Everything to Know About Heart Failure and Heart Transplant

More than 5 million people in the US suffer from heart failure. It's very important to understand the causes, signs, and symptoms of this condition, and seek medical attention as soon as possible.

Today on At the Forefront Live, our experts set the nation's best heart failure and transplant center. We'll discuss everything to know about preventing and treating heart failure, including when a heart transplant may be an option. And we'll take your questions. That's coming up right now on At the Forefront Live.

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And we want to remind our viewers that today's program is not designed to take the place of a visit with your physician. We have three folks in the studio today. We've actually added a separate camera so we're going to get as many people as we can in here.

And Valluvan Jeevanandam, you've been on here the show a couple of times before. So I'm happy to have you back. I appreciate you being here. So I want each of you, if you can, just tell us a little bit about what you do here at UChicago Medicine. And Dr. Jeevanandam, we will start with you.

So I'm the director of the Heart and Vascular Center. And I am the chief of cardiac surgery and been here for 23 years. And for 23 years, have been the surgical director of the Transplant program at the Heart Transplant Program.

Great. And Dr. Salerno, we're going to go to you next over in the opposite quarter.

Hi, I am the director of Adult Cardiac Surgery and the new surgical director of the Heart Transplant and Mechanical Circulatory Support Program. I've been here about three months. I'm very excited. I came from a long practice in Indiana, where we directed the largest program in the State for about the last 10 years.

Great. And Dr. Pinney, you're actually in the other corner of the studio. We'll go to you next.

Great. Thanks, Tim. Yeah, I'm Sean Pinney. I'm the director of the Advanced Heart Failure and Cardiac Transplant Program. And I also have the privilege of working with Dr. Jeevanandam as co-director of the Heart and Vascular Center. I've been here now for about 18 months, coming from New York City, where I practiced for 22 years before coming to Chicago.

Fantastic. Well, welcome to both of our newer doctors. And Dr. Jeevanandam, you've actually been here for over 20 years now.

23.

That's great. All right, well, we have a wonderful program first of all, I just want to start off by saying that, and you all have done just a fantastic job with the program over the years. And some exciting things have happened. We're going to get into more detail on that.

But one thing I do want to-- I'm putting kind of the cart before the horse, but you were saying before we started, and we're going to talk about bloodless transplants in a minute. But our bloodless program has done really well recently. And it kind of stunned me when you told me this just a few minutes ago during COVID. Tell us the story.

Yeah, so we started to focus on the bloodless patients because we've had a long history of doing it. I've been doing it for about 25 years. And there are a lot of people who are not getting the therapy that they really need to get. And so we started focusing on the bloodless patients, and we tripled our volume of being able to help bloodless patients within the Heart and Vascular Center. This was during COVID. And we've been so successful that we now have the resources, and we're going to become a bloodless institution for taking care of particular patients who can't take blood transfusions.

And we will get in more detail on the bloodless but that statistic was just amazing to me, particularly during COVID, and I wanted to say something about it before I forgot during the show. We also have a great video, we're going to show later on the show with one of the patients that you worked with.

So let's start with the basics. And Dr. Pinney, I think we'll start with you. And can you talk to us just a little bit about heart failure, in general, and some of the signs that people might look for, that could potentially indicate heart failure.

Absolutely. I think it's important to start off by saying that heart failure is a clinical syndrome. There are lots of things that can affect the heart that can result in this clinical syndrome of heart failure. But I think as people begin to wonder, do I have heart failure or may at risk of getting heart failure?

It's important to point out what are those things that could cause heart failure. Probably the biggest one is high blood pressure. Hypertension is the single biggest contributor to the development of heart failure.

Followed by those people who have coronary artery disease and may have suffered a heart attack that does weaken the heart and that can also lead to the development of heart failure. Some of the cardinal symptoms of heart failure to be aware of.

So one of them is breathlessness. People get short of breath, get tired with carrying out their activities of daily living or going out for a walk. Many times, patients will say that they get a little shorter breath walking up an incline or walking up a flight of stairs. Whereas it wasn't a problem before.

They're now beginning to notice that they're getting shorter a breath. The other symptom is congestion. So developing swelling in the leg, swelling in the ankles, sometimes swelling in the belly.

I know we're going through the holiday season. Now, people eat a little bit more. But it's really when you start to notice that you're retaining a lot of fluid in your belly, that's another hallmark of heart failure.

So when does a patient need to see a physician or see a specialist actually for heart failure?

Well, I think any time you have a change in your symptoms, you should touch base with your physician. It could be a primary care physician. The reality is that most heart failure care is delivered by primary care physicians across the country. So they're the first point of contact for most individuals.

I mentioned earlier those people who may have had a heart attack or those people who may have a heart murmur or valvular heart disease, they're probably already plugged in with a cardiologist. So if they notice a change in their symptoms, they should touch base with their cardiologist.

So let's talk a little bit about when we get to that stage where a patient actually needs a transplant, I don't know. Dr. Salerno, if you would like to answer this one or valve this, would be one for you.

But patients get to that point where other treatments have either run out or maybe haven't worked as well for them as potentially we might want. What is that stage when you know that a patient needs a new heart?

Well, the treatment for heart failure is medication and then specialized pacemakers. And once those start not working, and the patient is not able to take their medication because of low blood pressure, or they have more and more symptoms despite optimal medical management, then they become reclassified as advanced heart failure patients.

And those are patients who now have to go beyond medicines into other types of therapies. And that would be specifically things like a heart transplant or a mechanical assist device.

And Dr. Salerno, can you talk to us a little bit about just the transplant program here in general. And I know you're relatively new, but there's some exciting things that are happening here.

And it's really, really exciting things here. We have said an institutional record for the most minor transplants in a year. Excuse me, we have the best outcomes in the country and the shortest wait time.

At the same time, we're exploring other opportunities to grow the transplant program. We're actually looking at ways to improve organ preservation so we can grow from further distances, where we can find alternate sources of organs, either from patients who passed away from a cardiac standstill, not necessarily from brain death.

And then maybe even alternate options such as xenotransplantation using organs from animal donors. Our plan is to grow our program. We think there's an underutilization of transplantation. And we all believe it's the gold standard for advanced heart failure.

So we have a graphic. And John, if we could run that graphic. And Val, I don't know if you could kind of walk us through this because again, I think this is pretty exciting and it really shows the wonderful work that you all do.

So there's a program called SRTR that stands for the Scientific Registry of Transplant Recipients, and that is contracted through the Department of Human and Health Services. And it allows the government to get data on every single transplant patient to look at government policies, and whether allocation policies and distribution policies are working.

And so that's kind of the Holy Grail in terms of actual getting data. Every single transplant patient has to go into there. And so you can follow the transplant patients, you're going to follow how long you're on the waiting list, et cetera.

It's very unique in the world because it includes government pay patients, private pay patients, et cetera. And as far as I know, it's the only program like that in the world. So the SRTR has a report that comes out every six months. And in that report, they look specifically by each program is 143 programs in the United States.

They look at their actual mortality and their expected mortality. They look at transplant wait times and look at the composition of patients that are being transplanted. And so in the last report in July of 2021, they look at a three year running average.

So the data goes from 2018 and 2021. In that cohort, and we're very, very proud of the fact that we say we're the best transplant program according to SRTR, which means we're the best transplant program in the United States, and de facto, the world because no one else has data like we do.

And in that cohort, in that report, we had the best survival of any of the 143 programs. And on top of that, in a historic first, we also had the shortest wait times. So our average wait time or we call it the medium weight time was 1.1 months. And in the entire country, it was 6.9 months.

So we're seven times faster than the rest of the country in terms of getting a transplant. Now, 75, that's 50% of our patients. 75% of our patients got a heart within 2.8 months, and the closest program to us for the 75th percentile was 12 months.

So we are way faster than getting a heart. And it's a historic first because at no time at the SRTR has the program has had the best results, also had the shortest wait times.

Yeah, that statistic is just amazing. Well, there's those two statistics as you look at them together. The fact that we guys do such quick work with getting hearts for people but you have such a wonderful outcome. And I think your last 12 months, I mean, weren't you ranked around 100% as far as survival?

In that cohort, which goes over three years, we had 100% survival. We look at one year survival. So our one year survival was 100%.

That's fantastic. So what do you attribute that you can get a heart in somebody so quickly, yet you do such a fantastic job with the outcomes?

Well, it's absolutely as Dr. Pinney says. It's a team sport. It's the ultimate team sport, right? So you have cardiologists who have to identify the patients, get the patients to transplant, and then take care of them after transplant.

You have an ICU team, you have anesthesia, you have incredible nurses, and then you have the surgical team that actually ends up doing the transplant. And each one of those components is critically important if you want to have the type of survival that we do.

Now you know, the surgeons have to deliver a great product to the ICU, which means a patient who doesn't have any surgical problems. And then from there, they have to survive in getting immunosuppression, and then management of infections and stuff.

So it is a incredible team. And it's taken many, many years to put that team together. But right now we have a team that is working very, very well together.

Fantastic. And Dr. Pinney, I don't know if you can talk a little bit more about that team based approach that we see here at UChicago Medicine. And again, I think it's really critical to the success of a program like this. But we see it all across the campus. Can you talk a little bit about that?

Yeah, you're absolutely right, Tim. So there are three of us here in the studio, but we represent probably 80 members of the Advanced Heart Failure and Heart Transplant Team. And that's everyone from donor coordinators who take the phone calls, our pre-transplant coordinators who meet the patients, get them on the list.

Even before we get that first phone call, that goes to the donor coordinators. The harvesting team that flies out to the hospital to harvest the organs, the excellent surgical team that we have, the tremendous skill and dedication in our surgical colleagues.

And then cardiac anesthesia, the intensivist, the cardiologist, the nurse practitioners, who manage these heart transplant patients, not only around the time of transplant, but following transplant as well.

A dedicated, super dedicated team of social workers, pharmacists, you name it, a really deep committed team. And what is so impressive about this team is the way that we're all integrated, that we communicate extremely well. And that when you have a team where everyone is truly focused on the patient, I know a lot of places talk about it.

But it's true in our Heart Transplant Program. It's true here at the University of Chicago. Patients come first. And when that is your motivator, you're going to do your best work. And you're going to see great outcomes.

Right. And that it's building the foundation, right? So we have an incredible foundation and the foundation allows us to be innovative and to be able to supply care to patients who normally would not get care.

So for instance, we do a lot of different things that other people don't do, very high risk. So basically, we don't read the books, we write the books.

Well, and I want to delve into that more because that's fascinating to me. You all don't take the softballs. You don't take the easy cases. I mean, obviously you do take probably some what are considered more routine cases, if that is something--

I wish we could have more of those.

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But you take some really difficult cases, and I know for a fact because I've talked to some of these patients before that have been turned down in other places or their families have been told to make end of life preparations.

And then they come here, and they get treatment. Tell us about that, kind of delve into that a little bit. Why do you do that? And then what drives you when you're working on patients like these?

Well, we all love challenges. And the fact that we have a great team allows us to take on some of those challenges. You know, it's an interesting fact that almost a third of our patients come from other transplant programs. And we have these great results, but don't shy away from complicated patients.

And specifically, we're the leaders in the country in doing bloodless transplants. So this is for our Jehovah's Witness population or for people who refuse blood transfusions. And most transplant programs will not do those patients because when you do a bloodless patient, it's a high wire act without a net.

And so people love to have that net, but you know, we're confident enough in our team, and our procurement team. And our cardiologists are confident enough that they can take care of these patients without blood. So bloodless is one.

When you talk about triple organ transplantation, there's only been 25 and done in the entire world, and we've done 13 of them. And that's heart, liver, and kidney transplants. We also take on what we call highly sensitized patients, those are patients who have a lot of antibodies. And that's actually Dr. Pinney's forte.

And a lot of our patients now are people who are other transplant programs will turn them down because of a high-- we call it PRA or maybe Sean can comment on that.

Yeah, I am kind of curious about what that means Dr. Pinney because that's something that I think a lot of people probably aren't familiar with.

Yeah, something you don't really run into other than in transplantation. So there are people who develop antibodies against other potential donors. These are antibodies against the self antigens, the things that differentiate, let's say myself from Dr. Salerno, or Dr. Jeevanandam.

And there are some people, particularly women, because they've had pregnancies, people who have had blood transfusions, or even some people who have had previous organ transplants develop these type of antibodies.

And so unfortunately, when you develop antibodies like that, there's a large segment of the population that become immunologically incompatible. And what that means is that they have longer waiting times when they're on the waiting list to try to find an appropriate donor that matches them.

And we all know that these are very sick patients. And oftentimes, they don't have a lot of time to wait, not a lot of extra time. So we are doing some novel things, some innovative things here to try to reduce those antibodies in order to try to find an immunocompatible match for these patients.

That's fantastic. Very, very interesting. We are taking some questions from viewers that I want to get to as we go throughout the show, and then we're going to show this video here in just a moment with a patient named Lane Jenkins, excuse me, it's fascinating story. But let's get to a couple of these questions first.

Kathy wrote in and asked "What stage of congenital heart failure do you need to be before you need a transplant?" I'm not sure who might want to take that one.

I might go ahead and grab that. So we're very simple. We come up with a very simple staging system A, B, C, D. So A means that you're at risk of developing heart failure, B means that you have some structural heart disease but don't have symptoms of heart failure.

C is symptomatic heart failure, and then D is the stage where you have advanced or end stage heart failure. So we're talking specifically about those patients who have made that transition from stable chronic heart failure to stage the advanced heart failure.

And some signs of that would be just not being able to walk a city block or climb a flight of stairs, needing to reduce your medications because of blood pressure, like Dr. Jeevanandam mentioned a short while ago.

Requiring more hospitalizations one or two hospitalizations than a year or just remaining congested, can't get rid of the swelling, can't get rid of the edema. These would be some signs that you're transitioning over to stage D, and that's the population that we reserve heart transplantation for.

Interesting. So Jean asks, "When is the best time to refer a person for evaluation?"

Happy to jump in with that too.

Go right in.

Early is always better. You know, just because we evaluate someone for transplant doesn't necessarily mean that we're going to put them on a transplant list. And one of the things I really like is when I see someone and I give them a reassurance that we can put you on a different medicine, or we can do a different cardiac procedure, and we can delay the need for heart transplantation.

So knowing that, we want to see patients earlier. I think some rules of thumb, if you can't walk a block, if you can't climb a flight of stairs, or if you're taking more than let's say, 40 milligrams of your water pill, come in, set up an appointment to see an advanced heart failure cardiologist.

Fantastic. So I keep promising this video on the bloodless patient. So John, let's go ahead and roll that now, then we're going to talk about that particular case here. And after we see the video.

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I would say before, my activities were always been golfing, basketball, bowling, and I felt to the point where I couldn't do any of those things again. Fatigue, shortness of breath.

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It's extremely important based on Bible principles that blood is sacred. We view blood as sacred. And it's not that we don't want to live or get the best medical care possible, no. It's just that is what is outlined in God's word, the Bible. So for me, it's extremely important, and it's a life decision that I will not take blood.

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And we have a hospital liaison committee, and they had recommended University of Chicago as one of the places that was definitely excellent in doing bloodless surgery. And because of that, their team reached out to me here at UChicago. They reached out to my wife, and myself, explaining exactly what they do, exactly what time frame they do it in.

And based on the recommendation of the HLC and their representatives, then I was able to make a decision. Definitely, Joe was able to guide me in the right direction. And that's one reason why we chose here at the University of Chicago.

He went up and down the West Coast, went to other programs that say they do bloodless surgery, but their results weren't great and they weren't really interested in taking care of them. Because not only did he need bloodless surgery, he was also ill. And his pressures and his heart were very high, his output was low, and he was in borderline kidney failure.

And so we actually spoke to his cardiologist per the request of the family. And even the cardiologist, when he spoke to Dr. Jee said, are you guys sure you can do this because you know, he has this and this? And Dr. Jeevanandam said, yeah, we can do it.

My goal when I was in the hospital, I kept telling myself, I got to do what I have to do so I can get back home to my babies. Being a dad with two girls is a little sentimental, but I kept telling myself I got to get back home to my babies. I got to get back home to my babies.

What makes us able to do these patients that other people won't do is when you have a good program, you can have a certain margin of error. But with patients who need very, very tight margins of error, like, almost no error at all, you need to have a superlative team. And that's exactly what we've done, right?

So we've created a superlative team that starts with our cardiologists, and they understand what Jehovah's Witnesses need to go through. Then you have the surgical team. When we operate, it's not like every surgeon does this.

So we have a specific group of surgeons, we have a specific group of physician assistants, nurses, perfusionists that take care of these patients. And so everybody's in sync.

Almost you don't have to talk to each other because we all know what we're going to do and know all the little things that we do to preserve blood. And we go after every single area, where we can lose blood.

So I think within a week or so, he got a heart. It worked out great. His pressures were high in the beginning, but we knew how to manage them. Even in Jehovah's Witness, those pressures then normally came down with the heart was good. And I think he left the hospital in a very short period of time, like, 14 to 21 days, and he's doing great.

My life is, it's funny. It's a lot better. Not just a lot better, it's very, very good. It's fabulous, actually. To be able to walk, to be able to even run a little bit now, I'm starting running, to be able to go play golf, to be able to do all the activities I was doing without being hampered with being tired or fatigued. Those things, I can't describe the feeling.

It is so wonderful to be able to do those things on a regular basis. Because when you say heart transplant, everybody, your peers, your friends, like, heart transplant, that's major. But when you're at the University of Chicago, when you're there with the team, and you see how regularly they do these things, it puts you at ease.

It's a pretty neat story. that's pretty incredible.

Yeah, the incredible thing is it's not unique. So over the last two or three years, we've had over 35 patients from all over the country. And so we still need to get somebody from Wyoming and Montana, that's pretty good.

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So I'm just curious, because I've heard you talk about this before and it's always been fascinating to me. When you're doing a heart transplant but you want to do a bloodless transplant, how do you how do you make that happen without doing damage to the patient?

Well, there's many things that we have to do in terms of the bypass machine, in terms of techniques to save blood, so we save every single core muscle that we can. And we do a thing called chemo-dilution where we take blood out of the patient.

We kind of park it on the side, and then we let the rest of it go through the bypass machine, and then we give it back. So there's a lot of little tricks of the trees that we have established. But a lot of it just comes to the faith in the system, which is very, very important, right?

Because as we said, we don't have a margin of error. So you have to have supreme confidence that the cardiologists can get the patient to the operating room. And then you have that confidence that the team going out for the heart is going to get you a heart that's going to work right away.

And then you have to have the confidence that once you deliver the patient, then people can take care of that patient. And you know, that's what allows us to do these very, very high risk patients.

That's interesting. So Dr. Salerno, if you could talk to us a little bit about just that confidence as a physician, as a surgeon when you go into a situation that is challenging. And what gives you that confidence as you work with a team like this?

Yeah, it's a great question because the main reason I came to the University of Chicago is because there's no limit to what clinically possible here. So there's a focus this team has to do the best thing for the patient without limits and without competing interests.

So you have a team of individuals who never complain about the time of day, that went into the hours, and always put the needs of the patient ahead of their own personal needs. That is very unique. A lot of other institutions, even with a very high volume heart transplant programs have clinicians who have ongoing competing interests.

Dr. Jeevanandam created the team here over the years, which is primarily focused on excellent care of all cardiac patients, but a special emphasis on cardiac transplant.

So when somebody just kind of-- I'm curious about this one as well, if somebody receives a heart transplant, how long can they expect a transplant to last?

I'll take that one.

Sure.

It's highly variable, but a good rule of thumb is about half of the patients will survive around 15 to 16 years. But that's a bit of a skewed statistic because there's individuals who've survived in excess of 30 years.

We tell our patients, if you get a successful heart transplant, with very few exceptions, you should live a life without restrictions that gives you a normal quality of life. And hopefully, if you're compliant with the medical therapy, you'll live in the 20- 30 year range.

That's fantastic. So another question if patients, they may be seeing a program like this, but there may be a long ways away from Chicago. Is that an issue for someone who is looking for a transplant? And I don't know who wants to take that one.

It's a little bit of a challenge like Lane. Lane came all the way from San Francisco, and the care that he saw it just wasn't available in all of the West Coast until he came to Chicago. But we have services within our institution that allow them to relocate. We expect the patient to be here for about a year after transplant.

There's a lot of changes in their immunosuppression, and their steroids. And after about a year is when they start feeling really well and we feel comfortable handing them off to someplace closer to home. So we expect them to be in Chicago for a year.

And there are patients who are not able to do that. But it's amazing how resourceful patients are when it comes to trying to get a heart transplant.

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I can only imagine. They will do their research and really do their homework. And we've seen that.

Well, with the results we have, if anybody is doing their homework, they really shouldn't be going any place else.

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That's what we're hoping for.

Yeah, exactly. That's fantastic. So Dr. Salerno, can you talk to us a little bit about recovery. We're about out of time, but I'm kind of curious recovery from a heart transplant. What is that like for a patient?

It's not too dissimilar from people of other heart surgery. So the average patient probably in the hospital somewhere between two and three weeks. A lot of that has to do with education, of new medicines and procedures, and making sure that everything's OK with the heart.

And when they go home, we asked them to slowly increase their activity. They should be up walking, moving 3, 10 minute walks a day. Within a month, they're driving. Within three months, they have few restrictions from a physical standpoint.

There are still some restrictions from an exposure standpoint. The first year, they do have quite a few visits to the hospital that's why we asked them to stay your nearby for at least one year. But ultimately, when they recover, they have no limitations.

You're talking about people go on, and compete, and transplant, Olympics. And their parents and their grandparents and really do amazing things. There's transplant patients who have been professional athletes and run for political office. There are no true limitations for these patients.

In fact, Dr. Jeevanandam, you were talking about one of our patients here who is going to have you climbing stairs here.

That's right. Yeah, I was just looking at the picture back there, and you have the Hancock. And she's challenged me to climb the Hancock. So you know, it's going to be really embarrassing when somebody who has done a transplant on competes the surgeon.

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That's pretty impressive though, when you think about the fact that she's going to do that. That's exciting. That's great. Well, we're out of time. You gentlemen are fantastic. And you have a fantastic program. Lots to be proud of and congratulations on the wonderful numbers and outcomes.

Thanks very much.

Thank you so much.

So we are out of time. Special thanks to our guests obviously, for being with us today. A big thank you to those of you who watched and participated in the program. Please remember to check out our Facebook page for our schedule of programs coming up in the future.

To make an appointment, you can online to uchicagomedicine.org or give us a call at 888-824-0200. Thanks again for being with us today, and I hope everyone has a great weekend.