Shelley Hall, M.D., Chief of Transplant Cardiology, Mechanical Circulatory Support and Heart Failure at Baylor University Medical Center in Dallas, Texas, talks about new technology that is giving gravely ill cardiac patients their best chance for survival.
Interview conducted by Ivanhoe Broadcast News in July 2016.
That involves what, the artificial heart as well as other heart transplants.
Dr. Hall: Artificial hearts is one of many tools to deal with advance heart failure patients. It is probably the least commonly use tool because it has a very particular niche of disease for which it is applicable. The more common being the mechanical LVAD.
About how many people are getting completely artificial hearts these days?
Dr. Hall: Total artificial hearts are very rare. Somewhere between 40 to 50 a year in the country is being done.
That’s it?
Dr. Hall: That’s all.
And Brian got one?
Dr. Hall: He did get one and we had to debate quite a while because it is a very, very big surgery. Because it’s not done very often, you have to get all the proper resources in place and make sure that the team, the patient and their family are ready for the challenge.
Now the total artificial heart itself, is that sort of the target? Is that like someone’s going to live with an artificial heart for the rest of their lives? Is that the way it’s designed?
Dr. Hall: The total artificial heart is only approved and indicated currently to bridge somebody to transplant; people who cannot live very long. The longest is still in the one to two year range. The average survival of the total artificial heart is somewhere in the six to 12 month range. The technology is getting better and better. People can now go home with the total artificial heart but still not to the point where it is a true treatment for heart failure. For Brian it was a bridge to transplantation.
That’s typically how the artificial heart is used these days?
Dr. Hall: It is the only way it’s approved to be used. You are essentially removing both pumping chambers of the heart, the right ventricle and the left ventricle, and replacing it with this machine that’s attached to the remaining top chambers of the heart. That’s all there is in the body to circulate blood for the patient.
Obviously it takes batteries, and electricity. It doesn’t operate by itself?
Dr. Hall: Absolutely, they have big tubes coming out of their chest that is connected to batteries. You have two separate controls, one for the right ventricle, one for the left ventricle and they have to remain properly timed and coordinated. It is quite an intricate little machine.
Brian thinks that he was the first one that you used as a bridge here at Baylor or one of the first?
Dr. Hall: He was one of the first. He’s the first that successfully survived the transplant.
Oh, wow, so when you look at his case what do you think? Is this a Medical Breakthrough and if it is, tell me it is and why?
Dr. Hall: Well, I would say it’s not a breakthrough. The technology has been around for a couple of decades, but the technology is improving to the point where it is more widely applicable across the country. It used to be restricted to just very select center scattered across the country and now any advance transplanted VAD program with the proper surgical and team expertise has the opportunity to use it. It’s a relatively new technology to our team. This is exciting for our patient population to now be able to access this because typically, if you need a total artificial heart, it means you are not a candidate for the more commonly available devices.
The other devices being the artificial valves and things that you are putting into the heart?
Dr. Hall: No, the typical device for the advance heart failure is called the LVAD. There are two available devices right now that can bridge somebody to transplant; and one that can be used as its own treatment for heart failure. That is much more common somewhere in the five thousand implants a year now in the country. Total artificial heart is still very rare and under a hundred a year.
How important was it for Brian that you had these options available?
Dr. Hall: Well, it’s allowed him to stand here today. The reality is that he wasn’t a candidate for the conventional available pumps that we had. If we did not have the ability to implant the total artificial heart, we would have been forced most likely to make a decision to discontinue the temporary support device that he was on because it doesn’t last forever. He was too critically ill to try to go right to transplantation.
That is a long way of saying that he wouldn’t have made it.
Dr. Hall: That is a long way of saying he wouldn’t have made it.
How significant is having all these tools; how significant is that or has it been or was it for Brian?
Dr. Hall: Well, how do you qualify significance of a life? For him it was everything, for his wife it was everything, for our team it was everything to be able to provide this to him and get him to successful ultimate conclusion which for him was a heart transplantation.
Because he had the artificial heart did that change his status on the list and things like that?
Dr. Hall: While in the hospital with a total artificial heart, they qualify for the highest status on the list, status 1A. However, if they go home on the new portal driver they drop to the status 1B and that it can be a huge issue depending on the area of the country you are at. It is better for them to go home; it’s a healthier place to be, less infection, they are in their own bed, they get away from this place for a while, home is a very healthy place to be. But it does drop them down on the status for waiting for a transplant. Because of the short durability of the total artificial heart that can worry many centers if they don’t have the ability to get hearts very quickly in that IB category. They may keep the patient in the hospital so that the patient remains in the top category.
I think he stayed in, didn’t he?
Dr. Hall: He did not.
He was in for a while then he went home?
Dr. Hall: Correct. We sent him home and he was home for about a week and as a 1B and he got a call for the transplant. Brian got to be home for a week, get some rest in his own bed, and then got a successful call for transplant a week later.
Because you are transplanting a donor heart in where an artificial heart has been, how does that change the surgery? Does it make it easier, does it make it more challenging?
Dr. Hall: Well it’s certainly more difficult. I’m not a surgeon, I’m certainly not going to try and say it was simple, because it is not. Whenever you go back into someone’s chest, there’s scar tissue, there’s inflammatory changes. Ideally you would like to wait longer from the original surgery before we go back in. But with the total artificial heart we really don’t want to do that because of the short durability and high complication rate as it stays in longer and longer; so it was definitely a very big major surgery.
I guess I had an impression that you actually did the surgery?
Dr. Hall: No, I’m not the surgeon, Dr. Chamogeorgakis, was his surgeon and I’ve practiced a long time to say his name. Everybody affectionately calls him Dr. T. I was the cardiologist that received him when he arrived, kept him alive, and then eventually we went to the artificial heart and cared for him all the way through it and I’m still caring for him today.
I was pretty amazed at how healthy he appears to be.
Dr. Hall: Yeah.
Are you equally amazed?
Dr. Hall: Not really. The one thing Brian had going for him is that he had not had years and years of chronic illness. He was healthy, literally working out and then had a heart attack. He was doing everything right to try and minimize his risk because he had a genetic family history of heart disease. He was doing everything right to try and minimize that risk but he still had a heart attack. But because he did everything right and was taking care of his body, he was healthy. When we went to the surgery, it was a healthy body going into the surgery for the total artificial heart. It was still a healthy body recovering from that surgery and then we rehab him very well in the hospital to the point where we did let him go home. He did come back remaining in a healthy state to go for the transplantation.
When you look at where cardiology is today and where it’s going, what would you say things like his for example, what is it in indicator of? You say everything is getting better, are we going to be able to have more transplants or healthier outcomes, better outcomes?
Dr. Hall: We have been flagged in this country for over 15 years with the number of transplants from anywhere from 22 to 24 hundred a year. There are a lot of factors that go into that. One of the biggest is that we just don’t have enough donors even though the number of donors has increased over the past decade. All the education about donor awareness and putting on your license and things like that has helped somewhat. Government oversight also affects transplant programs.
Wow, I mean you lay it out there, it sounds like this is going to be a continued, especially for someone like you, and this is your business a lot of frustration.
Dr. Hall: I’ve served on the government amenities to try and advance this policy and problem. We are in the process of redoing the system for the waitlist to try and separate the patients more and get the sickest patients the hearts first.
Where is Baylor standing like on the national picture? You guys are doing pretty well now, right?
Dr. Hall: Baylor is in the top five in the country, we have been the top five for I think the past four years. We’ve been the top in Texas for the past five years as far as volumes and outcomes. Our philosophy is to try and make every donor work that we can.
But you can’t.
Dr. Hall: No we can’t. There are definitely donors that you cannot utilize and we certainly turn down donors just like everybody else. But we do try and push the conventional norm, so that it’s now becoming the focus more and more in our academic community. We had conferences focusing on solely trying to increase the donor pool and looking at things that used to be perceived as exceptions. We’re trying to debunk some of those myths that we need to avoid that particular topic or that particular issue on a donor.
Is some of that simple? Can you explain some of what those myths are?
Dr. Hall: Well, if you look back when transplantation began the typical heart donor was a young person who had traumatic brain injury, motorcycle, car vehicle; they didn’t have seat belts or helmets, so they were very young and healthy. They had brain injuries but their heart was healthy. Nowadays, we have a lot of safety laws so those types of deaths don’t occur as often. Now our donors are in their 30’s and 40’s with high blood pressure, obesity, diabetes, strokes, so as you can imagine when you have those problems that hearts not quite as healthy as that 20 year old who got into a motor vehicle accident.
So you’re making assessments on heart based on things like the age?
Dr. Hall: The age, now we have more screening test for viruses, and infectious diseases, and which ones do we need to avoid, and which ones we cannot and how far away is the donor. We now know that the longer the distance between the heart removal, from the donor and the implant into the recipient, the greater the risk of graft dysfunction; graft is what we call the heart. How far will a program fly to get a heart? Will they take it if it looks a little bit weak because the brain death process can cause that but the heart itself out of a brain death body can do fine? There are so many nuances that we are trying to explore that makes most programs nervous.
When you see somebody like Brian, I mean, that he’s like the poster boy for what the whole process can be, right?
Dr. Hall: Absolutely, he’s what it’s all about. To actually be able to, essentially die and go to his local community hospital and be saved in that moment. They put in new technology to temporarily support him. They immediately recognize the situation and transferred him to us for further evaluation. There’s nothing more than when I get that transfer, they get better and I send them back to their community. But, what happens more often is they’re sent too late. They are watched and they’re waiting in the community hospital to see if they get better. They’re not transferred till they are deteriorating and then it’s too late. Brian was sent here right away within 24 hours after the temporary device was put in. We were able to evaluate him, got out all the issues that were associated with an important decision like a TAH. We were able to stabilize him; we confirmed we could not get off the temporary pump that his heart had too much damage and we were able to prepare for this big endeavor.
Yeah, it’s got a big uh I imagine job satisfaction this is where you feel it?
Dr. Hall: This is actually the best part of my job; is to be able to take somebody who is that ill, get them to this point where they’re back to living their lives. He and his wife have a whole new perspective; I mean when you go through something like that you appreciate your life so much more. The little things don’t really bother you as much as they used to and you recognize the importance of friends and family and appreciation. That’s what makes it all worthwhile.
END OF INTERVIEW
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Susan Hall
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