Healing Hearts Without A Transplant

FRESNO, Calif.

Mornings spent together for Barbara and Walter Harsche are truly a gift. Three years ago, Walter was diagnosed with congestive heart failure and was told he needed a heart transplant.

"The thought of losing him was just horrible for me, really horrible," Barbara told Ivanhoe.

To support him when his body was in shock from heart failure, Walter's doctor implanted a pump known as the LVAD—a left ventricular assist device.

"I was all set to go if the phone call came," Walter told Ivanhoe.

But in the midst of waiting for a new heart, his own heart began to get stronger.

So Walter enrolled in a first-of-its-kind trial at University of Pennsylvania testing the LVAD as a bridge to recovery—a way to heal the heart so it can beat once again on its own.

"The patient is walking around doing what they want to," Dr. Eduardo Rame, Director of Mechanical Circulatory Support, Perelman School of Medicine, University of Pennsylvania, told Ivanhoe.

Patients' enlarged hearts begin to shrink on the device and slowly begin to heal.

Studies in Europe show after explant most patients are free from heart failure for more than two years.

"We're not talking about life with a heart on crutches. We're talking about a life lived well," Dr. Rame said.

Walter was on the device seven months. Now, two years later his heart, like his marriage, is going strong.

Dr. Rame says the LVAD is used in most patients for between six and nine months to strengthen the heart and then patients are slowly weaned off the device until explant.

Using the LVAD as a bridge to recovery is for the 50 percent of heart failure patients whose heart failure is not related to a heart attack or severe coronary artery disease.


BACKGROUND: Heart failure, despite its name, is not when the heart stops beating all together. Rather it means your heart has stopped pumping enough blood to adequately supply your body. The heart's inability to provide the body with sufficient blood causes it to expand and grow larger in order to hold more blood. Eventually this will wear out the heart, making it even less efficient. Heart failure also causes blood to congest in other parts of the body, like the lungs and vessels. It can also cause other tissue to hold onto fluid. Often this will be in the legs, abdomen, or liver. This "backing up" is why heart failure is often called congestive heart failure. (Source: http://www.scai.org/SecondsCount/Disease/Default.aspx?gclid= CKf394Pho7wCFTJp7AodkhsAzQ)

CAUSES: Many conditions can lead to heart failure, including the following:

Coronary Artery Disease: When plaque builds up in the arteries, less blood can reach the heart, causing it to work harder. Heart attack: heart attacks can essentially kill parts of the heart muscle which were starved of oxygen, making the heart work more to compensate for the lost muscle. Severe lung disease: if the lung's ability to provide enough oxygen to the body is impaired, the heart has to compensate by pumping more blood. (Source: http://www.heart.org/HEARTORG/Conditions/HeartFailure/UnderstandYourRiskforHeartFailure/Understand-Your-Risk-for-Heart-Failure_UCM_002046_Article.jsp

NEW TECHNOLOGY: Although they have been around for years, doctors at the University of Pennsylvania are now using left ventricular assist devices (LVAD) in a different way, as a bridge-to-recovery following heart failure or other cardiovascular conditions. As the heart enlarges in order to compensate for injury, the LVAD assists with its blood pumping duties, taking some of the stress off of the heart. The heart slowly regains its strength, and the LVAD system is slowly dialed back as the heart returns to normal functioning, which usually takes between six and nine months. Already in use in Europe, the LVAD bridge-to-recovery has shown 90 percent of patients had no recurrence of their heart failure after two years. (Source: http://news.pennmedicine.org/inside/2013/11/rest-recovery-reconditioning.html)


Dr. Eduardo Rame, Director of Mechanical Circulatory Support, Perelman School of Medicine, University of Pennsylvania, talks about a new way to heal hearts without a transplant.

Can you talk a little bit about congestive heart failure and the size of a problem it is in the United States?

Dr. Rame: So chronic congestive heart failure is a condition that has to be defined in terms of progression. That's one of the first components you have to understand about it. So someone that has a diagnosis of chronic heart failure has a progressive syndrome. That's why when they become symptomatic they start having breathlessness or an inability to do things like walk around. Even a slight change like 'I can't run the marathons I used to' or 'I can't run the 5K's I used to,' could begin to herald, in some patients, signs indicative of the heart not doing its work for the body. That's what heart failure is. In terms of the magnitude of the problem, it's big. There are a lot of risk factors in the population which can sometimes lead to a heart failing. We estimate half of one million patients have more advanced heart failure. That means that no matter what we do with the medicines, or make adjustments, or any improvement, heart function already has been maximized. The second component is that at a certain point the body is not doing well. It's not just focusing on the heart function that's important; it's focusing on the body's decline with worsening heart function that's important. And that's what a lot of us that do Stage D or advanced heart failure have to be more concerned about because there is an interplay between body function and heart function that gets worse, and worse, and worse, then somebody can't survive beyond a certain point. And that's the very advanced stage.

And that's where somebody might be considered for an LVAD?

Dr. Rame: That's exactly right.

Before we knew that this could actually help to rebuild the heart can you talk about what this was used for as a bridge to recovery?

Dr. Rame: Absolutely. So the initial intent was to design pumps that would allow patients to recover after bypass surgery. It was their bridge to recovery, so that their heart would get better in a short period of time and then while the heart is getting better the body is getting good blood flow. That's what these pumps were for. But from this came a mandate to go ahead and say 'could we do more? Could we support the body while the heart's resting longer?' And you had a wonderful ability in some patients to say 'well you're too sick for transplant, now let me consider an assist device for you,' so we could get you better for heart transplantation. That was sort of the interplay. And so that was a bridge to transplant and that's the intent there and that's how this field grew. As the technology evolved and things got really better they sent patients home. The first patient to go home with the left ventricular assist device (LVAD) and truly stayed home was 1991-1992, that period. So it took a long time it took twenty, thirty years to get someone home an LVAD. So if you fast forward now about twenty years now the expectation is for someone to go home with an LVAD, we don't keep them here [at the hospital].

At what point did you realize that this was more than just a bridge but it was actually helping the heart to recover enough that you wouldn't even need the transplant?

Dr. Rame: So great clinicians and pioneers in this era made the observation the heart was shrinking in size. When the heart is dilated, which is part of another component of chronic heart failure, the heart enlarges as an adaptation to failure. And the enlargement allows you to squeeze more blood out with function that is not as good. If you could imagine if you blow up a balloon you have more volume so you can squeeze more blood out even though you can't eject as much. So that's the adaptation. But as a heart enlarges it loses mechanical efficiency, so when it shrinks it gets back its efficiency. So the question was: what's going on here? Is it just a change in the heart structure that is a result of good remodeling or bad remodeling? As it turns out, there were components of both but a majority was good remodeling, meaning the heart function was coming back with the heart shrinking.

So this isn't for those that have had a heart attack?

Dr. Rame: That's exactly right.

It's for the forty percent of patients that fall in to those other categories?

Dr. Rame: Forty to fifty depending on the population, you're exactly right. In chronic heart failure you have to make an immediate distinction: is this due to chronic coronary disease potentially with the threat of heart attack or not, Ischemic chronic coronary disease or not. And the reason that distinction is so important is because if there is coronary disease you may benefit from having your coronary disease addressed fully and the heart can get better.

So what do we know right now in terms of how long someone can possibly live with a heart that's been repaired by the LVAD?

Dr.Rame: We know from series in Berlin and in Harefield, England, where two pioneers felt very strongly that a young person who could otherwise have this heart repair approach with the VAD should be looked at first. Now part of their interest was because in England there aren't many heart transplants like in the U.S. So there was a need to really believe this was the end stage. So when I visited England, I think that was 2005 or so, 2007 maybe, we had seen patients that had been out years without a need to support their body with diuretics, with the water pills from chronic heart failure and these patients looked well. Was their heart totally normal? A lot of them looked like a heart that was normal, some of them did not. But they were sustained with good medicines and doing very well. We have patients that are out three years, four years; we have one patient that's out five years.

It sounds like a nuisance to have to wear, but is there a certain amount of time that you can wear it or what's the optimal time that someone should wear it?

Dr. Rame: We believe that each individual patient has a time course for this observation of reverse remodeling. Now, it's not years, thank God, it's months. So it could be three months, six months, nine months, even up to a year you may see. You want to reach maximum benefit so that you're not leaving the patient kind of half-treated with that wonderful mechanical assist of the heart, of the failing heart. Because there's a time frame for reverse remodeling, reversing a failing heart signature along all those facets that improve or those that don't. You want everything in your favor, you want somebody to have good exercise capacity at the time you take the LVAD out, and you want the heart to reach its maximum functional capacity, so you have to test for that. So you want them fit for it and you want their heart at maximal capacity so it could be six months, nine months but it's not years. If you're waiting years for the heart to get better and it's not in line with the patient's wishes you should have a consideration for heart transplantation.

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