Cardiac Transplantation: Selection of Patients for Surgery

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Guest: Dr. John S. Ikonomidis - Cardiothoracic Surgery

Host: Dr. Pamela B. Morris – Cardiologist

Announcer: Welcome to an MUSC Health Podcast.

Dr. Pamela B. Morris: Hi! I am Dr. Pamela Morris, and I am here today with Dr. John Ikonomidis, Surgical?Director of Cardiac Transplantation at the Medical University of South?Carolina. Dr. John, there have been a lot OF changes in transplantation over the past 20 years.

Dr. John S. Ikonomidis: Certainly have Pamela. The changes have occurred in numerous areas including things like selection of patients, conduct of the operation, how we take care of them afterwards, and all of those who have contributed to improve results.

Dr. Pamela B. Morris: Let’s talk a moment about the best selection of appropriate candidates for this procedure, who are the best types of patients for transplantation?

Dr. John S. Ikonomidis: Patients fall under two broad areas. They are those patients that have heart failure based on end-stage loss of function of the heart and that happens either as a result of coronary artery disease and patients that have had multiple heart attacks in which case the heart largely gets replaced by scar tissue, nonfunctioning tissue and the heart slowly dilates and contributes to failure that cannot be treated with conventional medical therapy with medicines. Other patients have conditions called cardiomyopathies in which there is an intrinsic problem with the heart muscle causing it to fail. There is another subset of patients, which is a little bit less common and those are patients that have coronary artery disease that have reasonable function of the heart, but they have intractable chest pain and their coronary disease so bad that they cannot undergo coronary bypass surgery or other treatment measures to reverse the process and so they are also considered for transplantation.

Dr. Pamela B. Morris: What about certain types of patients who would not be good candidates for this procedure?

Dr. John S. Ikonomidis: So called comorbidities or other conditions, which would render a patient not suitable for transplantation would be first of all advanced stage and by advance stage, we view people in the range of sort of 65 to 70 years of age as being on the cutoff from age criteria for transplants. Historically, patients with severe kidney disease were considered to be not suitable candidates for transplants, but now we offer combined transplants where we could do a heart and a kidney transplant and so we do consider those patients now, but that used to be a contraindication. Advanced other diseases such as bad respiratory disease, bad lung disease, chronic smoker, very, very bad lungs, end-stage diabetic patients that have complications of diabetes like cataracts and nerve damage, and so forth are also not good candidates. Patients who have active infections are not good candidates. Patients with cancer -- fairly recent cancer with uncertainty with regards to whether or not the disease is going to recur are also not appropriate candidates for transplantation simply because we have to put them on immunosuppression afterwards and immunosuppression tends to accelerate in malignant process and so that’s definitely a concern.

Dr. Pamela B. Morris: Now at the Medical University, we have quite an active transplant program here, how many cases have been done at the University?

Dr. John S. Ikonomidis: We have over 300 heart transplants since the program started approximately 25 years ago.

Dr. Pamela B. Morris: And the longest living transplant patient now here at MUSC?Dr. John S. Ikonomidis:I believe it is 18 years.

Dr. Pamela B. Morris: Those are wonderful statistics. Now, let’s say that we have a patient who is referred to you for evaluation or consideration of transplantation, what would be the process they would go through to be evaluated?

Dr. John S. Ikonomidis: The patient is usually referred by an outside physician to our Heart Failure Team and at the present time, our Heart Failure Team physicians consist of Dr. Adrian B. Van Bakel and also Dr. Arthur J. Crumbley III; the patient will then undergo a very intense evaluation for fitness for transplantation, which is a multidisciplinary evaluation includes not just a cardiology evaluation, but also evaluation by social worker looking at things like economic status and social support, which are extremely important in transplant. The dietitian also sees the patient and evaluates the patient’s nutritional needs, the patient’s body mass index, which is very important in terms of how they will do with transplant and how they will do after transplant. Where necessary, we involve other team members such as Pulmonology, Nephrology, Psychiatry, and they also will see one of the heart transplant surgeons, which should be either myself or Dr. J. Matthew Toole. When all of that information is obtained and all of the tests obtained, which will include a detailed assessment of the heart, vascular system, renal system, pulmonary system, and all of the blood work. All of that is compiled on to about three sheets of paper and we have a weekly meeting in which we discuss all patients that have completed workups and decide whether or not they are candidates for listing for transplant.

Dr. Pamela B. Morris: What are the wait times now for candidates, who are considered good selection?

Dr. John S. Ikonomidis: Our waiting list now is waiting list time that is as probably in the range three months or so and it’s very dependent on the acuity of the patient and so there is a stratification system in which we decide how sick the patient is and depending on how sick they are and whether or not they need to be in hospital, whether or not they need to be on numerous medicines to keep their heart beating, whether or not they need mechanical support to keep their circulation going, all of those things figured into the equation, and that decides where you are in the queue. For example, if a patient is considered status 1 or status 1A, which would mean that they are in the hospital on mechanical support are waiting list times of probably about two to three weeks. For patients who are considered status 2, which means that they are probably at home, many of them have a little fanny pack that they carry around which is hooked up to an intravenous that has a medicine running through it, those patients can wait several months before a suitable heart becomes available.

Dr. Pamela B. Morris: I understand there is an advantage to living in the state of South Carolina and that we have very good rates of organ donation, is that correct?

Dr. John S. Ikonomidis: Some of the lowest in the nation, no question about it and some of the lowest waiting times.

Dr. Pamela B. Morris: Well, Dr. Ikonomidis thank you so much for being here with us this afternoon.

Dr. John S. Ikonomidis: My distinct pleasure.

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.

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