Guest: Dr. John S. Ikonomidis: - Cardiothoracic Surgery
Host: Dr. Pamela Morris - Cardiologist.
Announcer: Welcome to an MUSC Health Podcast.
Dr. Pamela B. Morris: I am Dr. Pamela Morris and I am here today talking about cardiac transplantation with Dr. John Ikonomidis, who is the Surgical Director of Cardiac Transplantation at the Medical University of South Carolina. John, how does an organ donor become an organ donor?
Dr. John S. Ikonomidis: Well, Pam this is obviously a sort of a sensitive topic for many people because it’s usually a rather unfortunate event. For adults, probably the two most common causes are accident such as automobile accidents in which there is severe head trauma or patients that undergo intracranial hemorrhages, bleeding to their head and because the skull is a closed space, bleeding into the head causes basically death of the brain and while all of the organs are functioning ? remaining organs are function, the brain is no longer functioning and this results in a somewhat controversial diagnosis of brain death in which usually one or two neurologist and a neurosurgeon will evaluate the patient who has been admitted to the hospital, stabilized in an intensive care unit on a ventilator, and there are numerous tests that are performed to show that there is no evidence of brain function anymore in the setting of completely preserved organ function. When that diagnosis is made, that is when our Organ Procurement Organization known as LifePoint is called and the ball is set in motion towards perhaps procuring organs from that patient.
Dr. Pamela B. Morris: Let’s say that someone has made that life giving decision to donate an organ, what is the next step in terms of then matching that patient to an appropriate recipient.
Dr. John S. Ikonomidis: The LifePoint Organization will send a representative, it’s usually a trained nurse to the hospital where the patient is usually in an intensive care unit. They do an initial assessment and make sure that patient is stable and then they gather information, which includes the height, the weight, and the blood type of the patient and this information is then crossmatched to their computer database of established recipients, who are in waiting lists and based on blood type, height, and weight, and the acuity of the patient; how sick they are and how badly they need a transplant, the organs are then allotted on a rank basis. So, in other words, patient A who is the sickest would be offer the organ first. At that point one looks at what institution that patient is from and then that institution is contacted to evaluate the donor and see if it’s a suitable match.
Dr. Pamela B. Morris: Is this done by region, or by nation, or by state?
Dr. John S. Ikonomidis: There is a 500 mile radius from the hospital where the patient is located, that is the catchment area. So, all recipients within that radius are considered.
Dr. Pamela B. Morris: And is the match as simple as a blood type?
Dr. John S. Ikonomidis: For cardiac surgery, for transplantation, the answer is yes. In rare circumstances, which usually means the patient has received blood products in the past or for some reason has developed immune tolerance to established factors in blood that a more detailed crossmatch is required through immunologic services that we offer at the Medical University and at that point we look at other things such as so called HLA antigens and there is a whole bank of those that are evaluated. All patients that have a combined transplant such as a heart-kidney, heart-liver received that detailed crossmatch because it’s more important for those organs than just for the heart.Dr. Pamela B. Morris:To be closely matched for those organs.
Dr. John S. Ikonomidis: Yes.
Dr. Pamela B. Morris :Now, we have identified a donor and a good recipient for that organ, what’s the next step?
Dr. John S. Ikonomidis: Next step would be to assemble a team to fly or be transported to the institution where the donor is located to harvest the heart and at the same time the patient, the recipient is called to come into the hospital and they will come into the hospital and receive history and physical examination, chest x-ray, blood work, signed their consent forms for heart transplantation, and will get their, usually their first dose of immunosuppressant before they go to the operating room. From there it becomes a time coordination issue where the patient comes to the operating room and is prepped for surgery at the same time as the heart harvest is coordinated such that there is no time loss between when the heart is harvested, comes to the Medical University and is transplanted. So, what we want to minimize as much as possible, how much the heart is kept out of the body.Dr. Pamela B. Morris:And that window is?
Dr. John S. Ikonomidis: It’s about 6 hours, but we would like to have the heart sown in and perfused with blood within about 3 to 4.
Dr. Pamela B. Morris: How technically challenging is the surgical procedure to place the donated organ into the recipient.
Dr. John S. Ikonomidis: If the patient has not had cardiac surgery before, the operation is relatively straightforward and it results consists of placement of appropriate tube, which we call cannulas around the important blood vessels to allow drainage of blood from the venous side of the patient to go through the heart-lung machine and then we pump back to the patient through their arterial side and once the heart-lung machine is on and supporting the patient’s circulation, we can then excise the heart in a predetermined standard way and then once the donor organ comes, we trim the tissue of the donor organ, so that it fits appropriately and it just a matter then of sowing up the various vascular connections all of which are quite large and relatively straightforward. If the patient has had numerous heart operations in the past such that the area around the heart is all scarred, then it can be quite challenging and once again the challenge there is to coordinate the harvest of the heart with the preparation of the recipient, so that there is no lag in time. So, that proceeds as seamlessly as possible without the heart having to sit on ice for a long period of time because the clock is ticking. As soon as the heart comes out of the donor, the clock starts ticking and there is no question that the shorter the time the heart is out of a body, the better it does.
Dr. Pamela B. Morris: I would imagine that the recovery time from cardiac transplantation is relatively quick in the sense that you have taken an individual who is critically ill and now given them a healthy heart.
Dr. John S. Ikonomidis: Well the recovery time in days is probably about 5 or 6 days longer than standard cardiac surgery for two reasons. The first reason is while the patient gets a completely healthy heart, the rest of the body is not usually healthy; it’s decompensated and it has been decompensated by years of heart failure and its ravages and so the recovery process can be slow for some people, but there are other issues as well. The most important of which is medicine titration, these patients go from being on a fairly significant battery of medicines now to a huge battery of medicines and these consist of very powerful immunosuppressants and they have a variety of side effects and over the first 14 days or so, which is about standard hospital stay for a heart transplant in contrast to the regular heart surgery which is probably 6-7 days or less. An important aspect of it is titration of this immunosuppressant to make sure that the patient is getting adequately immunosuppressed without the side effects that can limit quality of life. So, combination of decompensation from longstanding heart failure and also titration of immunosuppressant medicine and all the teachings and so forth that’s involved results in somewhat longer hospital stay.
Dr. Pamela B. Morris: Do you usually advise cardiac rehabilitation or any training program after transplantation?
Dr. John S. Ikonomidis: Absolutely, and it is also worth saying that these patients once transplanted are very closely followed in Heart Failure Clinic and we are very proactive and what I mean by that is that we have a regular schedule where small fragments of tissue are taken from the inside of the heart through a relatively straightforward procedure and then that tissue is looked at under the microscope to evaluate proactively for any signs of rejection. Any evidence that the immunosuppressants schedule is not succeeding in protecting the heart from being rejected and this proactive schedule is what contributes to excellent results.
Dr. Pamela B. Morris: You know Dr. Ikonomidis, I am very pleased to say that we have one of the premier cardiac transplantation programs in the nation and I am delighted that you could be here today with us to talk about it.
Dr. John S. Ikonomidis: Thank you very much.
Announcer: If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection at (843) 792-1414.