VUMC Now Leads World in Heart Transplantation
Vanderbilt University Medical Center's heart transplant program continues to set records, performing more operations in 2020 than any other center in the world -- 124 adult hearts, 23 pediatric hearts and VUMC's first heart-lung transplant since 2006.
Ashish Shah, MD, professor and chair of Cardiac Surgery, credits the program's success to innovation and willingness to push limits. In 2016, VUMC became the first center in the world to use Hepatitis C-positive hearts, which now constitute approximately one-third of their 90-plus donor hearts a year.
Now, they've embarked on another discovery expected to revolutionize heart transplant. In February 2020, the adult team used a novel organ preservation technique to transplant a heart from a donor who died from cardiac death (as opposed to brain death) for the first time in Tennessee. Hearts from these donors (often referred to as DCD) are anticipated to expand the donor pool by up to 30-40 percent.
Learning What's Possible
"In the last year, we've taken the lead on using hearts from donors whose hearts have stopped beating," said Shah. "Once they're declared dead we reanimate those hearts and use them."
Shah said it's biologically plausible to rescue a heart after 30 minutes without blood supply, and researchers are still learning how far they can push the envelope. "We've got multiple labs looking at rescuing whole organs and asking, for example, what are the molecular mechanisms that make a heart gone for good? For how long do we have where we can actually rescue it? Reconditioning and resuscitation are more than just CPR."
While Shah recognizes transplantation advances won't solve the public health epidemic of heart failure, he believes this promising window into organ resuscitation will be a huge win for heart patients. "Yes, we save lives right now, but we can save 10 or 100 times as many by what we're learning in doing this," he said. "Right now we resuscitate on pumps and circuits and use preservative solutions, which is nothing new but rather using old ideas in a new way."
The next step is novel therapeutics - combining drugs with novel techniques to better deliver potentially beneficial medications. "The circuits we have that allow us to keep hearts or lungs or livers profused for a long time also create an opportunity to take an organ, put it on a circuit, and start recirculating something very therapeutic or reparative for that organ," Shah said. "It's what we'll be looking at for years to come."
Improving Outcomes
Shah believes a program of VUMC's caliber also has the responsibility to improve outcomes for heart transplant patients post-surgery, meaning improved anti-rejection drugs and longer life expectancies. Today's adult heart transplant patient has a 90-plus percent chance of surviving one year, with a 70 percent chance of living 10 to 20 years. While those odds are promising for older adults, they're not good enough for younger patients, said Shah.
VUMC's ability to operate on immunologically complex patients and those in need of multivisceral transplants (more than one organ) means the center receives cases from throughout the U.S. In September 2020, the team performed the first dual heart-lung transplantation of a COVID-19 patient in the world.
The Vanderbilt Transplant Center is part of an elite group of heart transplant programs that have performed more than 1,000 transplants. The center's adult heart transplant program began in 1985, followed by the opening of the pediatric program in 1987. "We do in a month or two, what most programs do in a year, so we have a unique vision for this field," Shah said. "Transplantation remains for me exciting and unbelievably fulfilling."
VUMC Study: Arthritis Drug Impact on Cardiac Complication
A drug typically prescribed for rheumatoid arthritis may also be effective in treating a rare, but potentially deadly, heart complication some cancer patients experience after taking immunotherapies, according to a study published in Cancer Discovery and co-led by investigators at Vanderbilt University Medical Center. The researchers demonstrated that the drug abatacept reduced the severity of myocarditis in a genetic mouse model study - responses that have also been observed in three human patients who were given the same drug after corticosteroid treatments failed to reduce heart muscle inflammation. The mouse model revealed the mechanisms for how the drug works. The research received support from Cancer Prevention and Research in Texas, the National Cancer Institute and the National Institutes of Health.
Myocarditis in Athletes Recovered From COVID-19
In a letter published in the December issue of the American Heart Association's medical journal Circulation, a group of researchers at Vanderbilt University Medical Center (VUMC) dispute the most recent findings of the incidence of myocarditis in athletes with a history of COVID-19.
The Vanderbilt study, COVID-19 Myocardial Pathology Evaluation in AthleTEs with Cardiac Magnetic Resonance (COMPETE CMR), found a much lower degree of myocarditis in athletes than what was previously reported in other studies. COMPETE CMR is the first study that the group is aware of to use an appropriate athletic control group to assess athletes after COVID-19. "The differences in the findings are extremely important. The whole world paused after seeing the alarmingly high rates of myocardial inflammation and edema initially published," said Dan Clark, MD, MPH, first author of the report, instructor of Cardiovascular Medicine, and an adult congenital heart disease fellow.
The study evaluated 59 Vanderbilt University athletes and compared them to a healthy control group, as well as a group of 60 athletic controls. "The degree of myocarditis found by cardiac MRI in Vanderbilt athletes was only 3 percent, which is really good news," said Clark. "Since our first evaluation, we have screened almost double that number, and the same findings are holding true." However, he continued, there was also a piece of disappointing news. "None of the other screening tests helped us to identify the athletes with myocarditis," he said.
"Initially, we hoped that the standard screening tests for athletes would be definitive because we wanted something that was widely available and quick," said Clark. "We hoped that a cardiac MRI would only be used if absolutely necessary. However, their blood work, clinical exams, EKG, echocardiograms and other cardiovascular screening were normal. All of those traditional screening results would have led us to agree to allow some athletes to participate in a sporting event or practice, while the MRI told a different story."
Myocarditis is a disorder of abnormal inflammation of the heart muscle and is a leading cause of sudden cardiac death among athletes. The findings highlight the importance of considering cardiac MRI in addition to traditional screening measures to detect myocarditis.
It is well documented that COVID-19 may affect the heart. "Our data also demonstrated more scarring in healthy heart muscle than we would have thought," Clark said.
Those findings led the group to dig deeper and compare a healthy, athletic population with normal cardiac MRI values against those who had recovered from COVID. The athletic control group without COVID showed 24 percent (1 in 4) scarring in the heart muscle while the COVID athlete group had a 27 percent (1 in 4) scarring ratio. According to Clark, athletes commonly have a small area of benign scar due to athletic remodeling. This scarring related to athletic changes was evident in both athletic groups studied. "This particular piece of information is very important to share - myocarditis after COVID-19 tends to be in a similar spot," he said. "Without the knowledge that this area of scarring is common in healthy athletes, clinicians could attribute the scarring to consequences from COVID-19. Those assumptions might unnecessarily restrict some athletes from competition."
Clark says his team's findings suggest that the addition of cardiac MRI as an assessment tool for athletes may be very helpful in determining safe return-to-play guidelines. The paper was published in the February edition of Circulation.
TriStar Skyline Earns Elite Cardiac Accreditation
TriStar Skyline Medical Center recently earned the Get with the Guidelines® Stroke Gold Plus with Honor Roll Elite Quality Achievement Award, presented by the American Heart Association and American Stroke Association. They earned the award by meeting specific quality achievement measures for the diagnosis and treatment of stroke patients at a set level for a designated period.
Measures include evaluation of the proper use of medication and other stroke treatments aligned with the most up-to-date, evidence-based guidelines with the goal of speeding recovery and reducing death and disability for stroke patients. Before discharge, patients should also receive education on managing their health, get a follow-up visit scheduled, and well as other care transition interventions.
The HCA Healthcare TriStar Health hospitals are nationally recognized for quality outcomes in cardiovascular services, with cardiac surgeons performing complex surgeries with success rates above the national average. Using the latest surgical techniques, equipment and devices, TriStar Health's cardiovascular specialists continue to explore the latest in surgical procedures. They were the first in Middle Tennessee to offer minimally invasive and beating heart surgery at the TriStar Centennial Heart and Vascular Center, which has advanced to include the establishment of a VAD (Ventricular Assist Device) and ECMO (Extracorporeal Membrane Oxygenation) program. The Heart and Vascular Center was also the first hospital in Nashville to join the National Cardiogenic Shock Network and the first in Tennessee to perform a transcatheter tricuspid heart valve repair.
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