Like Indiana Jones on a crusade, doctors are on a quest for the holy grail of heart transplantation — and are gettingclose.
Advancements in anti-rejection drugs that have fewer severe side effects, longer survival rates for pediatric and adult heart transplant patients, and new devices are a few of the steps forward in treating patients with coronary heart disease and other defects. Many of the advancements are taking place at institutions like Miami-Dade’s Jackson Memorial Hospital and University of Miami, and Broward County’s Memorial Healthcare and the Cleveland Clinic.
“The best of all worlds is when we put in a heart transplant, or any organ, and some way induce the body to accept that organ without anti-rejection medications. That is the holy grail of transplantation and is something we have been working on for years, including myself in the research area, and we see the end of the tunnel now,” said Dr. Si Pham, chief of the Division of Heart and Lung Transplantation at the University of Miami Miller School of Medicine.
Heart transplantation, first performed successfully on an adult by South African cardiac surgeon Christiaan Barnard in 1967, gained traction in the 1980s. The United States leads the world in number of transplants performed — about 2,000 or more per year, according to the International Society of Heart & Lung Transplantation (ISHLT). But the procedures aren’t rising significantly because donors with suitable hearts remain in limited supply.
Jackson began performing heart transplants in 1984 and performs 27 to 30 annually.
“The reasons for the small numbers are that in our society heart disease is quite prevalent,” Pham said. “Even a 70-year-old can donate a kidney or liver, but not a heart because of coronary heart disease. Most of our donors come from a limited pool of younger donors who don’t have heart disease.”
Memorial Regional’s Joe DiMaggio Children’s Hospital performed its first heart transplant in December 2010 and has transplanted eight since, said Dr. Maryanne Chrisant, medical director of the heart transplant and cardiomyopathy programs. “Cardiac transplantation is still regarded as not experimental but certainly more extreme care, and it may not be the right therapy for everyone or every family,” she said.
The average waiting period for a patient to receive a new heart is about two to three months, Chrisant said, but the wait can extend to six months or more.
Chrisant cited figures on the half-life for patients who have received heart transplants — meaning how long the transplanted heart will function properly before requiring another transplant. For infants, it’s about 19 years; for children 17 and under, about 16 years.
“These are kids who would have died without transplants and it doesn’t mean they will wake up in 12 years and the heart will conk out. It means folks receiving heart transplants should ‘take heart’ because there’s an opportunity to have a relatively normal life span.”
For adults, a new heart will last about about 13 years but varies. “If they are obese or diabetic, it’s likely — even post-transplant — they will have some issues. Put in context, kids are pretty good about living purely and not having bad habits. There is the potential to need another heart and we counsel parents about that and tell them about all the risks.”
Anti-rejection medications, which heart transplant recipients must take for life, carry several risks, including a compromised immune system that can lead to cancer and kidney failure. But advancements are on the way here, too. Dosages that once required two medications and a steroid, which can cause weight gain and puffiness, have been reduced, and steroids eliminated in many cases.
“Newer medications have much less side effects than before … and we can get a patient home more quickly after surgery in our center,” Pham said. “Here, the median length of in-hospital after surgery is nine days; a decade ago it was months. Three years after a transplant here, the latest data is a 95 percent survival rate compared to the national average of 82 percent.”
More good news: For some patients who are waiting for a donor’s compatible heart, newer, compact versions of the ventricular assist device (VAD) can be implanted. These machines help the diseased or damaged heart pump blood through the body. In most cases, the patient can engage in normal activities while wearing the device. The new VADs are about the size of a cigarette pack, are implanted under the skin, and a wire is exposed from the chest to charge the inner battery.
“Over time these machines have become smaller in size and more sophisticated,” said Dr. Paolo Rusconi, associate professor of clinical pediatrics and medical director of transplants at the University of Miami and Holtz Children’s Hospital at Jackson. “On the machines available today, the patient can stay for months. And in the adult population this machine can be used in patients who are not a candidate for transplant because they have other chronic disease.”
Rusconi cites how the VAD helped Reno Lombrage, a 15-year-old with dilated cardiomyopathy. Reno, who lives in Fort Pierce, had a checkup with Rusconi at Jackson earlier in February.
“This was a perfectly healthy child until he started getting sick with flu-like symptoms and, in a matter of two to three days, had a very large heart, went into cardiac arrest and was transferred to us,” he said.
Reno did not respond to intravenous medications so he was whisked to the operating room and implanted with a VAD. “It’s quite impressive, the rapidity of how he recovered and in a matter of a couple weeks he was out of the hospital,” Rusconi said. “We even took him to a Heat game. Now this child is waiting for a heart transplant from home rather than staying in a hospital.”
Theodore Koby Hercsky, 18, had a pacemaker implanted after suffering severe heart failure about seven years ago because of a hole in his heart. Doctors at Jackson’s Pediatric Heart Failure Program were able to push back his need for a transplant. Theodore, despite taking daily medications, has competed in indoor-surfing in Hallandale, for which he has medaled.
“I’ve been good,” said Theodore, a senior at Felix Verela High School in Kendall. He plans to study pre-med or nursing at Pensacola Christian College.
“Theo’s getting better and better but this doesn’t mean he will never need a heart transplant in the future,” Rusconi said. “But at least we have been able to allow him to get seven years so far during which he was able to have his regular life to go to school and participate in indoor-surfing.”
Ronnie “Roc” Walker, a 1978 UM Hurricane football defensive end tackle, is another success story. Walker had a heart transplant in May 2010 about five months after being fitted with a ventricular assist device. “Physically, I feel as strong as I was when I played football at the UM and I’m 57,” he said from his home in Miramar.
At 17, a doctor told him he had an irregular heartbeat. “It didn’t mean anything to me. It didn’t stop me from playing football. I just assumed it was status quo,” said Walker, who works in corporate security.
But about 10 years ago Walker realized something was wrong when he was so exhausted he could barely walk. His symptoms worsened. He suffered from sexual dysfunction, couldn’t brush his teeth, and even chewing became too much of an effort. His kidneys and liver began to shut down and his breathing grew labored.
Walker’s first stop was the church, then the hospital where, ultimately, he met Pham and had his life-saving surgery.
“I’m going to get to the church and get it right with God first. I was sensing some impending doom there,” he recalled. “I went to the hospital and they gave me an X-ray and said, ‘You got a really big heart’ — and I said, ‘That’s what people tell me.’ ”
But it was no joking matter.
In January 2010 Walker was fitted with the VAD. “Once I got that device, I was pretty good to go. That was a bridge to the transplant,” he said. When a heart became available, Walker struggled with guilt.
“I got pretty accustomed to this mechanical device and it gave me time to reflect that someone will have to die for me to live. I couldn’t wrap my brain around that idea. I don’t deserve for anyone to die for me to live.”
Post-surgery, Walker talked to the donor’s mother and thanked her for her son’s heart. He wanted to know about the young man.
“She said, ‘Mr. Walker, though he was only 19, he loved animals and he loved people. I recall once giving him money to go shopping and he didn’t buy anything. I asked him why and he said, ‘Mommy, I saw someone who needed it more.’ ”
“I couldn’t hold back the tears. It hit me like a ton of bricks,” Walker said. “It made me realize I had a tremendous responsibility to live a life that was exemplary of the type of young man his mother told me about.”
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