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When you hear about a heart transplant, the image that most likely comes to mind is that of surgeons and nurses surrounding a body on life support, performing a gruelling operation. Family members pace in the waiting room until the head surgeon appears at the door, hours later, with a tentative smile. Success! The prognosis looks good, and while there's a chance of complications as the patient recovers, they'll be fine once they're released from the hospital.
Heart transplants are not, in fact, the way the movies make them appear. The surgery itself is just one facet of the incredible lifelong relationship each heart transplant patient has with the extensive group of surgeons, clinicians, nurses and other staff at UHN's Ajmera Transplant Centre.
Everyone works to optimize the patient's journey – whether it's creating technology to increase the number of viable donor hearts, developing less invasive ways to monitor for rejection post-transplant or other life-saving measures.
"It takes a village to care for one heart transplant recipient," says Stella Kozuszko, a nurse practitioner in the Heart Transplant Program at the Ajmera Transplant Centre, who is also part of the Peter Munk Cardiac Centre at UHN. She's been with the program for 21 years.
"We have amazing cardiologists, heart failure specialists, social workers, pharmacists, intensive care unit (ICU) staff, transplant unit staff, clinic staff – they're all responsible for ensuring every heart transplant recipient has a safe journey through their life," she says.
With patients from the start
When patients first come to the Ajmera Transplant Centre – after they've already been diagnosed with heart disease – they'll meet with a cardiologist, who could be Dr. Michael McDonald, Medical Director of the Heart Transplant Program at the Centre and the Martha Rogers Chair in Heart Failure Training and Education, who is also part of the Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research at UHN.
He and his colleagues make a determination about whether someone is sick enough to require a transplant. If they do need one, the team works with that person to keep them stable while they wait for a heart to become available.
When a heart is matched, the patient gets whisked into the operating room, where some of that movie-like magic takes place, though the process is more complicated and painstaking than many people think. A typical surgery takes about four hours, but complicated ones – the kinds of rare and difficult cases the Ajmera Transplant Centre often tackles – can take much longer.
Most surgeries, though, are similar. After the patient is put to sleep, a cut in the chest is made and the breastbone is separated in half so physicians can get to the heart. They then connect the person to a heart-lung bypass machine, which supplies the body with blood and oxygen while the heart and lungs are stopped.
Once the blood has diverted into the bypass machine, the diseased heart is removed. The surgeon then places the new heart into the body and carefully connects all the blood vessels, ensuring there are no leaks. When the heart is fully connected, the blood that's circulating inside the bypass machine will go back into the heart. The tubes to the machine are then taken out and the surgeon shocks the heart to get it beating again.
As stressful and complicated as the operation may be, it's the post-surgery process that's the most critical aspect of the patient's transplant journey. In the following days, weeks and even months, Dr. McDonald and his team must make sure the heart takes to the patient's body.
As soon as the chest is closed, the transplant patient is wheeled back into the cardiovascular ICU, where their heart function is monitored closely by his team. Dr. McDonald also works with ICU staff to handle the patient's medications, get them through the initial post-operative period and manage their immunosuppression.
Once vital signs and heart function are stable, and patients can breathe without assistance, they're transferred to the Ajmera Transplant Centre's inpatient unit, where they continue to recover and the transplant team prepares them to go home. This involves medication classes, transplant education, drug insurance lessons, regular meetings with social workers, physiotherapy to build their strength and endurance, and occupational therapy to assess whether a patient is physically ready to go home.
As this is happening, Stella is there to ensure heart transplant recipients recover from surgery safely. She monitors them for signs of rejection from the time they're in the ICU and well beyond their release from the hospital. This involves assisting in regular heart biopsies, as well as checking for potential infections or other complications with immunosuppressive medications.
The village approach
The first year following a transplant "is a very intensive process for patients to go through, and we're often reminding them: it's a marathon, not a sprint," Dr. McDonald explains.
Many experience side effects from the medications they're taking, which include lowered kidney function, elevations in blood pressure, diabetes and a negative impact on bone health. The key is finding the balance between having the immune system ramp down – so the recipient's body accepts the new heart – but not be so suppressed that opportunistic infections and cancers creep in.
That's why the "village" approach, as Stella calls it, is so important, says Dr. McDonald.
Once that first year of appointments, procedures, medication adjustments and rehabilitation is done, life starts to become a bit more normal. "We then continue to follow them, along with their primary care providers and other specialists, for life," he says.
Solving complex questions
One of the more challenging parts of post-transplant care for patients is the need for regular heart biopsies, in which physicians remove a piece of heart tissue, which is then used to check for any signs of rejection.
The biopsies are performed weekly during the first month post-transplant, biweekly for the next month and then monthly for the next year or more. While the biopsies are generally well tolerated by patients, they are invasive and can cause damage to particularly delicate heart tissue.
Fortunately, the Ajmera Transplant Centre is working on a revolutionary new alternative to those heart biopsies, something called a cell-free DNA test.
This blood test, referred to colloquially as a "liquid biopsy," can identify two different forms of rejection that would require further tests: cellular (in which the body's immune cells attack the cells in the new heart) and antibody-mediated (in which antibodies damage the coronary arteries). The best part is that the blood draws can take place at any clinic, reducing the number of hospital visits needed.
Not every heart transplant hopeful goes through this comprehensive process, because there aren't enough donor hearts available. In 2020 alone, 157 Canadians were waiting to get a heart transplant.
If Dr. Mitesh Badiwala, Surgical Director of the Heart Transplant Program at the Ajmera Transplant Centre, who is also part of the Peter Munk Cardiac Centre and Sprott Department of Surgery at UHN, had it his way, no one would be left waiting for a new heart.
He and a team of engineers are creating a new machine – the Ex Vivo Heart Perfusion System – based on a lung system pioneered at UHN, which they hope will one day allow surgeons to test a heart's viability before transplant outside one's body.
Once the technology is fully developed, a heart that's brought to UHN would be removed from cold storage and put inside the device. Physicians would then clean the damaged organ by pumping it full of infection-fighting drugs or operate to get it working like new.
"We want to put a heart on our device and make it work for an extended period of time," Dr. Badiwala explains.
"We can measure function, but also try to create a platform for us to repair hearts or modify them so that they work better."
It's clear that much more goes into a heart transplant than the operation. Whether it's pre-operative care, post-surgical monitoring or the procedure itself, every member of the Centre's team is working together to help patients recover and lead a full life.
"I always tell recipients the sky's the limit," Stella says with a smile.
"Tell me what you want to do and we will help you do it."