Episode 137: Heart Transplant and LVAD - a podcast by Rio Bravo Family Medicine Residency Program

Episode 137: Heart Transplant and LVAD

Future Doctor My explains two treatments for advanced heart failure, heart transplant and Left Ventricle Assist Device (LAVD). Dr. Arreaza adds historical information about the first artificial heart implant and the first LAVD.  

Written by My Chau Nguyen, MSIV, American University of the Caribbean School of Medicine. Comments by Hector Arreaza, MD.  
You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Introduction: Advanced heart failure is a major concern in the United States. Heart failure has a high 1-year mortality average of 33%. Although medical therapies have improved survival rates, some patients with progressive and advanced heart failure may still require heart transplantation or mechanical support such as left ventricular assist devices (LVADs) to prolong survival and improve quality of life.

It is estimated that 23 million people in the world have heart failure, and many of them are in end-stage heart failure. When it comes to treating severe heart failure, there are two main options: heart transplantation and left ventricular assist devices (LVADs). 

Heart transplant: The operation to perform a heart transplant typically lasts between five to six hours but may take longer in patients who have undergone previous open-heart surgery or have an LVAD in place. However, because donors’ hearts are a scarce resource, not all patients are eligible for transplantation. 

1. The following are absolute indications for referral for Heart Transplant listing:
   Cardiogenic shock requiring continuous intravenous inotropic therapy (i.e., dobutamine, milrinone, etc.) or circulatory support with intra-aortic balloon pump counterpulsation devices or left ventricular assist device (LVAD) to maintain adequate organ perfusion.
2. Peak oxygen consumption VO2 (VO2max) less than 10 mL/kg per minute.
3. New York Heart Association NYHA class III or IV despite maximized medical and resynchronization therapy.
4. Recurrent life-threatening arrhythmias unresponsive to medical therapy such as an implantable cardiac defibrillator, medical therapy, or catheter ablation.
5. End-stage congenital heart failure with no evidence of pulmonary hypertension.
6. Refractory severe angina without potential medical or surgical therapeutic options.
7. Selected patients with restrictive and hypertrophic cardiomyopathies.

My experience with a heart transplant: I consider myself extremely fortunate for witnessing the whole complex procedure involved in lung and heart transplantation at Jackson Memorial Hospital in Miami, FL. It was an incredible experience to join the transplant team in retrieving a donor organ. Timing plays a critical role in heart transplants. 

When a suitable donor becomes available, every second counts. We must quickly arrange transport and secure an operating room. It is essential that the distance between the donor and the hospital is within our designated region. 

For example, we are in Region 5, including Arizona, California, Nevada, New Mexico, and Utah. Once everything is in order, we divide into two teams. One team sets off to retrieve the donor while the other prepares the patient in the operating room. 

It is a race against time, as hearts and lungs must be transplanted within approximately four hours of removal from the donor. It was remarkable to see how everything was so precisely scheduled, from the arrival and departure of the teams to the transplantation of the organs. It is an inspiring experience to witness these life-saving procedures in action.

History of the artificial heart.

Arreaza: It is great to hear about your experience, but we know that not everyone can have a heart transplant. So, let us talk about other options. For example, an artificial heart. I lived in Utah for several years and I heard something about the first artificial heart being implanted there, so here is the information. William DeVries was the surgeon who led the implantation of the first artificial heart, the Jarvik-7, at the University of Utah on December 1, 1982. The patient was a retired dentist, Barney Bailey Clark, who survived 112 days connected to the device. Today, the modern version of the Jarvik-7 is known as the SynCardia temporary Total Artificial Heart. It has been implanted in more than 1,350 people as a bridge to transplantation.

Left Ventricular Assist Device (LVAD):

In recent years, LVADs have become increasingly popular as a viable alternative to transplantation, as they have demonstrated improved durability by using wear-free components, greatly improving mortality rates in heart failure patients. 

Arreaza: The first left ventricular assist device (LVAD) system was created by Domingo Liotta at Baylor College of Medicine in Houston, Texas, in 1962. It is basically a pump that is used for patients who are on end-stage heart failure. The LVAD is surgically implanted, it is a battery-operated pump that helps the left ventricle pump blood to the rest of the body. LVADs can be used as a temporary treatment while patients are waiting for a transplant. It is called a “bridge-to-transplant therapy”. In some cases, an LVAD may restore a failing heart and eliminate the need for a transplant. An LAVD may also be used as a “destination therapy” in patients who are not candidates for heart transplants. LVAD can prolong and improve patients' quality of life.

My: The purpose of an LVAD is to support patients with heart failure by increasing perfusion and reducing filling pressures in the heart. It is important to note, however, that LVADs only partially assist the pumping action of the diseased ventricle and cannot fully replace the function of the heart. Therefore, the decision to have an LVAD or heart transplant must be taken after careful discussion between the patient and the cardiologist to determine which option is best to reach the patient’s goals of care.

Example of an LVAD:Recently, The Berlin Heart Ventricular Assist Device (VAD) has been a game-changer in saving children with severe heart conditions. As you may guess from the name, it is developed in Germany. It is recently approved by US FDA in 2011. This type of LVAD has been used in approximately 1,000 children worldwide, including 12 cases in the United States. 

The Berlin Heart is a simple air-driven pump that takes over the work of one or both sides of a child's own heart. It pumps blood around the body to keep the brain and other organs healthy, allowing the child to grow and get stronger. 

The use of this device is required until the child is transplanted, or for a small number of children until their own heart recovers. I once again had the privilege of witnessing the procedure performed by one of the inventors, my preceptor, Dr. Loebe in the NICU at Jackson Memorial Hospital.

Conclusion: Now we conclude episode number 137, “Heart Transplant and LVAD.” My explained two options for the treatment of advanced heart failure: Heart transplant and Left Ventricular Assist Device, or LVAD. She shared her recent experience in her surgery rotation at Jackson Memorial Hospital. Dr. Arreaza added the history of the first artificial heart implanted in Utah and the first LAVD. We hope you enjoyed it.

This week we thank Hector Arreaza, and future doctor My Chau Nguyen. Audio editing by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! 

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1. Sources:
   Theochari CA, Michalopoulos G, Oikonomou EK, Giannopoulos S, Doulamis IP, Villela MA, Kokkinidis DG. Heart transplantation versus left ventricular assist devices as destination therapy or bridge to transplantation for 1-year mortality: a systematic review and meta-analysis. Ann Cardiothorac Surg. 2018 Jan;7(1):3-11. doi: 10.21037/acs.2017.09.18. PMID: 29492379; PMCID: PMC5827119. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5827119/.
2. Alraies MC, Eckman P. Adult heart transplant: indications and outcomes. J Thorac Dis. 2014 Aug;6(8):1120-8. doi: 10.3978/j.issn.2072-1439.2014.06.44. PMID: 25132979; PMCID: PMC4133547. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4133547/.
3. Birks, E. J., & Mancini, D. (2022, November 9). Treatment of advanced heart failure with a durable mechanical circulatory support device. UpToDate. Retrieved April 21, 2023. https://www.uptodate.com/contents/treatment-of-advanced-heart-failure-with-a-durable-mechanical-circulatory-support-device.
4. Drews T, Loebe M, Hennig E, Kaufmann F, Müller J, Hetzer R. The ‘Berlin Heart’ assist device. Perfusion. 2000;15(4):387-396. doi:10.1177/026765910001500417.
5. Middleton, J. (2021, August 26). What is the time frame for transplanting organs? Donor Alliance. Retrieved April 21, 2023, from https://www.donoralliance.org/newsroom/donation-essentials/what-is-the-time-frame-for-transplanting-organs/.
6. The Bridge to Transplant Team, The Child and Family Information Group. (2017, July). Berlin Heart Mechanical Heart Assist. NHS choices. Retrieved April 21, 2023, from https://www.gosh.nhs.uk/conditions-and-treatments/procedures-and-treatments/berlin-heart-mechanical-heart-assist/.
7. Royalty-free music used for this episode: "Tempting Tango." Downloaded on October 13, 2022, from https://www.videvo.net/

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