A Chance at Life: Heart Transplantation

Podcast Transcript

Announcer:

Welcome to Cleveland Clinic Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic.

Natalie Salvatore, RN:

Hello, my name is Natalie Salvatore. I'm a registered nurse at the Cleveland Clinic in the Heart, Vascular and Thoracic Institute.

Eileen Hsich, MD:

And I'm Dr. Eileen Hsich, I'm a medical director of heart transplantation at the Cleveland Clinic, and I've been here for 18 years, and we are so excited to actually talk to you today about transplantation.

Natalie Salvatore, RN:

Dr. Hsich, this is your specialty, your bread, and butter, but for other providers who might not have the same experiences that you do, can you provide a little overview of what heart transplantation is and who might need one?

Eileen Hsich, MD:

Oh, wonderful. Yeah. So, heart transplant is a surgical procedure usually for end-stage heart failure patients that replaces a failing heart with a healthy heart from a donor who has died or has no meaningful recovery. Really, it's important to recognize that there are three reasons you would actually consider someone for heart transplantation. The first, which is the most common, is that the heart is failing, so is an end-stage heart failure patient. The second is for a patient who actually has life-threatening ventricular arrhythmias that are not amenable to ablations. And then the third is actually for people who have severe symptomatic coronary artery disease that have no other revascularization options.

Natalie Salvatore, RN:

So, when we're talking about end-stage and no other options, when should patients be referred and how common is it?

Eileen Hsich, MD:

Again, great questions. So, they should be referred when they start to really require more than one hospitalization in six months. That's a warning to you that they're not doing well with medical therapy. If they've been hospitalized even just once for cardiogenic shock, I would also consider referring them to an advanced heart failure specialist. And I think the third thing I would consider referring them for is when you actually encounter a patient, a heart failure patient who needs their medication reduced because of hypotension, that really means that they have a failing heart that's unable to maintain adequate blood pressure. And so, I would also see that as a sign to refer a patient for transplantation.

Your second question was how common is it? And what was a procedure that really was very rare that it first began in 1968 has now had nearly 90,000 procedures performed. So, 90,000 heart transplants nearly in the United States with over 4,000 transplanted last year in 2022. And I think I also want to add that the Cleveland Clinic is one of the largest heart transplant programs in the country and is rated one of the best for transplant survival.

Natalie Salvatore, RN:

Wow, that's excellent. And I think that's a really important point to consider when we start thinking about what is going to happen to a patient before transplantation and going through that evaluation process. I can imagine it's pretty important to consider the health system or referrals based on experience. So, can you talk a little bit about what happens before transplantation and some of the pieces of that evaluation process?

Eileen Hsich, MD:

Yeah, those are again really great questions. I think the thing that people need to know is that this is different than actually any other surgery. And so, when referring a patient, the transplant center actually has to get approval from the insurance company because it is a requirement so that what center may be closest to you doesn't necessarily mean that it will be the center actually that is in network for that patient. So, there is always at every center a process to evaluate that patient from an insurance perspective as well as medically to evaluate the patient itself. The evaluation for a patient really starts with two main tests that help determine objectively whether a patient needs transplantation. The first is a cardiopulmonary stress test where a patient is on a treadmill or a bicycle and they're wearing an oxygen mask where we're measuring their peak oxygen consumption. And if that peak oxygen consumption is less than 14 mils per kilogram per milliliter, the patient may be considered eligible for heart transplantation.

The second test is a right heart catheterization where we measure the hemodynamics, and this enables us to determine eligibility for transplantation as well as placement on a transplant list. So, we're looking actually to see if the patient has heart failure. We're measuring the pulmonary capillary wedge pressures. We're also measuring the cardiac output and index to determine whether the patient has sufficient blood flow to meet the requirements of their other organs. So those are the main things. If a patient does have pulmonary hypertension, they will go through additional testing with vasodilators to determine whether or not this is reversible. And that kind of lets me go into the next segue about the fact that the rest of the testing is really done to determine the health of the body to withstand the surgery and the medications necessary.

And I think it's important to know that there are very few absolute contraindications and those that are absolute include non-compliance and drug or alcohol addiction. But there are many relative contraindications including age greater than 70 years old, pulmonary hypertension, tobacco usage, cancer, emphysema, poorly controlled diabetes, obesity and renal failure. Each transplant center reviews the eligibility of the patient and the risk factors that I just mentioned. These relative contraindications, they review this and their risk factors for early mortality and they determine whether or not that they feel that they can achieve a successful transplant. And that is how they decide whether or not a patient is really eligible at their center.

Age is something I think important to kind of spend a few seconds to actually reinstate. A lot of patients are not referred to transplant centers because people think that their patients are too old. I want to make it very clear that the international guidelines state that transplantation should be considered up to the age of 70 years for the average transplant center, okay? And only a few patients should be considered after 70 years that are deemed healthy enough to undergo the operation.

Natalie Salvatore, RN:

I can imagine this process has come such a far way over the last couple of years. Now for these patients who are considered appropriate candidates or on their way to consideration for transplantation, can you talk a little bit about the medications that a patient might be on, and do they differ in any way from the normal protocols or what you might see a normal heart failure patient on?

Eileen Hsich, MD:

A good question. Most of the time really the patients remain on guideline medical heart failure therapy, and I think that the only exception to that that comes to mind is actually anticoagulation for patients who require this for atrial fibrillation or venous thrombosis or pulmonary embolisms. The preferred choice for anticoagulation is a vitamin K antagonist like warfarin because it can be easily reversed at the time of heart transplantation. So other than that, it is really routine medical heart failure therapy until a patient becomes more advanced, requires hospitalizations, and may require drugs like inotropes such as dobutamine and milrinone or vasodilators that are intravenous that can help improve the cardiac output by lowering the afterload of the heart.

Natalie Salvatore, RN:

Now I can imagine medications only work for so long or do so much. What are the next steps once the medical therapies start too not be enough?

Eileen Hsich, MD:

Yeah, when medicines don't work, I think we're very lucky at this time to have technology to either bridge them to transplant with temporary devices or with durable devices. So, examples of temporary devices include intra-aortic balloon pumps or for patients that require more extensive bridging be used ECMO as a temporary device. When we talk about durable devices, these include left ventricular assist devices which enable patients to safely wait for years but still require close monitoring by an advanced heart failure team. These durable devices have gone through many generations and are actually now small and really fairly wonderful.

Natalie Salvatore, RN:

So, what is the wait list like for these patients? How is it determined where they'll be and how they move on the waitlist?

Eileen Hsich, MD:

That is an excellent question. The goal of transplantation is to reduce waitlist mortality. So, we base who needs a heart on urgency. So, it's medical urgency to reduce waitlist mortality, that is how our current heart transplant allocation system works. There are currently six active tiers, and the first tier is the highest tier, and the sixth tier is the lowest tier. The first few tiers that are the highest are the ones that are more likely to be transplanted, and they more often require a patient to be in the hospital requiring the temporary devices to keep them alive or the intravenous inotropes and vasodilators to help assist their heart. We will be having changes in our allocation system over time that they are going to a continuous distribution, which means that we're actually across all organs going to be looking at many other factors other than just medical urgency in order to provide the most fair and equitable distribution of organs. For heart, that will not take place for a few more years, but that will be in the future with regards to possible changes.

Natalie Salvatore, RN:

Thank you so much for that summary. If you could leave us with one piece of advice that you would have for your colleagues regarding heart transplantation, what would that be?

Eileen Hsich, MD:

I think it's really important to recognize that we're here for you and your patients, that actually I think often people do not refer because they don't know when to refer and they feel that their patient is too old or too sick. And that's exactly who we want to transplant, the patient who is most needy and really that we feel that we can get them through the operation and have them succeed. So I would say please, when you have a patient that is being hospitalized frequently or the patient actually has a need to have their medications reduced, please consider sending them to an advanced heart failure specialist and hopefully they can be considered for a heart transplantation or even the durable left ventricular assist devices for which patients can live a very meaningful, wonderful life, even if transplantation is not for them.

Announcer:

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