The Middletown Press (Middletown, CT)
EASIER SEARCH FOR HEARTS
Transplants up at Yale New Haven as doctors consider condition of recipient
NEW HAVEN — When someone is near death and needs a new heart, there may not be a donor available whose heart is strong and healthy.
That doesn’t stop the transplant team at Yale New Haven Hospital from giving that patient a chance at a longer life. If a patient desperately needs a new heart, the cardiologists and surgeons will transplant donor organs that might not be considered at other hospitals.
The decision to accept less robust hearts for the most ill or elderly patients was made deliberately in 2018, and since then, the number of transplants has soared.
“We did 49 transplants from September 2014 to August 2018, and since then we’ve done almost 60,” said Dr. Tariq Ahmad, a heart failure cardiologist at the hospital. “We reassessed the competing risks and assessed we needed to be more aggressive for our patients.”
That’s almost a 500 percent increase in transplants.
“We looked at all the data. We looked at the information and realized there was an opportunity to change our practice that would benefit our community,” he said.
Guided by that philosophy, Yale New Haven will accept hearts that other hospitals won’t.
“We want people to have a normal life. If you’re in your 70s and your normal life is in the 80s or 90s ... we will get you there,” said Dr. Daniel Jacoby, a cardiologist and director of the Comprehensive Heart Failure Program at Yale New Haven.
He said that when deciding whether to take a heart that isn’t as desirable as others, “we look at the severity of the illness in the recipient,” and, whether the patient has one day, a week, even six months to live, or is a person “whose daytosurvival is very touchandgo,” the transplant team will accept hearts they wouldn’t for a patient who is “more stable.”
“The conservative approach to donor selection would include taking only the donors who have the lowest risk ... the ones who are the closest, the ones who are the biggest,” Jacoby said. The Yale New Haven team, however, will accept a heart from an older donor, or one with mild coronary disease, for a very ill patient who would otherwise die.
However, “if you have a 25yearold needing a heart transplant, you would not consider a 50yearold donor,” Jacoby said.
Once word got out that Yale New Haven was willing to accept donated hearts that other hospitals wouldn’t, referrals came from Maine and Westchester County, N.Y., from topranked hospitals such as the Cleveland Clinic and New YorkPresbyterian Hospital.
“We’re doing really careful matching of donors with recipients, and we’ve done a good job of matching patients with the appropriate donor, which allows us to get more organs,” Jacoby said. “We look at hundreds of factors for any given individual match.”
In addition to blood type, age and body size, “people don’t realize that we look at gender, we look at the status of the coronary arteries, the wall thickness of the heart ... how far away the hospital is ... the complexity of the recipient,” he said.
‘We have the expertise’
Jacoby and his colleagues will consider transplanting hearts into patients who have had prior surgeries, and those who have had left ventricular assist
devices implanted because they are in endstage heart failure.
“We have taken on cases that other centers have turned down because of the risk” that come with performing surgery on very ill patients or using lessthanperfect hearts, Jacoby said.
The reason, according to Dr. Muhammad Anwer, a cardiothoracic surgeon, is, “We have a lot of experience. We have the expertise.”
It’s not just the cardiologists and surgeons that have devoted their expertise to highrisk heart transplants. Jacoby named the cardiothoracic intensivecare unit, nursing staff, anesthesiologists, as well as the medical and surgical heart failure teams, who “all need to have experience in these highrisk cases to make them successful.”
“Importantly, we all had to make a decision as a team that we would take on greater risk,” Ahmad said.
There are times when Yale’s patients — who also may be listed with other hospitals — are able to receive new hearts long before they would have at other hospitals.
Matching patients and hearts
Patients and hearts — as well as other organs — are paired through the United Network for Organ Sharing , a nonprofit organization that matches potential recipients according to “medical and logistical factors.”
“They take hearts from donors and they match them using a complex algorithm with potential recipients,” Ahmad said.
If a donor heart is not considered acceptable by a hospital when UNOS offers the organ to its patient, it is offered to the next patient on the list. “Supposing it is a heart that’s not from a very, very young donor and absolutely pristine,” many transplant centers will forgo accepting it, Ahmad said. The patient who finally receives the heart may be several hundred places down the list.
“You have a heart from a 50yearold patient with mild coronary disease in one vessel, for example,” Jacoby said. “Historically, many transplant programs will turn that heart down and the patient will die. … Our patient doesn’t want to die. They want to live.
“We might be center No. 512 and we might have that 70yearold patient who’s on the [LVAD] pump,” he said.
Yale New Haven has transplanted hearts into patients who are barely out of their teens and others who are past 70, Anwer said. Many centers won’t accept patients who are older than 65. “They’re apt to bleed more and their tissues are [fragile], the organs … have less reserve and they need extraordinary care.”
Ahmad said “the average age of accepted hearts from donors is dramatically higher in Europe than in the U.S. with similar outcomes. … There is a movement in the United States to not discard so many hearts.”
No longer a ‘boutique practice’
That movement runs counter to the way transplant centers have seen their roles, Jacoby said.
“Historically, the culture has been one of what I would describe as a boutique practice … that we should very much stay within a very narrow focus,” he said.
Before its change in philosophy, Yale New Haven had done about the same number of transplants each year.
Increasing the number of acceptable hearts and putting fewer restrictions on transplant candidates has meant fewer people die while waiting for a new heart. Ahmad said Yale New Haven’s rate of death while on the waiting list is 6.9 percent, compared with 8 percent nationally.
Yale New Haven also has had a high success rate, with one in 70 “graft failures,” meaning the transplanted heart fails to begin beating in the recipient’s chest. That compares to a national rate of one in 10, Anwer said.
Transplanting hearts poses major risks beyond the normal risks of surgery. Anwer said some patients have had multiple heart surgeries, creating scar tissue in the chest cavity. “That is very challenging,” he said. “In those cases, the heart will be … adhered to the chest wall and the lungs and it will be difficult to excise it.”
Anwer does not just perform transplant surgery. Once notified by UNOS that a heart is available, he travels, on very short notice, to hospitals as far as Missouri to remove the donor hearts himself, then carries them back to Yale New Haven. Going to retrieve a heart “is one of the most incredible experiences in all of medicine,” he said.
The ideal limit for how long a heart can be kept outside the body is four hours, but once Anwer was unable to land in New Haven because of poor weather and had to go to Bradley International Airport. It was five hours between surgeries, but Anwer said the patient is alive today.
“We have a responsibility to give our patients the best opportunity,” Jacoby said. “We have a very steadfast belief that every decision should be focused on advocating for the patient in front of us, what would be best to use the resources at our disposal to give them the best opportunity. We can’t be conservative with our resources to protect ourselves from risk.”
Jacoby described observing a transplant in the operating room. “I was blown away by the amazing work that was going on in there,” he said. “I stood there in awe as the new heart started to beat. It was my patient and I knew he was dying.”
Then a new heart gave his patient new life.