Beating Heart Transplants: Doctors Testing Warm, Beating Hearts In Transplant

LOS ANGELES — Andrea Ybarra's donated heart was beating rhythmically by the time she awoke from the grogginess of her surgery.

Lub-dub. Lub-dub. Lub-dub. In fact, it was warm and pumping even before doctors transplanted it.

Ybarra belongs to a small group of people who have had a "beating heart" transplant, an experimental operation that's mostly been done in Europe. The donor heart is placed into a special box that feeds it blood and keeps it warm and ticking outside the body.

"I felt peaceful when I woke up. I wasn't scared," recalled the 40-year-old from a Los Angeles suburb who suffers from lupus. "It felt like the heart was a part of me all the time."

Despite advances in heart transplantation, the way hearts are moved around the United States and most places remains low-tech.

A team of doctors and organ recovery specialists stuffs an off-the-shelf picnic cooler with ice and jets off at odd hours to a donor hospital where a heart from a brain-dead patient awaits. They inject a chemical to stop the organ and preserve it in the ice chest for the trip home.

Once a heart is harvested, it's a race against time. A heart can stay fresh in the cooler for 4 to 6 hours before it starts to deteriorate. Because of this constraint, doctors can't travel too far to heart-hunt.

It's been done this way for more than four decades, ever since the first U.S. heart transplant was performed on Dec. 6, 1967.

Research has shown that the longer it takes to remove a heart and transplant it, the greater the patient's chance of death or heart disease.

But what if a heart could beat on its own after removal from a cadaver?

It may sound a bit macabre, more like an Edgar Allan Poe story. The new high-tech heart box circulates blood from the donor to the heart so that it continues throbbing while in transit from hospital to hospital.

Based on some success overseas, the University of California, Los Angeles is currently heading an experiment along with several other schools that compares the safety and effectiveness of the new preservation method versus the standard cooler.

If the new technology succeeds in preserving hearts longer, it could change the field, experts say.

No longer will patients be limited by location. Doctors could make cross-country heart runs without worrying about how long it takes. Hearts are now given first to people on the waiting list who live near where the donor is hospitalized. If there's no match, then the circle widens until a recipient is found.

"The rush factor will be taken out. I can go all the way to the West Coast to get a heart," said Dr. Bruce Rosengard of Massachusetts General Hospital, who performed the first beating heart transplant in the United Kingdom in 2006.

It may also potentially help ease the organ shortage crisis. Some 3,000 Americans are currently on the heart transplant waiting list. Last year, 359 died waiting for a heart – almost one person a day.

The thinking is that hearts may be in better condition if they're kept beating instead of being cooled in ice. And if hearts can be monitored outside the body, proponents say this may help increase the organ pool by allowing less-than-perfect hearts to be transplanted.

Ybarra's surgery began like any other. The call came in to Ronald Reagan UCLA Medical Center shortly before 4 p.m. on Aug. 24. There is a heart available. Do you have a match?

The transplant team dialed Ybarra. Her lupus, an immune system disease in which the body attacks its own organs, had ravaged her heart, leaving it enlarged and weak. She desperately needed a transplant.

The following day, a brigade of doctors and technicians set off before dawn by limo to the Van Nuys Airport to board a private jet to the donor hospital in the Palm Springs area east of Los Angeles.

Since Ybarra signed up to be part of the beating heart experiment, she had a 50-50 chance of having the new operation.

Before the team left, a nurse practitioner drew a card at random: Ybarra was getting the experimental heart transplant.

The doctors arrived at the donor hospital at 6:20 a.m. and cut open the patient's chest an hour later. After examining the heart, they stopped it to remove it. Instead of packing the heart on ice, doctors transferred it to a box filled with blood and nutrients to revive it. The box was then tucked inside a portable machine for transport.

On the way back to UCLA, the heart was closely checked to make sure it was stable.

In the meantime, Ybarra was wheeled into the operating room and put under. She was placed on a heart-lung machine as doctors took out her failing heart. The new one was ticking nearby. Surgeons re-stopped the donor heart and sewed it into Ybarra. As her own blood coursed through, it began to pound.

All told, the donated heart had been beating in the box for a little over three hours.

If a heart can survive outside the body longer than the current limit, heart transplants may someday be less an emergency procedure and more like an appointment that can be scheduled – a convenience for both patients and doctors.

"If you knew an organ could be preserved, instead of doing a transplant at 3 a.m., you can push it back to 6 a.m.," said UCLA's Dr. Richard Shemin, who performed Ybarra's operation on his 39th wedding anniversary.

The world's first beating heart transplant was performed in Germany in 2006, using an organ box invented by TransMedics Inc., a private medical device company in Andover, Mass., as part of a multi-center study in Europe.

The company followed up with a pilot study in the U.S. It is currently funding the UCLA-led experiment, which will enroll 128 patients nationwide, randomly chosen to get a beating heart transplant or the traditional kind.

About 100 patients, mostly in Europe, have had a beating heart transplant, according to TransMedics.

Early signs from two European experiments involving 54 patients are encouraging. There has been 97 percent survival a month after the operation and few episodes of rejection and heart-related complications. But since there were no comparison groups in either study, it's impossible to know whether a beating heart transplant is actually better.

The current U.S. study is the first to test the methods head-to-head.

Doctors admit some patients are spooked by the idea of a heart beating on its own before the transplant.

"It's very difficult to remedy their anxiety. But when you think about it, the human heart was never meant to be in a cooler on ice," said lead investigator Dr. Abbas Ardehali of UCLA. TransMedics paid his travel expenses to a medical meeting, but he does not have other financial ties to the company.

Transplant doctors with no connection to the research note that the current system works despite the antiquated way hearts are carted around. Before beating heart transplants can be routine, researchers must not only prove that the technology can preserve hearts better and longer, but that recipients also have improved survival and health than if they had a regular heart transplant.

"In theory, it's a fabulous idea," said Dr. Stuart Russell, heart transplant chief at Johns Hopkins University. But more data is needed to determine whether "it will or won't fly."

There's also the issue of cost. A typical heart transplant in the U.S. costs about $787,000 including hospital stay and anti-rejection drugs. An Igloo cooler costs $35 compared with the heart box, which is sold in Europe for about $200,000. The interior is not reusable so there's an added expense each time a hospital does such an operation.

Like other transplant recipients, Ybarra was monitored closely after her August surgery to make sure her body wasn't rejecting the foreign organ. Her health slowly improved. She could walk around the block without getting tired – a small victory for someone who couldn't even take a few steps before.

During a recent checkup in October, Ybarra laid on a table as a doctor snaked a thin tube into her jugular vein and removed small pieces of her heart for a biopsy. She then walked over to her cardiologist's office where she got the scabs on her chest checked out.

Her last stop was getting an echocardiogram, a sonogram of the heart.

It looked normal.

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Richard C. Senelick, M.D.: Angry Patients Make Angry Doctors: Tips for Coping With the Stress of an Emergency

What happens when disaster strikes? No one goes on the Internet and orders up a stroke or brain injury. It's not something that you plan for or are prepared to cope with. As health care professionals, we deal daily with families who are angry because they didn't ask for this tragedy and are having a very difficult time dealing with it. We too are under unusual stresses with our autonomy taken away and the confines of payers (insurance companies) restricting us in ways we may feel unreasonable. Just like the families in distress, health care professionals feel a loss of control. The people who successfully navigate these events can turn a negative experience into something positive.

We know Sarah Brady had to be very angry when her husband, Jim, was shot during the assassination attempt on President Reagan. However, from this she and her husband became the leading advocates for gun control and eventually saw the Brady Bill passed. The anger was turned around into something constructive.

Patient Stories
Frequently, we just see and hear the anger, but don't really hear the story or the feelings behind the rage. Ellen had a brain injury eight years ago and she recalls: "The clock just stopped ticking the day I was injured. I no longer felt connected to my family, my friends or my job. I looked around at my family and they were all angry, but I couldn't remember the accident, so I didn't know what to be angry about. I feel an enormous loss of who I was, what I had and what I might have become. But, my family has other feelings. They are angry at the person who caused the injury. They seem angry that I don't try hard enough to get better. They get angry and embarrassed by my behavior. And, they get angry at the lack of financial resources and the poor service of the health care delivery system. My doctor thinks my parents are unrealistic and that we need to be more accepting of what my futures looks like. Everybody just seems upset and distressed."

Her doctor is upset. He's busy, having to see more patients in the same day for less money. He can't just order the tests that he wants because he has to ask permission. Ellen's family is constantly calling with the same questions and they just "don't seem to get it." "Why don't they just accept the way things are and make my life easier?" On a particularly bad day, Ellen's father suggested that her doctor didn't care enough and that he was having a lawyer look into the case. The usually patient doctor lost it, yelling at Ellen's father and telling him to get a new doctor if he didn't appreciate what he was doing and particularly since he had mentioned the "L-word," a lawyer.

Ellen's family and the doctor's reaction are not unusual. They are both dealing with real losses. Mothers tell me constantly how they look at their injured child and know it is someone that they love deeply, but that the person they are taking home from the hospital after a brain injury is someone else. They have lost part of the person who used to be. Both the family and the doctor have lost control of the situation and both are angry.

Why Are They Angry?

• Both have a perception of having lost control of the problems that are causing them distress. Families may feel swept up in a system that doesn't care or can't make their child better. Doctors share the same concerns and frustrations, having to adapt to a new way of delivering care that seems to move them out of a position of control.

• Parents may feel responsible that a child had an accident. A wife may be angry with the patient for getting sick. A husband is mad because his wife is not supposed to get sick. The doctor is upset because she has done everything she knows to do and the patient isn't improving. She's not used to being a target for people's anger and wants to be the recipient of their praise for a job well done.

• Society gets angry for having to deal with difficult people who can't just fit into the system. Look at the anger of employers towards the American's with Disabilities Act. Why should I have to make concessions? Is it my fault that Ellen is different?

• Families and patients are angry with a public that tends to patronize the disabled and look at them as "less than whole." I have parents who want to put a sign on their disabled child that says, "He is not retarded!" This, in and of itself, reveals their own prejudice toward our citizens with mental handicaps. It is not easy.

• Everybody is troubled by the "miracle stories" that show up on the front page of the newspaper tabloids and on the latest television gossip shows. Health care professionals resent the "false" expectations that are being set. Families are particularly upset because the miracle didn't arrive at their home.

Coping With Anger
Iris Dement, one of our most soulful singers, wrote a song that could be the anthem for patients and doctors: "Easy's gettin harder every day." Ms. Dement can be hard to reach, so I sat down with Hal Hoine Ph.D., Director of Rehabilitation Psychology at the Rehabilitation Institute of San Antonio (RIOSA). Although Ms. Dement clearly identifies the problem, Dr. Hoine gives us ways to cope and deal with our anger. In particular, health care professionals need to realize that these strategies also apply to them, not just to patients and families.

Take Control
People have the perception of having no control and being attacked. You need to identify those things that you can control, make a list of those things that fit into two columns -- those things you have control over and those you don't. Identify strategies to get input into the system. Education and information are power. Families and professionals are helpless when they don't understand what is going on and don't know how to access the necessary tools to manage a difficult situation.

Illogical Thinking
Under the enormous stress of terrible tragedies, we don't always think logically. We feel responsible for events when we are not. The parent didn't cause the accident and the doctor is not responsible for an insurance plan that doesn't provide adequate coverage. Talk about the anger. Identify the sources of distress. Help all involved to think logically about an illogical circumstance. Frequently no one is to blame. Rabbi Kushner wrote the wonderful little book, "When Bad Things Happen to Good People." It is natural to shift blame to a God who doesn't care, a doctor who is inaccessible, or an insurance plan that is heartless. It is natural to shift blame, but not constructive. We need to acknowledge self-responsibility and the difficulties it proposes.

The White Coat
As health care professionals we frequently hide behind the white coat and feel that it allows us to be immune from the wrath of angry families and patients. It should add responsibilities. Health care professionals need to listen and let their patients and families ventilate. Never argue! We want to talk angry families out of their position and convince them that we are right. The younger the doctor or therapist the more difficulty they have in this role. This is not a contest. The white coat comes with an obligation to absorb the abuse and anger. When the angry family refuses psychological help or counseling, we accomplish nothing by abandoning them or getting angry ourselves. Continue to listen, encourage the patient and family to gain control and continue to constantly educate them. Understand your own feelings when a patient or family ventilates and gets angry; remember that you are the outlet for their anger. If the doctor or therapist is having difficulty controlling their anger, they should seek help. There are seminars and courses for professionals. We frequently ask the family to seek help, but how often do we seek it for ourselves?

Maintain Hope
It's like walking a tight rope or precipice at times, maintaining hope while trying to give patients and families a realistic view of the future. It's hard work for everyone, holding on to hope can be essential, but difficult. It's our job to intervene at the person's current level of distress and disturbance, understanding not only their feelings, but our own. Control the anger.

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Follow Richard C. Senelick, M.D. on Twitter: www.twitter.com/RichardSenelick

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