do a lot of swimming, for example? Why would they want a heart transplant instead of this destination LVAD? What鈥檚 the population that does better with a living organ, versus this mechanical device?

Chang: I think we all have our various biases, and we certainly have many LVAD patients who do not want a heart transplantation for a variety of reasons.

Falk: Is that age-related?

Chang: It鈥檚 often age. There is an age cut-off for eligibility for heart transplantation, and that鈥檚 variable and individualized. Some patients who get an LVAD who could get a heart transplant are just not interested. The reasons they describe as why they鈥檙e not interested are: financial, or further risk, again they鈥檙e not having issues with medications that has their immune system suppressed. They鈥檙e not having to take medications that might be very expensive, that would be potentially life-sustaining for them, and certainly more expensive than what is needed to take care of someone who just has an LVAD alone.

I think the heart failure provider has their own biases. My personal bias is that machines are really great, but machines are machines and eventually they break, until we have a machine that doesn鈥檛 break. Tissue probably lasts longer than a machine, current data suggest that heart transplant survival is better than mechanical circulatory support or LVAD survival in the long-term.

Falk: A young patient, for example, a young individual, who needed a transplant, probably would be better in the long-term getting a heart transplant than a left ventricular assist device.

Chang: Absolutely.

How a Match is Determined

Falk: How do you decide whether a heart鈥檚 a match? How do you decide that deceased donors heart is a match for one of your patients?

Chang: There are many factors that we consider as we look at donor hearts. Donor hearts do get classified by blood type, so first it needs to be matched by blood type.

Falk: An A, B, or O, or AB, in other words.

Chang: That鈥檚 right. Then, the size is important. For someone like me, who鈥檚 not very tall, I could take a not very tall person, but someone who is very tall, over six feet, could not take a five-foot donor heart, for example. Size is important, blood type is important, and ultimately, we want our donor hearts to be as healthy as they can as they go into the recipient. Although there are sometimes cases where we might need to consider cases where the donor heart isn鈥檛 perfect, but is good enough.

Recovery from Heart Transplant

Falk: Once the patient has had a heart transplant, what鈥檚 the recovery like? How quickly do they leave the hospital?

Chang: We like to see patients leave within roughly one or two weeks. That would be very average. What a patient goes through, is not just the opening and closing of the chest, but having chest tubes drain the chest, and often times, ironically, it鈥檚 the chest tubes that take the longest to come out, that limit the patient鈥檚 discharge time. We certainly do a lot of medical management after the transplant, so it鈥檚 a combination of making sure all the medical issues and surgical issues are resolved before they leave.

Falk: How much of the recovery time is dependent upon the ability of the patient going in? In other words, if the person is in reasonable physical shape, they probably have a shorter recovery time than somebody who, because of their heart failure, has become substantially deconditioned?

Chang: That鈥檚 absolutely right and that is why we encourage our patients who are waiting for a heart transplant to be as functional as possible, even if they鈥檙e stuck in the ICU, our intensive care unit, waiting for a transplant. If they are able to ambulate, we encourage them to ambulate. They do better than patients who are bedridden until their transplant. That鈥檚 why we also encourage patients to consider an LVAD before transplant if they need it, or if they are eligible, because that allows them to be more functionally ready and have better outcomes if they are doing better before transplant.

Falk: When does somebody say to you, 鈥淗ey, I feel pretty normal!鈥�

Chang: For a heart transplant, it probably takes about a month, or even less for some patients. It depends on their activity after transplant. If everything goes as wished, they’re walking around after a day or two of being transplant. Then they鈥檙e walking out of the hospital, and it鈥檚 just a matter of them continuing to walk. As they come to follow-up appointments, a lot of them feel great within a month or two.

Follow-Up, Monitoring & How Long the Transplant will Last

Falk: How long do they end up following up with you?

Chang: Essentially forever. We love to have our patients do well, and they really should be hooked in with a transplant center for the rest of their lives, simply because their medication regimen is so specialized, and we would want to make sure that any medication changes are double-checked by transplant professionals. In the early year, we tell them that they鈥檙e going to see us at least twenty times. They see us as frequently as every week for a little while, and then every month, and then after their first year, it鈥檚 every few months, and then after the first couple of years, it鈥檚 just every six months. Then at some point, if they鈥檙e doing great, maybe it鈥檚 once a year. More frequently it鈥檚 every six months follow-up, indefinitely.

Falk: The worry of course, as in all transplants, is rejection. How does a patient know that they鈥檙e having a rejection, or is that something that you determine by a variety of tests?

Chang: We often think that if a patient feels rejection, it may be too late. So, we encourage very frequently follow-up and monitoring of patients鈥� symptoms. The symptoms we worry about the most are symptoms of heart failure, just like they had before their transplant. At that point, if they have those symptoms, we worry that rejection has been happening for way too long. As a result, what we do to monitor them is frequent testing, like heart biopsies and other blood tests to monitor for rejection before it becomes clinically symptomatic.

Falk: How do you do a heart biopsy?

Chang: We do need to get inside the heart, so we do a procedure, typically in the cardiac catheterization lab, where we access one of their veins to get catheters into the right side of the heart and take little, tiny pieces from their heart and look at them under the microscope. When we look at the microscope, we hope we don鈥檛 see inflammatory cells attacking the heart, but if we do, then we do worry that there could be some rejection. We have all sorts of classification schemes to tell us how significant the results are.

Falk: It鈥檚 really careful monitoring. Does the chance of rejection decrease over the course of time? Is rejection more likely in the first year, for example, than year five?

Chang: It鈥檚 been quoted that ninety-nine percent of all rejection occurs in the first year, perhaps heaviest in the first month. Thereafter, we monitor with biopsy because we do want to decrease the immunosuppression over time, that way their immune system is not so compromised as time goes forward.

Falk: Heart transplant rejection rates have really plummeted over the course of time. The hope is that once you get a heart transplant, it will last for a really long time.

Chang: That鈥檚 right, and we really quote to our patients that the average survival after transplant is well over a decade.

Falk: That鈥檚 fantastic. What鈥檚 the longest heart transplant you鈥檝e taken care of?

Chang: The record-holder right now is about thirty years and that patient is doing great.

Falk: That鈥檚 a remarkably long period of time, and that speaks to the difference between heart transplantation and mechanical assist devices, because there鈥檚 no mechanical assist device that would last anywhere near that long.

Chang: That鈥檚 right, and I think we have heard of survivors with a mechanical assist device over ten years. Our personal record is over eight and going, so it can be very durable for a long time, but still not as good as transplant.

A Rewarding Part of Work for Dr. Chang

Falk: Dr. Chang, what brings you joy when you come to work?

Chang: That thing that gives me the most professional gratification is seeing my patients live their life to the fullest. I really enjoy having my patients send me photos or videos in their life, which includes hiking across Banff National Park, or giving lectures in Vienna, or climbing mountains or running marathons, or raising awareness just by doing local Raleigh-based heart transplant or heart disease awareness campaigns.

When we see them in clinic, they tell us all these great stories of what they鈥檝e done, obviously they鈥檙e very thankful. Every year we celebrate these patients with a heart reunion. These reunions are both for our heart transplant recipients and our LVAD recipients, where they have the joy to come and share their experience with others and encouraging others. We all show our thanks to each other.

Falk: Dr. Chang, thank you so much for spending time with us today.

Chang: Thank you.

Falk: Thanks so much to our listeners for tuning in. This episode completes our series on organ transplant, and we hope you have enjoyed it. Stay tuned for new episodes in the near future where we will talk about HIV. You can or . Thanks so much.

 

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