In 1983, when Orlando Felice was 28 years old, a summer virus caused his heart to fail. For three months, the Baltimore accountant lay teetering on the edge of death until surgeons found him a new heart, from a 16-year-old girl who died in a motorcycle accident. Felice’s operation was the third heart transplant performed at Johns Hopkins Hospital.
Since then, side effects from his anti-rejection drugs have caused Felice to undergo a kidney transplant and numerous skin cancer operations. On the most important score, however, Felice has beaten the odds: He’s had 30 years with a stranger’s heart beating in his chest, making him one of the longest-lived heart transplant patients.
Contrast Felice’s story with that of 63-year-old Chris Einhorn. Three decades after Felice’s transplant, Einhorn was out drinking coffee at a Starbucks in Rockville, Md., when Johns Hopkins called to say her new heart was ready for her. That night she underwent surgery, and she left the hospital nine days later. Soon she was on her feet and playing with her grandson.
Felice and Einhorn are both success stories. But Einhorn was in relatively good health when she received her transplant, because for the previous 17 months her native heart had been getting a boost from a left ventricular assist device, or LVAD — a machine that has transformed prospects for patients with serious congestive heart failure. Increasingly, such devices sustain people, including most notably former Vice President Dick Cheney, who probably would have died before they could receive a transplant. And the support the devices provide often allows patients to recover faster after they do get a new heart. Felice, without use of an LVAD, had to spend a month in the hospital after his transplant.
As many as 500,000 people suffer heart failure in the United States each year.
Yet the number of hearts available for transplant
plateaued at around 2,500 in 1995. Medicine is getting better at transplanting hearts and the need for them is growing larger, but the number of organs available is static. So devices are filling some of that gap.
“The whole field is being dominated today and tomorrow by LVAD and artificial hearts, and is becoming a problem of engineering, miniaturization and, believe it or not, batteries,” said cardiologist Michael Hess, who directs the Pauley Heart Center’s heart transplantation program — one of the world’s oldest — at the Medical College of Virginia in Richmond. “The next big breakthrough is going to come out of [engineering schools such as] MIT and not medicine.”
He added: “We can now take someone near death’s door, put in a mechanical device, rehabilitate them over several months and improve their state of health, so that when they do have the transplant, they are in much better shape.”
First transplant in 1967
It used to be that transplantation was the only solution when a heart was beyond repair.
The first transplant was done in 1967 by South African surgeon Christiaan Barnard, who learned much of his technique at the Medical College of Virginia.
Transplantation was rare — and post-transplant life expectancy was measured in months, not years — until the early 1980s, when the FDA approved cyclosporin, an immunosuppressant less damaging to the body than anti-rejection drugs used up to that point. In 1994, the FDA approved the first ventricular assist device, and in 2008 the agency approved the HeartMate II, the current leader in the LVAD market, as a bridge to keep patients healthy until transplantation. Another popular LVAD is made by Heartware International.
No measurable heartbeat
The 10-ounce LVAD contains a finger-size pump that pushes blood through the heart. LVADs drive a flow of blood through the heart continuously rather than in pulses. As a result, the patient usually does not have a measurable heartbeat, because the device is doing most of the pumping that the heart once did. “At the hospital they liked to call us the zombies,” Einhorn said.
Use of these devices has expanded quickly. According to heart surgeons at three Washington area hospitals, more than half of the patients who received transplants at heart centers in this area last year had previously gotten an LVAD. In 2012, about 2,000 LVADS implantations were done — a tenfold increase over 2006 — and doctors said they expect the numbers to continue to sharply increase. A 2011 study suggested that 40,000 to 200,000 patients each year would benefit from either an LVAD or a heart transplant .
Ventricular assist devices — in addition to LVADs, there are units that support the right ventricle, or both sides of the heart — allow doctors to give transplants to older, sicker patients. When Felice got his new heart, 50 was the absolute upper age limit for transplant recipients, said his cardiologist Edward Kasper. Now, the absolute limit is 75. Hearts are a scarce resource, and doctors are reluctant to put them into people who aren’t likely to live very long. Cheney, who had suffered five heart attacks and undergone many surgeries, was one of the oldest patients at Virginia’s Inova Fairfax Hospital ever to receive a new heart.
Patients in search of a new heart face an uncomfortable reality: Most hearts become available when young people die of head trauma, usually through homicide, suicide or car wreck. Medicine is getting better at keeping such patients alive, which decreases the number of hearts available for transplant.
Given this fact, the future points to a device industry making gadgets that guarantee longer lives without transplant. In 2012, 40 percent of LVAD recipients got their devices as “destination therapy,” meaning they are permanent implants. Already, many LVAD recipients don’t expect ever to receive a heart transplant.
Some recipients of the HeartMate II have lived with it for eight years.
The device theoretically could last in a patient for at least 17 years, according to Gary Burbach, chief executive of Thoratec, the Pleasanton, Calif., company that makes it.