COMMENTARY

Lessons From 500 Heart Transplants

Charanjit (Chet) S. Rihal, MD; Sudhir S. Kushwaha, MD; Brooks S. Edwards, MD

Disclosures

March 17, 2014

Editorial Collaboration

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A Team With Heart

Charanjit S Rihal, MD: Good morning. I am Dr Chet Rihal. Today my guests are Dr Brooks Edwards, director of the William J Von Liebig Foundation Transplant Research Center of Mayo Clinic, and Dr Sudhir Kushwaha, director of cardiac transplantation and [left ventricular assist device] LVAD service here at Mayo Clinic.

We are here to celebrate the 500th cardiac transplant that has been done here at Mayo. Brooks, you have been involved in this practice since the beginning. Tell me what it was like at the beginning of this incredible journey.

Brooks S Edwards, MD: It was a very well-organized experience from the beginning, and the success of transplant was the development of an integrated, dedicated, multispecialty team. That team has met from day 1 through this morning at St Mary's Hospital for the care of every patient.

Dr Rihal: You pioneered the heart team, right?

Dr Edwards: You could think of it as the early service line. It is cardiac surgery, cardiology, infectious disease, pulmonary medicine, nursing, and social work, and we meet together every day to discuss each individual patient. In many ways, that has been the success of the program.

Dr Rihal: What were the major challenges then? Were they technical, surgical, or medical?

Dr Edwards: The practice has changed. In the early days, the cases were, in many ways, very straightforward. We didn't have good treatment for cardiomyopathy, and so many of the patients were young people with dilated cardiomyopathy.

Now we see much more complex cases, patients who have had multiple previous operations, and patients who have been bridged with one or more mechanical devices. There are technical issues and different immunologic issues that have to be addressed.

Dr Rihal: Sudhir, what are the recent advances in the field of cardiac transplantation?

Drugs, Devices Extend Survival

Sudhir S Kushwaha, MD: They are partly medical immunosuppressive-type advances, which we have had a role in pioneering here at Mayo. The field has changed as well, in the sense that we now have assist-device therapy that has changed the way we practice end-stage heart failure to a large degree.

As far as immunosuppression is concerned, we have started using a lot more sirolimus. We try to transition most of our patients by around six months to this particular immunosuppressive agent because it is a powerful antiproliferative and it has been shown in our studies to attenuate the development of allograft vasculopathy, which is the major limitation to long-term survival and always has been since the early days of transplant.[1,2,3,4]

If we look at the survival figures from the International Society for Heart and Lung Transplant (ISHLT) database, which is a worldwide database of all transplants that have been done, we can see that historically we have a survival of about 15 years, and some patients obviously live longer. Now with the change in immunosuppressive strategies, which we have instituted here and now other centers are catching on, we hope to extend that significantly.

Dr Rihal: Most cardiologists in the United States aren't transplantation experts, and yet they occasionally encounter patients who have had cardiac transplants. Are there other medications that all transplant patients ought to be on other than the immunosuppressive regimens, such as statins or aspirin?

Dr Kushwaha: Yes, and this is a very good point because some of the research that we have done has demonstrated that many of the risk factors that apply to what I would call nontransplant coronary disease also apply to vasculopathy.[5,6] We are very aggressive in treating high lipids, and, in fact, most patients are on statins unless there are major reasons for them not to be. Furthermore, we are increasingly realizing the role of antithrombotic therapy because it seems that platelet activation has as much of a role in promoting vasculopathy as it does in traditional coronary disease.

Dr Rihal: When should practicing cardiologists begin to consider advanced therapies for heart failure, whether it is a ventricular assist device [VAD] or transplant? What is the appropriate time for referral to a transplant center? Brooks, perhaps I'll direct this to you.

Dr Edwards: We think about the patient who has declining functional capacity, the patient who is requiring one or more hospitalizations for heart failure in a year, and often we think the patients who have been well-treated on standard therapy (ACE inhibitor, beta-blocker, and so on) and are now not doing well on standard therapy. They have perhaps had cardiac resynchronization therapy, and they are having a functional decline.

Because of the long waiting period and the fact that many patients are waiting for transplant, we would rather see those patients earlier rather than later. Some of the risk is seeing them too late, and then it becomes a problem.

Dr Rihal: This is a really important point, Brooks. We are all aware of the shortage of organs, but what about the future? You are involved in regenerative medicine. Are we actually going to be able to regenerate myocardium or even organs?

Dr Edwards: It's very exciting. This field is going to blossom and change the way we take care of patients, and I don't know whether it's going to be in five years or 10 years. It is going to be in our practice era that we are going to be able to help some patients, maybe not every patient but some patients, to restore normal or improved cardiac function with cell-based therapy or even some medications that may stimulate their own regenerative systems.

Dr Rihal: This is very exciting. My guests today have been Dr Brooks Edwards and Dr Sudhir Kushwaha, who have given us an update on cardiac transplantation and VAD therapy. To summarize what they have said, the cardiology community is well aware of the benefits of cardiac transplantation, and those of us who don't practice in this field ought to consider referrals for VAD or transplant therapy when patients are on optimal medical therapy and faced with a declining functional status or recurrent hospitalizations. Options include implantable LVAD or cardiac transplantation, and we hope in the future, cardiac regenerative therapies. So Brooks and Sudhir, thank you very much for joining me this morning.

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