"Just Have Hope": Advice from Dr. Eileen Hsich for Patients Needing a Heart Transplant

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy and information about diseases and treatment options. Enjoy.

Natalie Salvatore, RN:

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

Eileen Hsich, MD:

Hi, I'm Dr. Eileen Hsich and I'm the Medical Director for Heart Transplant for Cleveland Clinic, and I've been working here for 18 years. I'm so excited. We're going to actually be talking to you today about heart transplantation. What do you want to know?

Natalie Salvatore, RN:

What led you to this being your area of specialization and your specialty?

Eileen Hsich, MD:

Gosh, I think that that actually is wonderful. I loved the opportunity to see people who were struggling and dying actually have a whole new opportunity for life that was a long productive life and one that was fulfilling. So, I don't think I could even think of doing anything else. It is one of the greatest benefits to actually meet my patients that I've already seen as they were waiting [for a transplant] to then see their normal life afterwards and all the wonderful things that they do.

Natalie Salvatore, RN:

That's so amazing. The first thing I think we should review is what is a heart transplant?

Eileen Hsich, MD:

That's a great question. A 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.

Natalie Salvatore, RN:

So, what type of patient would need a heart transplant?

Eileen Hsich, MD:

Yeah, the majority of the patients are actually patients with end stage heart failure, but you can also sometimes require a heart transplant for life-threatening ventricular arrhythmias, and if you have severe symptomatic coronary artery disease with no other options to actually fix the blockages.

Natalie Salvatore, RN:

You see this all day, every day. How common is it for a patient to receive a heart transplant or have a patient who needs one?

Eileen Hsich, MD:

In some ways it's rare. In other ways it's actually incredibly common. Although heart transplant may be more rare than other procedures, there have been nearly 90,000 heart transplants performed in the United States since 1968 with over 4,000 adults transplanted last year in 2022. Cleveland Clinic is one of the largest heart transplant programs in the country and is also rated one of the best for survival.

Natalie Salvatore, RN:

Now what happens to patients before a transplant?

Eileen Hsich, MD:

Patients are actually evaluated by a multidisciplinary team. So, I think that it's important to recognize that this is very different than just going for valvular surgery or bypass surgery. This is really a team approach, and the entire team needs to evaluate the patient, and this includes physicians, surgeons, specialists that match the organs, nutritionists, pharmacists and social workers or psychiatrists. This multidisciplinary team reviews all the records to determine if heart transplantation is possible and the best option for you. If the patient is accepted by a committee, the patient's information is then submitted to UNOS to be registered on the national wait list.

Natalie Salvatore, RN:

Are there any other steps in that evaluation process? I can imagine it's pretty thorough. And what happens if one committee deems a patient not an appropriate candidate? Can they go somewhere else?

Eileen Hsich, MD:

Absolutely. Yeah. There's a long process of evaluating a patient and the very first is to determine whether your heart really needs to be replaced. And then the rest of the testing is actually to make sure that your body is healthy enough to actually withstand the surgery as well as the medications that we use afterwards, that can be sometimes hard on the kidneys especially. So, these testings for the heart, the two that are really done are, one is a stress test, but it's a little different than your regular stress test where you're just on a treadmill. You're now wearing an oxygen mask, kind of similar to what they say on an airplane where you put the mask on and here, they're actually measuring the oxygen that you take into your body and the carbon dioxide that you breathe out. This enables them to see how your heart pumps that oxygen around the body after it is absorbed into the bloodstream. And it allows us to know that you've given it your full effort by measuring the carbon dioxide.

The other test that is done to assess whether the heart needs to actually be transplanted and how sick your heart is at that moment is a right heart catheterization, which is an invasive procedure, which is like an IV but in your neck. And that is actually a catheter that runs to the heart and to the lung to measure the pressures to determine whether you have fluid in your lungs, whether you have high blood pressure in your lungs, and whether the amount of blood coming out of your heart is adequate to actually meet the needs of your body.

All the other testing, as I said, is actually to make sure that the health of your body is adequate. And it is important to know that most hospitals have very few absolute contraindications, but that there are many relative contraindications which include age, obesity, kidney, lungs, and other factors that are really a decision that each hospital has to decide, they're all risk factors for actually for things not going well. And so, the hospital that feels that they can actually handle that is the hospital that's best for you. So, if you are rejected from one hospital, it is possible that another hospital feels that they have done that and have enough experience with that high risk. So, it doesn't make it less risky, it just actually means that they have enough experience with that to get you through. But there are times where that risk is really prohibitive and so you will possibly encounter a situation where it is not in your interest to pursue a surgery that you may not survive.

Natalie Salvatore, RN:

That's some great advice and explanation of the evaluation process. So, some places, there are absolute exclusion criteria, which mean they cannot deviate from that, but the relative exclusion criteria means that there is a little bit of wiggle room and what I'm hearing is some facilities or hospitals may not be the best equipped to handle some of those risks. So, choosing a center that does this often and has good experience would be beneficial. And if one place deems you not a candidate, it would be appropriate or possible to be evaluated by another health system.

Eileen Hsich, MD:

Absolutely. I think that what you need to keep in mind for yourself is that transplant is not just one operation and then you walk away like a bypass operation or valvular surgery. You need a lifelong commitment to that program to be followed there very regularly. So that's the only factor that kind of needs to actually be considered as you're choosing another center for consideration, can you really physically go to that center regularly enough to have that good and great outcome? Because it is not a cookbook. You don't just get a set of pills and then it all works out. In order to have that full success of extended life and high quality, you really need to be able to follow up and meet the needs and demands of that center. Their request is really only for your benefit so they can ensure that you are going to do well.

Natalie Salvatore, RN:

So that brings another really important thing into light is management before and after transplantation. So, I can imagine that there's quite a variety of medications that patients who might need transplantation have to take. Can you tell me a little bit about some of those medications and what they may be used for?

Eileen Hsich, MD:

Yeah, so I think for the most part it's kind of the same. I think that's important to recognize that you as a heart failure patient are used to actually taking all your pills and those pills are the same. When your body cannot tolerate those pills anymore and the medication gets reduced in the strength of the medicine because your blood pressure's too low because the heart isn't doing as well, that's when your team is going to recognize that you may need to come into the hospital to actually get those special other therapies.

And so, what are they? Often do, which for which you're very comfortable and familiar with, is getting the water pills into your veins just to get the fluid out. That is done, whether you are on a heart transplant list or not. But what you're referring to be their additional medications to aid the heart to actually help it function when medicines alone are not good enough? And the answer is yes. We have special medications that actually give a better squeeze to the heart, that actually infuse through your veins and provide the heart with the extra push it needs. And they're called inotropes. And currently we have two, dobutamine and milrinone, that help to push the blood forward.

Sometimes we don't need an inotrope, we can just readjust our blood pressure with other medications that are given intravenously. They're called vasodilators. And that is when the heart doesn't have to push against a lot of pressure. So, imagine yourself pushing against a door and if the door had resistance, someone on the other side not letting you open it, you're not going to be able to easily open that door. But if there is no one behind the door and you can easily push it open, then you are going to be able to get through that door faster. And the reason I'm using that analogy is that your heart is pushing against your blood pressure. So, when we use these special medications, if your blood pressure is lowered with medications that are highly supervised in a hospital setting, then your heart sometimes can perform better, and you can actually do and feel much better. But this does require that you stay in a hospital and often in intensive care.

Natalie Salvatore, RN:

So, I think that will lead to my next question about being on the wait list. At what point does a patient become on the wait list and how do they move on this wait list? And then when they get to a certain point, are there other devices? So, you did a great overview of the medications, but are there any devices that a patient might need to help get them through while they're on the wait list waiting for their organ?

Eileen Hsich, MD:

Such important questions. Yes. So, our current system for how you actually designate a heart transplant is based on medical urgency. This is not something like a machine that you actually have to wait for a donor that matches your size as well as your blood type. We need to actually give it to the person who needs it the most at that moment. So, to prevent death, we do need to give it to the most urgent need patient. And so, the medical urgency is rated one to six with six being the lowest and one being the highest. And really the first few statuses, the higher statuses for which most patients get transplanted, require that you are in the hospital using these drips to keep you alive or machines to keep you alive.

And so, the machines can be temporary devices such as intra-aortic balloon pumps, or they have some temporary left ventricular assist devices, but these can be machines that can go into you but also just be easily taken out after transplantation. Or they can be more durable devices where actually they're implanted, and you can go home with them and wait safely while you're at home. And that is what people are talking about, left ventricular assist devices, these are now devices that have gone through many generations that are deemed safe for you to actually go home and live a fairly functional life that is really fairly high quality. So, I think that we refer to those options, both the medication that comes in a drip as well as actually the devices, as machines that actually bridge people to transplant. Because when medications fail, we need to still get you there.

Natalie Salvatore, RN:

So, my last question is, for a patient or family with a loved one who's going to require a heart transplant, what is your biggest piece of advice?

Eileen Hsich, MD:

Wow. It's had hope. Your team is rooting for you, everyone's rooting for you. And I think at times patients wonder, is this really going to happen because nobody has that crystal ball to know what day or what month it's going to occur. And I think you need to know that we have a lot of ways to help you get to that point. So don't ever give up faith and hope, and our goal is to get you there.

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