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Lisa Catanese:
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The Success of Cardiac Transplantation
By Lisa Catanese

As the academic medical centers of the Partners HealthCare System, Massachusetts General Hospital and Brigham and Women’s Hospital comprise the largest cardiac transplant program in New England, offering a wealth of experience and expertise for patients with advanced heart failure.

Survival rates for heart transplant patients are extremely favorable today. "We feel this is a very viable option for patients with advanced heart failure who have not responded to conventional medical therapy," says William Dec, MD, medical director of the cardiac transplantation program at MGH. "It’s a technology that works."

Annually, Brigham and Women’s Hospital performs about 30 cardiac transplants, and Massachusetts General Hospital performs about 20. Throughout New England, the total number of transplants ranges from 95 to 100 annually but is severely limited by the availability of donor organs. The contribution of physicians in the community is significant not only in identifying patients with symptoms of progressive heart failure, but also in encouraging organ donation.

"Cardiac transplantation is at the highest level of a full spectrum of services available to patients with heart failure," explains Gilbert Mudge, MD, medical director of the cardiac transplant service at BWH. "Both Partners hospitals are expert not only in technology and clinical care, but also in the medical management of patients with advanced heart failure," he states. "Transplantation is one dimension in a full range of services that we can offer to these patients."

Today, the average cardiac transplant patient is in the hospital less than two weeks – some go home within eight days – and up to 95 percent of recipients are back to normal capacity within the first year. Acute problems of rejection and infectious complications are much less common today. "There’s really no age criteria right now for heart transplantation," says Joren Madsen, MD, surgical director of the cardiac transplant service at MGH. "We are willing to see any patient who may be a candidate for transplant, even the very sickest patients."

The ideal transplant patient is generally under age 65, with very limiting heart failure symptoms despite optimized medical therapy, and is relatively free of other co-morbidity that would limit recovery, such as renal or vascular disease. "But we’ve had patients ranging in age from 16 to 70," Dr. Dec points out. "The one-year survival rates today are above 90 percent. That contrasts pretty strikingly with a natural history that shows 50 percent of patients with advanced heart failure will die within a year."

Organs for transplant are supplied through the New England Organ Bank, a six-state regional sharing facility. The decision of who receives a donor heart is based on factors that include blood group, body size, priority of need, and time spent on the waiting list.

The advent of the immunosuppressant cyclosporine in the 1980s revolutionized cardiac transplantation by dramatically boosting survival rates. Survival still declines after 10 years due to transplant vasculopathy, an obliterative process of the transplanted arteries, which progresses at different rates in patients. Nonetheless, some patients have survived over 20 years following transplantation.

Among the unique offerings at Massachusetts General Hospital and Brigham and Women’s Hospital is the use of nitric oxide, a chemical developed by the chief of anesthesia at MGH. Nitric oxide is used for diagnostic purposes and in the treatment of patients with severe right heart failure and pulmonary hypertension following a heart transplant.

Dr. Dec suggests that the personal physicians of potential heart transplant patients may want to help heart failure patients to plan ahead. "It’s better for the cardiac team to see someone even if the referring physician believes the patient is not sick enough to need a transplant right then and there," he advises. "In this way, we have an opportunity to establish a relationship over the course of several years. Many patients who have an immediate need for a transplant are frightened, anxious, and don’t always hear what we’re telling them."

Becoming more common and successful at the two Partners HealthCare hospitals is the implantation of a left ventricular assist device (LVAD) to artificially aid the natural pumping action of the left ventricle. Patients who are not transplant-eligible are benefiting from the implantation of a permanent LVAD. "We have the ability to implant and take care of patients with artificial left or right ventricular assist devices," Dr. Madsen points out.

LVADs are having a significant impact on quality of life and survival. "One additional dimension is that the heart transplantation program is now integrated with other replacement technology, such as LVADs," Dr. Mudge adds. "We have a nationally sponsored research program available to patients for using an artificial heart as a permanent replacement device."

On the horizon at the two hospitals, and an area of particular interest at Massachusetts General Hospital, is xenotransplantation, involving the transplantation of animal organs. "We are probably the forerunners in the area of xenotransplantation," Dr. Madsen comments. Although the immunologic barriers are significant, it offers promise for the future and is under study at both MGH and BWH.

The success of the cardiac transplant programs at the two Partners hospitals – and the entire scope of cardiac services they offer – represents an excellent chance for patients with advanced heart failure to survive, and to thrive.

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