Building on pioneering work performed during the first wave of heart-lung transplantation, Brigham and Women’s Hospital has resumed its heart-lung program and is once again performing the rare procedure.
In March, patient Camille Frede, 28, received a heart-lung transplantation that cured the pulmonary hypertension she had lived with since age 4, the result of an atrial septal defect (ASD). It was the first heart-lung transplant at Brigham and Women’s Hospital in more than 20 years.
Her successful surgery came about through a confluence of factors: The arrival in recent years at the Brigham of two surgeons experienced in the double-organ transplantation, teamwork and innovation among the many necessary departments, and a patient who was extraordinarily involved in her own care.
“It went incredibly smoothly,” said Aaron Waxman, MD, PhD, director of the Brigham’s Pulmonary Vascular Disease Program and Frede’s pulmonologist for the past decade. “And for the next heart-lung transplant here, it will go even more smoothly.”
“The Brigham has a unique ability to bring together highly trained and capable experts in multiple disciplines to focus on a problem,” said Hari Reddy Mallidi, MD, FRCSC, section chief for Transplant and Advanced Lung Diseases in the Division of Thoracic Surgery, who performed the transplant. “The heart teams and the lung teams all got together and everyone’s expertise was utilized to the full potential to bring back this great treatment option for patients with end-stage heart-lung disease. Now, these patients will be able to stay in the Northeast for their treatment.”
Dr. Mallidi joined the Brigham in 2015, after building lung and heart-lung transplant programs at Baylor College of Medicine and the Texas Heart Institute. He previously completed a Cardiothoracic Transplant fellowship at Stanford University and led the program there in Ventricular Assist Devices.Also involved in the surgery was Steve Singh, MD, surgical director, Heart Transplantation and Mechanical Circulatory Support, in the Department of Cardiac Surgery. Dr. Singh previously served as surgical director of Lung and Heart-Lung Transplantation at Baylor College of Medicine and as chief resident in the Department of Cardiothoracic Surgery at Stanford, where he also completed a fellowship in Mechanical Circulatory Support.
From the time of Dr. Mallidi’s arrival at the Brigham, his colleagues at the Lung Center and in the Heart & Vascular Center expected to resume heart-lung transplants at the hospital. In late 2017, as Frede’s lung failure worsened and all medical options were exhausted, Dr. Waxman thought it may be time.
“When I got concerned, I called Dr. Mallidi and talked about the possibility of a heart-lung transplant,” said Dr. Waxman. The patient’s heart function was adequate, but her ASD necessitated a single-block transplant of both organs. “We talked about the timing to bring her into the hospital.”
In February, Frede was admitted to the Brigham, which is an accredited Pulmonary Hypertension Comprehensive Care Center. Within weeks, she required ECMO (high-flow oxygen and extracorporeal membrane oxygenation) to sustain her until donor organs became available.
“Everyone needs to be willing to listen to each other . . .”
The wait for suitable donor organs gave the care teams – mechanical support, two transplant teams, and the ICU — time to plan and address any hurdles in their coordination. The transplant teams already had a close collaboration through shared research, common use of ECMO and other mechanical supports, and monthly meetings of the Brigham’s solid organ transplant teams, said Michael M. Givertz, MD, medical director of the Heart Transplant and Mechanical Circulatory Support Program. “But we needed some structured meeting time to ask: ‘What are our current indications and contraindications for heart-lung transplant?’”
“It was important to get everyone in the same room to discuss when to make things happen,” said Dr. Waxman. “The inputs from these conversations made it easy. You need to be able to communicate freely. Everyone needs to be willing to listen to each other and agree, without egos getting in the way.”
After decision-making algorithms were created, the teams came together in real time to work through specifics of the surgery itself. During this exercise, “the surgeons were the least concerned,” said Hillary Goldberg, MD, medical director, Lung Transplant Program. “Technically, this was less complicated than a lung transplant alone. While the surgeons were experienced with the double transplant, it was very helpful that the anesthesiologists spoke up and asked the surgeons to walk through potential complications that could arise during surgery.”
“It’s important to have patients like this to give feedback when you try new things”
Frede was an unusual patient, in part due to her commitment to staying fit and being “meticulous in her own care,” said Dr. Givertz. Even while on ECMO in the hospital, she exercised on a stationary bike. Another factor was her training as a nurse. Above all was her desire to share in all decision-making.
“She became a real team member,” said Dr Goldberg. “We incorporated her input, and we will use it for other transplant patients. It’s important to have patients like Camille to give feedback when you try new things.”
Her case also gave her physicians ideas for process improvement for the next heart-lung patient, such as presurgical examination of chest wall bronchial vessels in a cath lab and, if needed, embolizing them before the transplant.
Looking back on Frede’s successful transplant, the physicians agreed that the greatest challenge was maintaining her health before the surgery. “The most gratifying part was the ability to support her so that she could be healthy and involved,” Dr. Goldberg said.
Candidates for heart-lung transplant are a small patient population, but one that Dr. Givertz expects to grow due to success in managing pediatric heart disease. “There’s an emerging epidemic of patients living into adulthood with surgically-corrected defects, which can lead to cardiac or heart-lung failure,” he said. The Brigham’s Adult Congenital Heart Disease Program in the Heart & Vascular Center can address their needs. “We have the ability to evaluate these patients,” Dr. Givertz said. “There may be other medical treatments that we can offer or surgeries that we perform here to correct a heart defect structurally” before considering transplantation.
At the Lung Center, the growing lung transplantation service – which tripled in annual volume, from 26 transplants in 2015 to 75 in 2017 – is prepared.
“These patients need an advocate,” said Dr. Waxman. “If they are here, within our care, we are their advocate.” As for Frede’s case he added: “We definitely put the patient first. And the outcome reflects that.”