Health Sciences Report Summer 2004

Organ Transplantation
For Patients: Promise and Unpredictability
By Susan Sample

Photos by Sean Graff

Only desperately sick patients consider organ transplants. But it’s a decision they shouldn’t make out of desperation.

“A transplant can give you five, 10, 15 or more years for whatever makes your life wonderful. That’s a great thing,” said LeAnn Stamos, R.N., M.S., heart transplant coordinator at University of Utah Hospital. “But post-transplant is not an easy life. There are issues now that patients a long time ago didn’t have to deal with.”

That’s why the Solid Organ Transplant Program (SOTP) at University Hospital works as a team to prepare patients and their families emotionally and financially, as well as medically, for a future that holds promise—and unpredictability.

Once the most dramatic, cutting-edge medical procedure, organ transplantation has become commonplace. In January, the U Renal Transplant Program will celebrate its 40th anniversary, having performed 1,745 kidney transplants as of last April. The UTAH Cardiac Transplant Program, a cooperative venture between University Hospital, LDS Hospital, Salt Lake Veterans Affairs Medical Center, and Primary Children’s Medical Center, will be 20 years old next March. The first of its 852 recipients—a 35-year-old Idaho man who received his heart at University Hospital when he was 16—has lived more than half his life post-transplant. The U Lung Transplant Program, the only one in the Intermountain West, has extended the lives of more than 84 patients with pulmonary disease since it began in 1992.

“Since much of the sensationalism has been removed, patients think they’ll get an organ transplant and everything will be back to normal,” said James C. Stringham, M.D., surgical director of the U heart transplant program and associate professor of cardiothoracic surgery at the U School of Medicine. “That’s not the case. They’ll live longer, but they can’t just forget about it. They still will require a significant amount of medical care.”

With survival rates at the U matching or surpassing national averages, it’s easy to mistake longevity for a limitless future.

  • About 92 percent of kidney transplant patients at the U survive the first year; 90 percent, the first three years. Both rates match the national average.
  • The one-year survival rate for Utah heart transplant recipients is 93 percent, compared to 86 percent nationally. More than 70 percent live five years, compared to 60 percent nationally.
  • Lung transplant patients at the U have an 83 percent survival rate the first year, compared to 75 percent nationally. Their five-year survival rate is 62 percent.

Improved organ preservation methods and surgical techniques, in addition to better patient-selection criteria, each have contributed to recipients living longer lives. The single most important factor, however, has been the prevention of organ rejection through improved immunosuppression, which also has given new meaning to living post-transplant.

“It’s a four-hour surgery and a lifetime of immunosuppressants,” said Troy Somerville, Pharm.D., a transplant pharmacist with the Solid Organ Transplant Program who took another position last spring. “People are living longer—thank goodness—but now we’re asking: what’s happening to them when they take these medications for five, 10 years?”

“Transplantation takes away something you’re familiar with and replaces it with something unfamiliar that has big names and lots of drugs,” said Barbara C. Cahill, M.D., medical director of the lung transplant program. Post-transplant lung patients take from 11-17 different medications every day—all with side effects. “We try everything short of transplantation, so patients can make a balanced decision.”

The issues are much the same for kidney transplant recipients. John M. Holman Jr., M.D., Ph.D., medical director of the renal transplant program, tells pre-transplant patients, “You’re trading kidney disease for transplant disease.

“Any treatment is a balance of risk factors and outcomes to ensure the patient does well,” explained the associate professor of surgery. “I don’t want patients to think of themselves as sick, but they do need to think of themselves as having a chronic disease.”

Stamos tells patients preparing for heart transplants that “‘it’s the biggest thing that will ever happen to you.’ It is. But it doesn’t mean they’ll live forever.”

That concept can be difficult to grasp for many people, especially desperately sick patients. As surgeon Stringham noted, “I think anyone who is really sick is looking for hope. They don’t think of 15 years down the road.”

“We have to deal not only with the heart, but the whole patient and all of their potential medical issues: blood pressure, renal function, bone density,” said Edward M. Gilbert, M.D., professor of cardiology and medical director of the U heart transplant program. “They need a comprehensive team. This is where our multidisciplinary approach is so valuable.”

The heart, lung, adult and pediatric renal transplant teams at University Hospital were brought together as the Solid Organ Transplant Program in 1998. This spring, the program consolidated its offices and moved to the hospital’s A level, where all transplant clinics are held. As one of the few multidisciplinary programs in the country, SOTP provides patients with a continuum of care, from pre-transplant evaluation through surgery to post-transplant clinic visits for their lifetime, according to Kim Phillips, R.N., M.S.N., SOTP manager.

The staff includes transplant coordinators who oversee patients’ clinical care pre- and post-transplant, physicians, surgeons, pharmacists, social workers, pediatric dietitians and child-life specialists, and a financial advisor. Transplant surgeries can cost from $70,000-240,000, depending upon the organ. Medications the first post-transplant year run from $20,000-30,000, then average $10,000-25,000 annually for life.

“We’ve achieved real benefits from joining people together in the program. We’ve gained expertise and efficiency. This really makes us stand out,” said Phillips. He noted, however, that each organ has its own medical and surgical directors. “University Hospital is one of only two transplant programs in the U.S. that offers a pharmacy residency in transplantation,” added Phillips.

When Somerville, a 1997 U College of Pharmacy graduate who completed residency training in transplantation and immunology at the University of Tennessee, joined U Hospital in 1998, he was the first pharmacist dedicated to transplant. Two other full-time pharmacists and one resident are an integral part of SOTP.

Transplant recipients are discharged from the hospital with anywhere from 8-17 new medications, depending upon which organ they received. In terms of a daily routine, this means they have to learn to take from 20-50 tablets and capsules—some with food, some without—at five or more different times during the day. “It’s very individualized,” said Somerville, “but the concept of immunosuppression is equal for everyone.”

So is the threat of graft rejection. “Missing medications over time will shorten the life of the transplanted organ,” said Somerville, explaining just how complex the issue of compliance can be for patients. “They don’t feel rejection coming on. It’s a long-term condition. In fact, they probably feel better the days they don’t take medications. Some of these drugs don’t make them feel better—just keep their organ.”

Prednisone, a common immunosuppressant, can cause not only weight gain, but also redistribution of fat in the body. “It can feel awkward to gain weight at the back of the neck,” noted Somerville.

Adolescents especially can have a difficult time taking the required immunosuppressants. Side effects, such as facial hair on a female, can be traumatic. “Teens face peer pressure. They don’t want to appear sick, so they rebel by not taking their meds,” said the pharmacist. “If mom or dad gave them the kidney, it can be a very difficult set of social issues.”

Looking to the future, transplant pharmacists have a new goal in sight: “to eliminate medications,” said Somerville. If they reduce the number of immunosuppressants, they can prevent adverse side effects and “co-morbidities,” such as cardiovascular disease, bone disease, cancer, and diabetes. Coronary artery disease has become the leading cause of death in kidney transplant recipients. Patients who’ve had transplants are at a higher risk of developing cancers, especially post-transplant lymphoproliferative disease (PTLD), a type of lymphoma, and skin cancer, particularly basal and squamous cell carcinomas.

“We used to focus on improving the short-term survival of the graft,” said Fuad Shihab, M.D., medical director of the adult renal transplant program and the only nephrologist in Utah trained in transplantation. “Now we’ve realized that patients are dying earlier from cardiovascular complications. So the focus has shifted to improving long-term survival and minimizing co-morbidities.”

To this end, SOTP participates in and instigates clinical drug trials. A pharmacist directs clinical research for the renal transplant program, which is participating in seven national multi-center trials. The pharmacist meets with all pre-transplant kidney patients to acquaint them with research studies, since there is only a short window of opportunity to enroll patients in clinical trials after surgery.

Research is one of the advantages offered by a broad-based transplant program. Not only does it advance clinical care, but it also allows patients to take advantage of the newest findings. As Gilbert, medical director of the U heart transplant program, noted, “In 1984, we had no medical therapies that had been shown to improve survival of patients with chronic heart disease. Now, through clinical trials, we’ve shown that ACE inhibitors and beta-blockers do improve survival.

“If you factor in the benefits of all these new drugs, there is at least a 50 percent reduction in the risk of death with medical therapy alone. These therapies work not only in end-stage heart disease, but they also have a role early on when patients are just developing symptoms. In fact,” noted the cardiologist, “it’s been shown that the benefits precede the development of symptoms.”

That’s good news for patients who may be at increased risk for chronic heart failure: they can consider less invasive options than heart transplants, which seem to have a stronger emotional component than those involving other organs.

“Hearts are the most sentimental organ,” said Geri Etringer, M.S.W., L.C.S.W., one of two kidney transplant social workers, who previously was part of the heart and lung transplant teams. “People associate feelings with their heart. It’s their core, their center of love. Heart recipients often feel more survival guilt for the death of their donor.”

Transplantation is unique among medical procedures in that one patient lives only because another gave up an organ. For kidney transplants, the donor can be living. For heart and lung, the donor must be deceased.

“As social workers, we try to separate those events,” explained Etringer. “We say to the patient, ‘The donor didn’t die so you can live. You didn’t have responsibility for their death. You didn’t wish that.’

“We reframe the issue. ‘Instead, why not think: isn’t it wonderful that now we can do something good? It’s a gift given to you.’

“This can be a hard thing for patients to accept,” acknowledged the social worker. “Some people really dwell on it; others, not at all. Some people integrate it by giving the organ a separate name. They give it an identity as an entity different from them.” To which, she quickly added, “That’s not an unhealthy response. It’s just their way of honoring something given to them.”

What Etringer does find unhealthy is when patients avoid the issue. “I try to talk about it from the beginning, so it doesn’t first occur to them when they’re lying in the recovery room.”

To help patients cope with the complex psychosocial aspects of transplantation, Etringer has found support groups can be valuable. “Anecdotally, I can tell you these people have better outcomes. It’s because of the educational aspect. They see former patients and think it’s do-able.”

“Talk” sessions often are scheduled after more formal lectures on topics ranging from how medications work to diet and exercise to financial concerns. This helps ease in reluctant patients who tell her, “‘I’m not a group person.’ They think it’s the touchy-feely thing.”

Heart and lung pre-transplant patients usually are more willing to participate in support groups, because, as Etringer noted, “they have to be on site. They’re a captive audience.”

In order to be on the waiting list for either a heart or lung transplant, patients must live within approximately one to one and a half hours of University Hospital. These organs must be transplanted within four to six hours after being recovered. For most patients, that means relocating to Salt Lake City with at least one caregiver. Social workers help patients find accommodations, as well as adjust to maintaining two households. “This has a huge impact on families. At a time when the patients need their support the most, they’re here alone. And they just wait.”

But while they’re waiting, they’re usually “very dedicated to being here. They devote their time to their recovery and rehab. Then they can return and get back to their lives.”

Although kidneys can be preserved for up to 24 hours before transplant—allowing transplant candidates to live a greater distance from the hospital—these patients still face challenges of their own. “They come for evaluation, which usually takes one entire day. We educate them, then they go home. Often they’ll put the transplant and what it means at the back of their mind. Then they get the call, and everything happens at once. It’s more crisis-oriented.”

Hospital social work often involves crises, but Etringer finds transplantation rewarding in a different way. “We get to know patients such a long time. We see them over the years, through all their experiences.”

Her sentiment is shared by everyone on the transplant team. “When you do a normal surgery, it’s a one-time procedure,” said S. V. Karwande, M.D., professor of cardiothoracic surgery and surgical director of the lung transplant program. “Every two weeks, we review all of our patients. We know their ups and downs—where they go on vacation, who has a new job—because what happens to their families affects their health. I personally don’t get to see them, but the sense of involvement is there.

“You want them to do well,” said Karwande. “Everyone on the team takes pride in our patients’ survival.”

“I can’t think of any other medical condition quite the same as transplant,” agreed Phillips. “It has a unique emotion linked to it. It’s a treatment that spans someone else’s life, and you’re a part of it.”

Charts

Heart:
343 Total Patients Transplanted at U of U
14 Patients Transplanted in 2003
7 Patients on Waiting List
93% 1-Year Survival Rate
70% 5-Year Survival Rate

Kidney:
1,745 Total Patients Transplanted
67 Patients Transplanted in 2003
71 Patients on Waiting List
92% 1-Year Adult Survival Rate
85% 5-Year Adult Survival Rate

Lung:
84 Total Patients Transplanted
9 Patients Transplanted in 2003
6 Patients on Waiting List
83% 1-Year Survival Rate
62% 5-Year Survival Rate

Yes, Utah! Yes to Life!

Every 13 minutes, someone’s name is added to the list of Americans waiting for an organ transplant.

Every day, 16 people on the waiting list die, because a donor organ wasn’t available, according to the United Network for Organ Sharing (UNOS).

“Oftentimes, people have a visceral, negative response to organ donation,” acknowledged Kim Phillips, R.N., M.S.N., manager of University Hospital’s Solid Organ Transplant Program. “But if you think of it in human terms and the benefit it provides, it can give a donor’s family something positive out of a tragic situation.”

One donor can help save the lives of more than 50 people by providing many organs: heart, kidneys, lungs, pancreas, liver, intestines, corneas, skin, tendons, bone, and heart valves, according to UNOS.

“We’re always aware of the difficult circumstances under which these decisions are made,” said Phillips. “Our nurses and other staff are trained to recognize the need and opportunity for donation.”

That awareness earned University Hospital recognition last year for having the seventh-highest organ donation consent rate in the United States, according to the Association of Organ Procurement Organizations. Between August 2001 and July 2002, the U accounted for the highest number of organ and tissue donors in its region, which includes 2.7 million people and 79 hospitals in Utah, southeastern Idaho, western Wyoming, and Elko, Nev. Phillips attributed the high rate to staff training about donation.

Recent surveys have shown that 97 percent of Utahns favor the idea of organ donation. A new option was added last year with the Good Samaritan Living Kidney Donation Program. As of last April, 12 people had participated by donating one of their two kidneys to help save the life of someone they didn’t know who didn’t have a living donor available. “These people are incredible. They do it, because they truly want to help humankind,” said Phillips.

The program is a joint effort between University and LDS hospitals, and Intermountain Donor Services (IDS), a federally designated nonprofit organization dedicated to the recovery of organs and tissue for transplantation. The Good Samaritan Living Kidney Donation Program aims to reduce the time a patient must wait for a transplant.

“It’s had a dramatic effect on the waiting list,” noted Phillips. “There are 140 people at University and LDS waiting for a kidney transplant. Twelve people have donated, so 12 have been taken off the waiting list. That’s a significant percentage.”

University and LDS hospitals joined with IDS to help launch the Yes! Utah donor registry two years ago. The names of individuals who have designated themselves as organ donors on their driver’s licenses are entered on a computerized list. If the occasion should arise, IDS then has permission to approach the individual’s family and discuss his or her wishes regarding donation.

For more information about organ donation, call Intermountain Donor Services in Salt Lake City at 801-521-1755, or toll-free, 1-800-833-6667. To register as an organ donor, go to www.yesutah.org.

U Kidney Transplant Program

“We used to think that only quality of life improved with a transplant. One can survive on dialysis,” said Fuad S. Shihab, M.D.

Patients with end-stage renal disease once were thought to have two equally effective treatments that could prolong their lives: dialysis or a kidney transplant. “But with a transplant, the quantity of life also improves. Transplanted patients live twice as long,” explained Shihab, professor of nephrology and medical director of the U Renal Transplant Program.

“For the most part, dialysis is a back-up,” agreed John M. Holman Jr., M.D., Ph.D., surgical director of the program. “Medicare studies have shown that transplantation produces better outcomes: it reduces mortality; quality of life is better; and it’s a cost-effective treatment.”

Utah’s first kidney transplant was performed in 1965 by a U of U faculty member, Lawrence E. Stevens, M.D., at the Salt Lake County General Hospital. The patient, known only as “D.L.,” was the world’s longest surviving kidney recipient, according to Medicine in the Beehive State 1940-1990. “He died just recently, but his kidney was still working,” said Kim Phillips, R.N., M.S.N., manager of the U Solid Organ Transplant Program.

“The U has had amazing historical events at this hospital that are the foundation of who we are today,” he added. Willem J. Kolff, M.D., distinguished professor emeritus of internal medicine and surgery at the medical school, was honored last year with the prestigious Lasker Award for his work developing renal hemodialysis, which helped transform kidney failure from a fatal to a treatable condition.

In transplantation, the biggest advance in recent years has been the improvement of immunosuppressants. They have added years to the lives of transplant patients, but the length of time patients must take these medications and the intensity of dosages pose new health risks. “Cardiovascular disease has become the main cause of death in kidney transplant patients,” said Shihab, noting how anti-rejection drugs raise cholesterol levels. “The focus of our practice now is to minimize the risks associated with cardiovascular risk and to treat it. As we’ve moved to long-term care, we’ve added physician-extenders to our team.”

As a nurse practitioner, Jacke Corbett, R.N., M.S.N., FNP-C, is trained in preventive medicine. She makes sure that the 500-some patients the team follows are up-to-date with cholesterol screening, bone density tests, immunizations, mammograms, pap smears, and prostate screening, among others.

“I help take care of the day-to-day problems of the adult kidney patients. For many, we are their primary care providers,” said Corbett. For those who live outside Utah, the U team still reviews their laboratory tests four times a year not only to check for signs of rejection, but also to ensure that any new treatments or medications prescribed are not adversely interacting with the immunosuppressants.

Holman, associate professor of surgery, noted how improved immunosuppression has resulted in fewer “re-transplants.” “Twenty years ago,” he said, “it was not uncommon to put in a third or fourth kidney. Now it’s rare to put in a second one in an adult.”

Children, however, can expect as many as three re-transplants, depending upon the length of their life. Transplanted kidneys function an average of 10 years, if the donor was deceased. If the donor was living, the average extends from 17-25 years. That’s one reason about 40 percent of the 67 kidneys transplanted at University Hospital last year were from living donors.

“The half-life of a kidney from a living donor is at least two times better than the half-life of a kidney from a deceased donor,” said Shihab. He noted, however, that “at the U, we’re very conservative when evaluating living donors. They need to be at the high end of kidney function and have no other medical illness that could affect their kidney function or quality of life.”

Shihab, the only nephrologist in Utah trained specifically in transplantation, chose his specialty, because “this is the way you can make a large difference in patients’ well-being: making them functioning individuals again and active members of society.”

His point is echoed by many on the renal team. While dialysis can keep patients alive, it limits their independence. Many are unable to keep their jobs; many may not have the skills to work. The stress eventually can dissolve their motivation. Transplant can give patients a new life, but do they become active, independent individuals?

Pamela Grant, M.S.W., L.C.S.W., social worker for the U pediatric renal transplant program, wanted to answer that question. “We save lives, but are we saving them for a productive end? Have we done any good for these kids?” wondered Grant. In an informal study four years ago, she surveyed 80 renal patients who were transplanted between 1980 and 2000. The youngest was two years old at the time of his first transplant; the oldest was 18. She found that 92.5 percent of the transplanted children had graduated from high school; 63 percent had attended college or received advanced training; and 15 percent had graduated from college or earned advanced degrees.

“I was very impressed—and relieved,” said Grant, who plans to follow up the survey. “Other questions regarding quality of life still warrant answering. Are they married? Having families? What were their career choices? And have there been ongoing interruptions related to their illnesses?”

U Lung Transplant Program

No matter how few miles they pedal the exercise bicycle, lung transplant patients gain a new perspective.

“Hardly anyone goes through pulmonary rehabilitation without benefiting,” said Barbara C. Cahill, M.D., assistant professor of respiratory, critical care, occupational, and pulmonary medicine at the U School of Medicine. “The patients will come to transplant in better physical shape, they’ll already have an exercise routine in their mind, and they’ll have seen people who’ve gone before them.

“That’s the language patients speak: ‘I saw this man who was worse than me go from here to there. I can, too.’”

Cahill, who joined University Hospital’s Lung Transplant Program as medical director in 1996, believes so strongly in the value of pulmonary rehabilitation that it’s required of every patient, pre- and post-transplant. They work out for one hour three times a week at the hospital, where they’re monitored and supervised by exercise physiologists.

“It’s basically education and exercise therapy,” said Carrie Sullivan, R.N., B.S.N., one of two lung transplant coordinators. “It’s low level, but for transplant candidates, it’s critical to how well they do afterwards, especially if they can improve their skeletal muscle mass and cardiovascular reserve. It helps with the anxiety of waiting, too.”

A majority of people needing lung transplants are middle-aged and suffer from smoking-related diseases. “People here live under the illusion that there’s less smoking in Utah,” said Cahill. “But we mirror national rates: 50 percent of our transplants are done for emphysema.” Other causes include cystic fibrosis (CF), pulmonary fibrosis, and pulmonary hypertension.

Younger patients usually have CF. However, a U of U study, published two and a half years ago in The Journal of the American Medical Association, found that most CF transplant recipients gained no benefit from the surgery, or would have lived longer with their own diseased lungs. As a result, researchers developed a mathematical model that identifies CF patients who will derive a survival benefit from a lung transplant.

Unlike heart transplant candidates who move up on the waiting list when they become critically ill, lung patients must remain in stable health to be on the transplant waiting list. “You can’t be bed-bound,” noted Sullivan. “You have to be able to walk and exercise.”

In addition to matching blood type—but not tissue type—of donor and recipient, chest size is an important consideration for transplant. “The lung has to be a good fit mechanically. Two airways have to match up,” explained Sullivan.

When S. V. Karwande, M.D., U professor of cardiothoracic surgery, started the lung program—“my pride and joy”—in 1992, he performed two heart-lung transplants. Now he surgically corrects most heart abnormalities, then transplants only the lung. James C. Stringham, M.D., performed Utah’s first double-lung transplant in 1996, but most often transplants single lungs.

“Optimal organ utilization” is the reason Cahill cites. Only 20 percent of organ donors have lungs suitable for transplantation. If donors were victims of trauma, their lungs often have been pierced or bruised. If they were on ventilators for more than 72 hours, their lungs usually can’t be transplanted. As Karwande, surgical director of the program, noted, “A breathing tube is a highway to infection.”

Lungs are unique organs in that they are one of the body’s first lines of defense. When we breathe in, our lungs act as barriers, preventing bacteria, noxious agents, dust, and other foreign matter from entering the body. At the same time, our hearts pump blood from throughout the body through the lungs, which complicates post-transplant immunosuppression.

“Lungs have to display enough of an immune response to keep a cold at bay,” explained Cahill, “but not enough to reject the organ. For lung transplant recipients, the Achille’s heel is chronic rejection. Our five-year mortality rate hasn’t changed, because we still have the problem of chronic rejection.”

Someday, says the pulmonologist, “we’ll look back at transplantation as a huge step forward, but a primitive procedure.

“Transplant five years ago wasn’t what it is today, and five years in the future? We won’t recognize it,” said Cahill. Most likely, we’ll have pharmacological alternatives to lung transplantation, as well as advances in stem cell research and in utero methods of treating cystic fibrosis.

U Heart Transplant Program

On the nation’s highways, lowered speed limits, seat belts, airbags, and helmets have proven effective: fewer people are dying from trauma. At hospitals, though, this means fewer donor organs are available for transplantation.

“There are roughly 10 times as many people on waiting lists as those receiving transplants,” said Edward M. Gilbert, M.D., medical director of the U Cardiac Transplant Program. Reviewing figures from the United Network for Organ Sharing, the cardiologist pointed out that “we’ve reached a plateau worldwide. Since 1997—when we peaked at 2,300—there’s been an actual drop in transplants. We’re now at 2,000.”

That’s why University Hospital is looking to mechanical devices, such as the Left Ventricular Assist Device (LVAD), as the next frontier. “Mechanical support is where heart transplantation was 30 years ago,” said James C. Stringham, M.D., surgical director of the heart transplant program and director of the mechanical support program.

“LVADs are an accessory to the heart, not a replacement—yet. When the technology improves, though,” he predicts, “mechanical support may become as good as transplantation as a destination therapy for end-stage heart disease but applicable to more people.”

Since 1996, U cardiac surgeons have implanted LVADs as a “bridge” in patients awaiting transplants. By improving the function of their heart, the devices enable the patients’ bodies to recover from the effects of heart failure, including diminished kidney function and a decrease in muscle mass. Once stabilized, patients return to the transplant waiting list.

Last October, the U received approval from the Food and Drug Administration and Medicare to begin using LVADs as destination therapy in patients with end-stage heart failure who don’t qualify for transplant due to their age or co-existing diseases.

“Survival rates and quality of life do improve with the LVAD,” noted Stringham. However, the devices seem to last only about three years due to problems such as worn bearings in the electrical motor and valve degeneration. LVADs can be replaced, but that involves additional surgeries—with adherent risks for patients.

Stringham is optimistic about future generations of LVADs. Models with continuous flow pumps are being tested in clinical trials. Instead of pulsatile pumps—powered by a battery pack patients wear around their waist—second-generation LVADs have a miniature rotary pump with axial bearings. The size of a D battery, the device will especially benefit smaller patients. “There’s a small turbine inside a cylinder the size of a thimble,” explained the surgeon. “Patients will have a minimal pulse, but we’ve found that most of our organs will tolerate continual flow very well.”

Third-generation LVADs, still under laboratory investigation, have centrifugal pumps that are suspended in a magnetic field. “There will be no bearings, no wear-and-tear, so they should have a longer life span,” he said.

LVADs are only one of many therapies available to patients at the U: pacing devices, defibrillators, and conventional and experimental medicinal therapies, as well as high-risk bypass and valve surgery also are offered. “The goal of our heart transplant program was not to be a stand-alone surgical specialty, but a comprehensive program,” said Gilbert, who came to the U in 1984 as a cardiology fellow and became involved in the post-op care of the first transplant patients. “In reality, it has evolved that way.”

Gilbert, professor of cardiology at the U School of Medicine, and S. V. Karwande, M.D., professor of cardiothoracic surgery, remember the first heart transplant at University Hospital March 8, 1985. “I’d just come to Utah from New York, where I’d been Bill Gay’s resident,” said Karwande. Gay, a cardiothoracic surgeon, served on the U faculty from 1984-1992. “I still remember how we sat in his office while we waited and looked at photographs of the heart.

“I was the one who harvested the heart. I was in room 3 in the old OR. Bill was getting the recipient ready in room 4 next door. It was very exciting.”

By July, U surgeons had performed about 25 heart transplants, recalled Karwande. That’s when the U formed the UTAH Cardiac Program with LDS Hospital. Later, the Salt Lake Veterans Affairs Medical Center and Primary Children’s Medical Center joined the consortium. “Basically, we wanted to do transplantation and research, provide good clinical care, and be a resource for the community,” said the surgeon. “It really flourished. The organization of this program has been a model for many other programs in the country.”

What UTAH Cardiac learned also has been significant. More than 100 peer-reviewed scientific articles, and as many invited reviews and book chapters, have detailed new findings ranging from improved surgical techniques to surgical complications, immunosuppression, and cardiac failure. “We were pioneers in donor management,” said Karwande. “What is now standard—getting an echocardiogram of the donor heart—we started.”

Most importantly, some 852 patients have received new hearts—and new lives. As clinical coordinator for the heart transplant program, LeAnn Stamos, R.N., M.S., noted, Tony Shepard, Utah’s first heart recipient, “is doing great. He’s working. He’s productive in society.

“That’s so cool,” she said, “to see patients so sick they can’t do anything get a chance to have a life they otherwise wouldn’t have had.”

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