Running After a Scarce Commodity: Is it Time to Think Outside the Box?

Nov 3, 2015 | Nisha A. Gilotra, MD

It’s 3:30 in the morning. The crew slowly gathers on the hospital lobby couches, sleepy-eyed and clad in matching cobalt blue pajamas. It’s too early even for coffee, much less conversation. A black SUV pulls up and everyone knows to stand. I follow, eager and anxious – eager for my patient who has been living in the hospital for the last three months, yet anxious about the upcoming experience.

We are going on a donor run; we are going to get a new heart for my patient.

Upon arrival, we are directed toward the general operating rooms. Role call: there’s the liver/pancreas team from across town, the lung team from two hours north, the kidney team and us. We swap our cobalt blue for midnight blue, don masks and bouffant caps. The patient is rolled into the operating room. We review blood type, age, height, weight, social history, family history, labs, the echo, the angiogram and the cause of death. Suddenly the surrealistic nature of the whole experience sets in. I forget about my patient. All I can think about is…“This is a 23-year-old firefighter found at a friend’s home.”

The surgeons start prepping the patient. I scrub in as well, paranoid of breaking the sterile field, having flashbacks of scrub techs scolding me in medical school. There is a moment of silence. And then it’s go time.

I peer over the shoulders of my cardiothoracic surgical colleagues as they meticulously dissect out the heart, the great vessels, our share of the inferior vena cava (IVC). I gingerly step forward and feel the beating heart that will go into my patient. The smooth walls contract strongly; the vessels are soft and free of plaque. The liver team is working below the diaphragm, the pulmonary team is finishing up their bronchoscopy – everyone plays nice in the sandbox, trying to make the most of this life that has ended too quickly but which can give five others a second chance.

What could be better?

With the growing heart failure epidemic, there is a supply and demand mismatch for donor hearts. In 2012, in the U.S., only 36 percent of patients listed were transplanted, with a median wait time of 78 days for those patients listed as United Network for Organ Sharing status 1A. As a result of long wait times, the field of mechanical circulatory support (MCS) has burgeoned, providing not only a bridge to transplantation, but also destination therapy. However, current MCS options are fraught with their own limitations: only 30 percent of patients in the INTERMACS Registry of current generation continuous flow devices are free of adverse events at one-year post-implant. The next generation of ventricular assist devices will incorporate strategies to minimize the currently common complications of bleeding, thrombosis and infection while also creating devices that are more miniaturized, implantable and durable. While these new devices are yet to be studied in clinical trials, there is also a parallel ongoing interest in development of a total artificial heart.

Recognizing the need for further specialization in heart failure, the American Council for Graduate Medical Education initiated formal certification for advanced heart failure and transplantation fellowship beginning July 2014. As we embark on this additional training, my colleagues and I will be challenged to think outside the box in order to develop durable alternatives to heart transplantation for our patients.

But for now, my patient is the lucky one in three.

When everyone is ready, it’s time for cardioplegia. The heart comes out first. The aorta, the pulmonary artery, the IVC – snip, snip, snip. Our surgeon inspects the valves, the walls, the vessels. It’s a good one. The lifeless organ is packed up – now simply a heart in a box.

The cardio thoracic surgeon fellow grips onto it tight as we rush through the emergency room to the ambulance bay and pile on to our ride home. Despite the flashing lights and blaring sirens, we all sigh in relief. In no time, we are back. We put the box on a wheelchair and wheel our precious cargo through the hallways to the operating room as if it is a patient. In the operating room, my patient is intubated, on bypass, with his dilated and exhausted heart ready to come out and be replaced with the miracle inside the box.

The surgeons work carefully and quickly, stitching the new heart in place as if putting together puzzle pieces. Hours later, the foreign organ starts beating again, coming back to life as it gives my patient his life back, showing no signs that it had just lain limp and cold inside a box.

Nothing could be better.

By Nisha A. Gilotra, MD, a fellow in training at Johns Hopkins School of Medicine.