I hope we are starting a new era in transplantology
The first surgery was performed in urgent manner. Who is the patient and what were his indications for transplantation?
We performed the surgery on a 16-year-old boy. He was admitted to our clinic on July 29th with severely depressed cardiac function. His heart practically did not contract. In order to keep the patient alive, we put him on a catecholamine infusion, i.e., intravenous medication which stimulates the heart. During the interview with the boy and his parents it turned out, that his health impairment became apparent only a dozen days before the boy arrived at our clinic. He continued to feel worse each day, until he suffered from emesis and syncope. The district hospital performed echocardiography and he was immediately referred to UCC MUW. We performed Magnetic Resonance Imaging and another echocardiography. At is turned out, the patient suffered from dilated cardiomyopathy. It is a type of a genetic health impairment which causes depressed cardiac function. The illness develops for multiple years. It is not a condition which suddenly, acutely, as it is the case with myocardial inflammation. Dilated cardiomyopathy at our patient was developing slowly, gradually and, unfortunately, imperceptibly. And the boy would adapt to its symptoms, without being aware that he is ill. Which is why this diagnosis turned out to be quite surprising for him, as well as for his family.
Was the patient immediately qualified for the transplant?
The sixteen-year-old was admitted in critical condition. We were even considering transplanting artificial ventricles for his safety. We had dimensioned and ordered them from Berlin. Luckily, the patient’s condition has stabilized. However, we had to qualify him for urgent transplant. Luckily, a donor was found after only three days.
How did the heart reach the MUW and how long did the transport take?
We had to use air transportation, because a card transport would take too long. We asked the police for assistance. They gave us a helicopter which allowed the heart to reach us in 1 hour and 20 minutes. Had it been transported with an ambulance; it would have taken between 2.5 up to 3 hours.
Why time is of as much importance when transporting organs, in particular the heart.
The maximum time of the so-called cold ischaemia of the heart is 4 hours. They are counted from the moment the donor’s blood flow to the heart stops (which occurs when we begin to excise the organ) until the aorta and the left ventricle are sewn into the recipient (blood flow to the heart is resumed at that moment). This does not leave much time for transport. During extraction, the heart is stopped with a dedicated preparation, which also aims to prevent the death of myocardium cells. Subsequently, it is stored in low temperature (4 degrees C). This is where the expression “cold ischaemia” stems from. If we implant the heart after 4 hours, the treatment is going to give much worse results.
Let us talk about the first cardiac transplantation at the MUW – how did the operation go and how long did it last?
The surgery was performed at the Józef Polikarp Brudziński Public Pediatric Clinical Hospital UCC MUW. It happened on 2 August, i.e., four days after the diagnosis.
The transplantation was carried out without complicating conditions. Sewing the heart in took us half an hour. It is worth to emphasize that this was a so-called transplantation under normal circumstances. This means that we were transplanting the correct heart to the correct chest cavity. Severely more complicated operations occur when the recipient has, for instance, a single ventricle and has undergone other cardiac surgeries. In such cases, the patient’s thoracic cavity must be appropriately prepared to ensure that the appropriate donor’s heart fits inside. This required considerably more time than just sewing the organ in.
It is also worth to emphasize that transplantations require excellent coordination. The heart should reach the operating room at the exact moment when the recipient’s chest cavity is empty and prepared. In the case of the first heart transplantation at the MUW, Krzysztof Zając, the transplantation coordinator at the CCH planned the process perfectly.
What is the condition of the patient now, after the transplantation and what is his prognosis.
He had his first protocol biopsy on August 10. We received assistance from the team led by Prof. Marcin Grabowski at the MUW UCC 1st Chair and Department of Cardiology who has extensive experience in that. Biopsy and echocardiogram allow us to monitor if transplant rejection occurs. During the first month after the surgery, the biopsy is performed once per week. Next, during the first 6 months it is performed twice a month. Next, the period between the examinations can be extended. This monitoring is significant, because transplant rejection is dangerous and must be treated accordingly. Luckily, our sixteen-year-old is less at risk than, for instance, patients with a history of surgeries of congenital heart defects. If nothing happens during the first postoperative period, and the patient takes immunosuppressive agents – the prognosis is very good. He or she will be able to lead a normal, active life. I emphasize that the medication regime cannot be discontinued even for a single day, as it may cause rapid rejection.
How many heart transplantations will you be able to perform at the UCC MUW?
Currently, we are only able to perform urgent cardiac transplantations. If a patient who requires a new heart immediately, we are going to apply to the National Health Fund for approval for a lifesaving transplant. If we receive the approval, we can carry out the procedure and the National Health Fund is going to finance it. When it comes to planned heart transplantations, we are not permitted to perform them yet. It is going to be possible after we sign a contract with the National Health Fund, which I hope is going to happen within the next 1-2 months.
What about lung transplantations?
We are also waiting for signing the contract with the National Health Fund. In the case of lungs, urgent transplantations are practically not required. The only indication for such procedure is a situation is when the patient relies on ECMO, i.e., the lungs do not operate at all, and a machine is breathing for them. As far as I know, we already have four patients who are on their qualification period for a planned lung transplantation.
We have recently received an accreditation from the Ministry of Health to perform heart and lung transplantations. What does that mean for the patients and the MUW?
So far, we have performed liver, kidneys, pancreas, marrow and corneal transplantations at the UCC MUW. We needed chest cavity organs, i.e., the heart and the lungs, as well as multiorgan transplantations. The specialists at the MUW have started to perform them several years ago in cooperation with the employees of the Institute of Cardiology in Anin.
The last accreditation which we have received from the Ministry of Health covers an approval for heart, lung and multi-organ transplantations. We have therefore established a centre which allows for performing transplantations of all organs. This chance allows us to save the lives of many sufferers. Not only adults, but children as well, as the Józef Polikarp Brudziński Public Pediatric Clinical Hospital UCC MUW is located there. Moreover, we intend to allow organs from one donor to be transplanted in one specific place. This means that the heart, lungs, liver, pancreas, kidneys, cornea of the donor who stays in UCC MUW or was transported to the UCC MUW can be transplanted. In such case, the organs do not have to be transported. This allows us to save time and increase the safety of the teams responsible for collecting.
Are heart and lung transplantations in children performed anywhere else in Poland as well?
Heart transplantations in children are performed in only one other Centre in Poland – Silesian Centre for Heart Diseases. Lung transplantations on the other hand are not performed in children’s hospitals. Some children may undergo such transplantation in centres for adults. There is only one condition – the child must be taller than 140 cm. In our centre, we also perform transplantations in children who do not meet that requirement. This may involve transplantations from live donors. During one such procedure, we collect one lower lobe of the lung from the father and the mother and we implant them as complete lungs in the child. Before the procedure, we have the opportunity to carry out a thorough examination of the donors and the recipient, and to select the best time for the transplantation. The total ischemic time of the organ to be transplanted is also significantly reduced. This allows to reduce the risk of complications, and the results of such procedure are better compared to collecting an organ from a cadaveric donor.
Why is accreditation so important in case of multiorgan transplantations?
In the case of persistent depressed cardiac function, in particular in the case of right ventricular dysfunction, venous blood circulation stops which causes organs such as the liver or kidneys to be oversaturated with blood, and tend to get damaged despite the best conservative measures. In such case, heart transplantation alone is not going to bring the patient back to live. The organs must be then transplanted together, i.e., the heart and the liver, the heart and the kidneys. Multiorgan transplantation of the heart and the lung is also an exceptionally complicated procedure. An indication for such transplantation is a severe heart disease, which had been operated multiple times, and which does not only cause depressed cardiac function, but also limits the flow through the lungs. We wish to be able to carry out such complicated multiorgan operations at our centre. MUW has excellent clinical facilities and a great potential at its disposal, which is yet to be utilised in the transplantations of chest cavity organs and multiorgan transplantations. This is changing now. I hope that we are entering a new era of transplantology, not only at the Medical University of Warsaw, but also in Poland.
Interviewed by Iwona Kołakowska
Photo by Michał Teperek
University Communication and Promotion Office