Individualized Approach is Key to UCSF's Heart Transplant Success

A core group of UCSF cardiothoracic surgeons and cardiologists has created a growing heart transplantation program with excellent survival statistics by focusing on the particular needs of individual patients and using technology to prepare them for surgery. Advanced heart failure has become epidemic in the United States. The increase in heart failure is generally ascribed to the growing incidence of obesity, metabolic syndrome and high blood pressure. Technology has also played a role. "Technology has improved so much that now people have a chance to survive heart attacks that would have killed them 20 years ago," says J. Eduardo Rame, MD, a cardiologist recently recruited to UCSF from Johns Hopkins University School of Medicine. A percentage of those who would have died from an acute heart attack will instead go on to develop ischemic heart failure and need a transplant. Part of the reason for the UCSF team's success is found in evaluating individual patients on their own merits. The population of heart failure patients that comes to UCSF differs somewhat from the "average" nationwide. "We tend to see more dilated cardiomyopathies, and our patients tend to be smaller on average than elsewhere," says Charles Hoopes, MD, who has overseen the development of the UCSF thoracic transplant program over the last few years. "We will evaluate people who might not meet traditional guidelines, but who might be good candidates nonetheless because of other contributing factors. That flexibility is, in part, a response to the diversity of the patient population." Once a patient is deemed a candidate for surgery, the UCSF team immediately tries to support the failing heart. "One of the most important things we advocate is to be very aggressive about initiating therapy," Rame says. "One key to our success is not just getting the heart or lungs in on time, but doing it when the patient is physically ready and not at death's door." Preparing the Patient
The team may use various therapies to prepare the patient for surgery. Cardiac resynchronization therapy (CRT) increases the efficiency of the beating heart, an implantable defibrillator can prevent sudden death in the heart failure patient, and a ventricular assist device is sometimes used to mechanically support the failing heart. The patient may even be kept on an extracorporeal membrane oxygenation (ECMO) machine for a few days, thus allowing a machine to take over the function of both the heart and the lungs in the short term. "In the past, devices like ventricular assists have been seen simply as a bridge to surgery, something to tide the patient over until a heart can be found and transplanted," Hoopes says. "But if you can take a patient who is sick and failing and give them near-normal cardiac output for a couple of weeks, you can fully perfuse tissues and allow them to heal, making the patient much healthier and better able to tolerate surgery." Sometimes tissues have sustained too much damage. Because kidneys are such an important contributor to hemodynamic homeostasis, it is not unusual for heart transplant recipients to develop renal insufficiency, even years after receiving a new heart. Severely damaged kidneys have long been a bar to successful heart transplantation because antirejection drugs can be somewhat toxic to the kidneys. Even slightly damaged kidneys are often enough to knock a patient off the transplantation list. UCSF surgeons, however, have decided that the answer may not be to give up on the heart transplantation. Instead, in a handful of recent cases, surgeons have performed combined heart and kidney transplants in patients. UCSF is one of the few medical centers in the nation to advocate such an approach. At the same time, UCSF researchers are investigating what level of kidney damage indicates whether a heart transplant alone will be successful. "Unfortunately, we don't have good markers that tell us whether someone's kidney will return to normal function after heart transplantation," says Rame. "We are taking a leadership role in finding the markers that indicate whether kidneys will recover after transplant or cardiac support." Their work with combined heart and kidney transplants is only one element of an approach that emphasizes preparation in many organ systems and tissues as a route to successful heart transplantation. "Chronic heart failure takes a toll on the body," Rame says. "All sorts of processes that mediate cell death are turned on by it. People used to believe that if you get someone through the transplant they will be fine, but now we know that there has to be a certain level of aggressiveness in getting people ready for transplantation." To contact Dr. Charles Hoopes, call (415) 353-1606.
To contact Dr. J. Eduardo Rame, call (415) 476-1326.