Cardiac surgeon: We are revolutionising heart transplants from donors
Transplantology is being completely transformed. We perform heart transplants together with transplants other organs, kidneys or liver, we repair hearts from donors to take advantage of those in a somewhat worse condition, soon we will transport a still "beating heart" - the President of the Polish Society of Cardiothoracic Surgeons, Prof. Mariusz Kuśmierczyk told PAP..
Since 2017, surgeons at the Institute of Cardiology in Warsaw perform both simultaneous and sequential transplantation procedures. The former consists in replacing both organs (heart and kidney or heart and liver) during one surgery. There is also the second variant: first the heart is transplanted, and then in another the kidney, if it turns out that it can not be regenerated anymore.
"Patients with primary renal failure have indications for the simultaneous heart and kidney transplantation. In other cases, we can first use an artificial kidney and then transplant the kidney in the second procedure, if the organ does not regenerate. Our experience shows that in the majority of cases, patients` own kidneys start functioning after some time" - explains Prof. Mariusz Kuśmierczyk, head of Department of Cardiac Surgery and Transplantology of the Institute of Cardiology in Warsaw.
Formerly, renal failure was a contraindication to heart transplantation and many patients were disqualified from this procedure for this reason. However, the possibilities of transplantology and surgeons are increasing, while technical progress changes the transplantation strategy.
"It started with delaying the kidney transplant in one of the patients; we used ECMO (Extracorporeal Membrane Oxygenation) instead. We implanted the kidney only on the seventh day, when the heart muscle had already recovered. Thanks to this, it turned out that it was possible to do a non-synchronous transplant, a sequential one" - the specialist describes.
Sometimes the second transplant is unnecessary. "Some patients, previously disqualified, had renal failure not because of kidney disease, but because of low cardiac output. If we perform a heart transplant and improve their cardiac output, the condition of their kidneys can improve. In a few of these patients we only performed heart transplantation, and the kidney function improved" - explains Prof. Kuśmierczyk.
Due to the lack of donors, to rescue patients transplantologists now more often use hearts in a slightly worse condition, which used to be disqualified until recently. "We use ever-worse hearts in transplants because we have to. If we have a twenty years old patient with Polish artificial chambers and we know that they are safe for three months, then if we do not risk it with a worse heart, the patient will die because of neurological complications. We have the necessary experience, we know how to do it and we are prepared to it" - assures the President of the Polish Society of Cardiothoracic Surgeons.
Where do the worse hearts come from? "In the past, patients after transport accidents were not considered as donors, as well as those after resuscitation. Similarly, patients who had been in the intensive care unit for over 10 days. Now we have to consider each heart. We recently transplanted the heart from a traffic accident donor that suffered a lung injury. We had to take the risk because the patient was on circulatory support and might have not survived, and the transplanted heart turned out to be good".
Older donors with coronary heart disease are increasingly used. "Of course, it`s best when the donors have normal coronary vessels in the heart muscle. But even if they are abnormal, but the heart contracts properly, we perform bypass during surgery. If there is a valve defect, we can replace or fix it. We have to do it sometimes due to the lack of donors. We have seriously ill patients who need a new heart or they will die" - emphasises Prof. Kuśmierczyk.
A new method allowing to increase the scope and effectiveness of transplants is the transport of a still "beating heart". It is used in some countries of Western Europe, and it may become available in Poland in 2019.
"If the heart contracts properly during collection, that does not mean that after stopping, transporting and then transplantation it will continue to behave the same way, because for some time it has been deprived of metabolites, substrates necessary for normal functioning. Therefore, we are making efforts to obtain a device for transporting heart muscle, called TransMedics"- Prof. Kuśmierczyk says.
"This device" - the expert explains - "allows to collect the heart from the donor and it connect to the device so that it can continue to beat, and then provide it with substrates, nutrients to improve metabolism, because donors are often malnourished. This device even allows to check if the heart is suitable for a transplant. It also increases the available transport time of the harvested organ from four to twelve hours. In over 90 percent cases we can be sure that the heart is good".
The specialist hopes that such equipment will be available in Poland later this year. But it is very expensive, as are the fluids it uses. The cost of this fluid is PLN 200,000, while the National Health Fund only reimburses PLN 137 thousand for heart transplantation. This amount would not even cover the costs of the organ transport. "But the Ministry of Health promises that such a machine will be purchased for Poland and we hope that one of the transplantation foundations will buy fluids for the transport of some hearts for transplantation in Poland" - he emphasizes.
According to the expert, a patient who is waiting for a heart transplant also requires expensive hospital treatment, has an implanted pump to support blood circulation, receives expensive antibiotics and other medications. The cost of treatment for such a patient is also high. "In some cases, it makes sense to use such a device to transport a beating heart" - argues the President of the Polish Society of Cardiothoracic Surgeons.
PAP - Science in Poland, Zbigniew Wojtasiński
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