In December 1967, a South African surgeon made history when he successfully transplanted the heart of a woman who died in a motor vehicle accident victim into a heart failure patient.
Flash forward 50 years to December 2017. Heart transplantation has made vast strides today. While the wait for a heart still can be long and tenuous, we now have the ability to transfer donor hearts cross-country in a matter of hours, and anti-infection protocols are much more stringent.
In honor of the 50th anniversary of heart transplantation—and my 30th year performing heart transplants—let’s take a look at how far we’ve come giving people their lives back after heart failure.
LVAD: Better quality of life pre-transplant can mean trickier procedures
The basics of heart transplantation haven’t changed much in the past 50 years. We still open the chest, saw through the sternum, and remove the failing heart to replace it with a donor heart. The tricky part today is that in the Mid-Atlantic region, roughly 80 percent of patients who undergo transplantation are currently living with left ventricular assist devices (LVADs), which leads to more complicated transplantation procedures.
LVADs help patients’ hearts pump blood more effectively and allow heart failure patients to have social lives, play sports and go to work instead of lingering for months on the transplant list. There are many delicate, implanted components of the devices that we must work around. Then, we must remove the LVAD before we remove the failing heart and implant the donor heart. From there, the procedure is similar to how we’ve always done it. We sew in the healthy donor heart, close up the chest, and begin the recovery process and advanced medication therapy.
Improvements in anti-rejection
A heart transplant recipient in the 1960s wasn’t expected to live long after surgery. In fact, the first heart transplant patient in South Africa died of an infection within a few weeks of surgery. Cardiologists then simply didn’t have the knowledge of anti-infection and anti-rejection drugs we have today. They’d use massive amounts of drugs which caused toxic effects.
Immunosuppressive drugs are much more advanced and our understanding of organ rejection is much more robust than it was 50 years ago. Today’s drugs help us achieve the fine balance between prevention of rejection and infection more often.
Patient outcomes and heart availability
In the 1980s, donor hearts were more widely available. Fewer people needed them, and fewer people who were eligible for transplantation chose to undergo the procedure. Transplantation had developed a bad rap because so many people died soon after surgery. As we gained more pharmacologic knowledge throughout the ‘90s, we peaked in efficiency and donor heart availability. Then came the downhill slide we’re faced with now: fewer available donor hearts because of increased acceptance of the procedure and a tidal wave of people facing heart failure.
In the past two years or so, the donor base has expanded for an unfortunate reason— the overwhelming number of opioid overdoses. When I share this, it often shocks people. How can a substance abuse patient’s heart be safe for donation? When a person overdoses, the brain often suffers the greatest damage. If we can get an overdose victim to the hospital in time, we try to save their life by keeping the brain alive. If the brain dies, we try to keep the heart pumping and healthy enough to transplant (if the individual was a registered an organ donor).
Life expectancy after heart transplant plateaued in the 1990s at an average of 12 years post-surgery. Today, between LVADs and heart transplantation, we can add many quality years to the lives of heart failure patients, even in older adults. For example, baseball hall-of-famer Rod Carew received a heart transplant at age 71 in December 2016. The heart was donated by 29-year-old Konrad Reuland, a Baltimore Ravens player who died from a brain aneurysm.
Now, the first instinct might be to assume Carew got a heart because of his celebrity or wealth. But to get a heart at an advanced age, patients must go through more rigorous screening than a person age 50 or younger. And it’s important to realize that, while aging causes many health problems, one remarkable change that can work in our favor is lowered immune response. The bodies of older patients don’t react as intensely to the transplant procedure, so their pain responses and rejection rates are lower than, say, patients in their 20s or 30s.
As such, older patients tend to have better post-surgical outcomes than younger patients. One of my patients is in her 80s and she had no pain following transplantation. She bopped into my office like a rock star for every post-transplant visit. But most of my younger patients have discomfort for two to three weeks and rely on pain medication to get through recovery.
What’s the future of heart transplantation?
I foresee a time, likely within 25 years of this writing, in which patients will not have to wait for a donor heart from a deceased person. Rather, patients of the future will apply for a heart to be grown specifically for them. Doctors will strip the cells from within pig hearts, which are anatomically similar to human hearts, and repopulate them with patients’ own stem cells.
If this sounds ludicrous, remember that 15 years ago, smartphones weren’t a thing. Self-driving vehicles didn’t exist, and we certainly couldn’t shop online for groceries. Today, we take these technological advances for granted. Through that lens, farm-to-operating-table hearts don’t seem so far-fetched!
At the end of the day, heart failure is the No. 1 killer of women and men in the U.S. End-stage heart failure has a higher mortality rate than nearly every cancer. The more we can improve patient care pre-transplant and continue to advance technologies to improve transplantation processes, the more quality years we can add to the lives of people with heart failure.
