Hoag Awaits New Heart, New Life for a Dying Man

By LANIE JONES

Feb. 7, 1988 12 AM PT

Times Staff Writer

Since Jan. 9, a middle-aged Orange County man with congestive heart failure has been tethered to a beeper.

The device means he has passed a battery of tests--blood tests, a heart catheterization, an intense psychiatric evaluation--to become the leading candidate for the first heart transplant to be performed in Orange County.

It could happen any day now.

When the beeper sounds, signaling that a replacement heart is ready, the patient must be prepared to rush to Hoag Hospital in Newport Beach to endure four to six hours of cardiac surgery, the prospect of severe infection if his body rejects the donor heart and a lifetime of taking toxic drugs.

That is the price of a transplant that, overnight, could give him new life.

‘Instant Results’

“With heart transplants, you see instant results,” said Douglas R. Zusman, one of his cardiac surgeons. “You see people who are basically dying and within a week they’re on a stationary bicycle and can basically lead a normal life again.”

But donor hearts are scarce.

Across the nation, transplant registries list 681 people, 15 in the Orange-Los Angeles-Ventura County region, as urgently needing new hearts. These are people who are beyond the help of drugs or coronary bypass operations. Their only hope is a transplant.

So for now the Hoag patient and his doctors are waiting.

His surgeons estimate that he can live another six months without the transplant. But it isn’t much of a life.

The patient, who asked his doctors not to identify him for now, is confined to his home, unable to walk more than a few steps without gasping for breath. At night, he must hook himself up to an intravenous line, injecting adrenaline and other cardiac support medicines to keep his frail heart beating until morning.

“He knows he’s deteriorating,” said Aidan Raney, another of his surgeons.

For doctors and prospective recipients alike, the wait for a new heart can be agonizing, because 20% to 30% of all transplant candidates die before a suitable heart can be found.

But if and when a donor heart is found, its arrival sets in motion a precisely choreographed medical drama in which the actors--cardiac surgeons, highly skilled nurses, anesthesiologists, respiratory therapists, pathologists and more--begin a race against time to save a patient’s life and then keep him alive.

This, then, is the anatomy of a heart transplant--the story of how a hospital and its leading players are preparing for that drama.

When Dr. Christiaan Barnard performed the world’s first heart transplant in Cape Town, South Africa, in 1967, it was considered experimental surgery. And there was little doubt that that initial surgery was risky. Barnard’s patient, a 54-year-old man with congestive heart failure, died of pneumonia 18 days later.

In the next two years, doctors around the world performed more than 100 heart transplants. But enthusiasm for the procedure waned quickly; most of the patients died several days or months after a transplant.

In 1979, Sandoz Pharmaceuticals in East Hanover, N.J., introduced a new immunosuppressive drug, cyclosporin A, that greatly improved survival rates from a heart transplant. The Food and Drug Administration initially approved the drug for “investigational use” at a handful of transplant centers around the country. In November, 1983, the FDA licensed cyclosporin as safe for widespread use in transplants.

Overnight, the impact was extraordinary.

At Stanford University Medical Center, cardiac surgeon Norman E. Shumway had been one of the few doctors in the world who had continued to implant new hearts and perfect heart transplant techniques. Only 20% of the people who received a transplant in 1968--the first year of Stanford’s program--were alive one year after their surgery. But with the advent of cyclosporin, that one-year survival rate rose to 68% in 1984. Currently at Stanford, it is 81%.

The American Council on Transplantation reports that 83% of all heart transplant patients in the United States now live for at least a year after their surgery and that 62% are still alive five years after a transplant. There are also reports that some transplant survivors have lived as many as 18 years after their surgery.

As the survival rate has increased, so has the number of hospitals eager to perform transplants. In 1984, there were only 37 transplant centers. Now there are 117, all certified to perform the surgery by a national transplant organization, the United Network of Organ Sharing in Richmond, Va.

Hoag was accepted by the network Jan. 1, joining four other Southern California transplant centers--UCLA, Sharp Memorial Hospital in San Diego, Loma Linda University Medical Center and UC Irvine Medical Center, which has not yet done a heart transplant.

Enter Raney and Zusman.

When Hoag hired the two doctors away from the transplant program at Sharp last February, they were only trying to replace two cardiac surgeons, not start a heart transplant program.

But Raney, 40, and Zusman, 37, said they would only come if they could continue doing transplants. “We’ve invested too much time and training to stop,” Raney said recently.

They had performed a total of 77 heart transplants, most of those at Stanford, where they both trained under Shumway, and 17 others at Sharp’s recently established transplant program. All 17 of their patients have lived a year or more.

Initially, Hoag officials were lukewarm to the idea. Senior vice president Peter Foulke said that he was concerned that heart transplants were too “experimental.”

Eventually, the surgeons’ experience as well as national data on heart transplants convinced Foulke that they were “a proven modality,” and Hoag agreed to go ahead. The hospital expects to charge from $80,000 to $93,000 for the procedure, which is expected to involve a 3-week to 4-week hospital stay.

To accommodate its new surgeons, the hospital spent about $120,000 in preparations, Foulke said.

It hired a transplant coordinator--a nurse who serves as liaison between the transplant patient and the rest of the hospital--and hired another nurse as the manager of the cardiac surgery program. The hospital also spent $80,000 constructing a special “transplant room,” a recovery room modeled after one designed by Shumway with its own air filtering system to protect transplant recipients from infection.

Now that the deed is done, the new transplant program appears to be a public relations coup for Hoag, which is marketing it in newspaper ads and, in conjunction with Valentine’s Day, a public seminar on heart transplants Monday. And though they don’t like to admit it, Raney and Zusman are clearly the hospital’s new stars.

After a morning of surgeries, Raney and Zusman were in shirt-sleeves, relaxing in the high-rise office they share across the street from the hospital.

Raney, who has a boyish manner and close-cropped, ash-blond hair, sat behind a mound of medical journals, fielding questions. Zusman--tall, dark, intense but a little more outspoken than Raney--sat across from his partner, sipping a soda and occasionally interrupting him to offer more details.

Both have an impish sense of humor that was revealed recently when they posed for photographs and kiddingly picked up a large plastic model of the human heart, suggesting that it looked like something that could have been tossed around in the Super Bowl.

Colleagues said they are a rare breed of surgeon.

“They’re extremely compassionate,” said Dr. Joel H. Manchester, Hoag’s cardiology chairman who was on the search team that hired them.

“Sometimes you don’t find that in surgeons. Surgeons come. They do the cutting, and you don’t see them again. These guys show a tremendous amount of empathy not just for the patient but for the patient’s family.”

Both Zusman and Raney worked as chief residents under Shumway, and Shumway has high regard for the surgical team, said Manchester, who talked to the Stanford surgeon in the search for cardiac surgeons.

“The way Shumway put it . . . ‘You can always find a heart surgeon, but it’s hard to find a gentlemen. And these men are gentlemen and excellent technical surgeons,’ ” Manchester said.

Zusman and Raney described Shumway as a demanding teacher and extraordinary surgeon who had shaped their views on medicine.

From Shumway, both had learned to think “total patient care,” Zusman said..

They stressed that they would not just remove the damaged heart, sew in a new one and be done. Their responsibility would not end with the transplant surgery.

Following Shumway’s example, they would be responsible for monitoring a transplant patient’s frequent heart biopsies and staying with him if, as they expect, his body rejects the donor heart. More than that, Raney said, “we’ll be following the patient intensively for life.”

To prepare for the transplant, Raney and Zusman’s first had to get Hoag up to speed on open heart surgeries and then assemble their team.

Hoag’s transplant committee, which screens transplant candidates, consists of 25 people from nearly every department of the hospital, from administration to social services.

Among its key members: cardiac pathologist Lloyd Silverman, 55, who will perform the heart biopsies after the transplant and who recently took a refresher course at Stanford; Stanford-trained anesthesiologists Scott Connolly, 36, and Charles P. Steinmann, 42; transplant coordinator Mary Jane Jones, 39, a nurse who used to work for the Los Angeles organ procurement network; cardiac surgery program manager Linda Pascaralla, 34, a nurse who assisted Zusman and Raney in San Diego; and cardiologist Brian M. Kennelly 52, who from 1968 to 1978 worked in Cape Town, South Africa, with Barnard, monitoring the progress of some of his first heart transplant patients.

After a series of consultations with the committee, Zusman and Raney selected their first candidate for the surgery.

Typical heart transplant candidates suffer either from cardiomypathy (a disease that has damaged the muscle of the heart) or from coronary artery disease. Typically, he or she must be 60 years old or younger with no active infection or major systemic illness like diabetes.

Though the first Hoag candidate has “end stage” congestive heart disease, his other organs are healthy, Raney and Zusman said. And he passed a tough psychiatric screening to determine that he could emotionally handle a transplant.

That latter evaluation was significant because they did not want to “waste” a heart. At Stanford, Zusman recalled, “there were a number of people who became newborn Christians after a transplant. They stopped taking their medications and died. We want to prevent that.”

“We’re talking about the soul of a man, the heart,” said Mary Jane Jones.

Jones, who is Hoag’s transplant coordinator, expects to be the first to learn from the local organ procurement network that somewhere--probably at a trauma center in Southern California--a traffic victim has been declared brain dead and that they may have their donor.

When that call comes, she will page Zusman and Raney, alert the transplant candidate, ask the hospital to prepare to admit the transplant patient and either charter a Lear jet from John Wayne Airport or request that Long Beach Memorial Hospital’s Lifeflight helicopter fly to the heliport at Hoag.

An eligible donor can be a man under age 30 or a woman under age 35 who has the same blood type and about the same weight as their transplant candidate. The age of the donor is important, Raney said: “You don’t want to give someone an old heart because of all the possible complications later.”

But even if the donor heart sounds like a match, one of the two cardiac surgeons must personally inspect it, Raney and Zusman said.

“You don’t want someone you’ve never met to take out a kid’s heart,” Raney said. “It’s not like a kidney transplant where if the kidney doesn’t work, they can go on dialysis. If the heart doesn’t work, our patient dies.”

Ideally, Raney said, the donor will be a Hoag patient and Raney or Zusman could remove the heart in one operating room, then perform the transplant surgery in an adjoining operating room.

But chances that the heart will come from a Newport Beach donor are slim. More likely, Zusman or Raney--accompanied by Pascaralla and another operating room nurse--must take Lifeflight to a distant hospital to retrieve the donor heart.

When they get there, they check to see if the heart is beating properly. “If the donor was in an accident, we’ll also look to see that there are no bruises,” Raney said. Only if he is sure the heart is healthy will he remove it, he said.

Once, at Stanford, “we went ahead with one donor where the heart seemed OK. The heart looked good, but it also looked a little bluish.”

Several days later, the donor heart failed, and the patient had to have another transplant.

So if there is any doubt about the heart, the surgeon will close up the chest, scratch the transplant operation and wait for another donor, Zusman and Raney said.

But if the heart is acceptable, they will telephone the news to Hoag. Only then will their transplant candidate undergo anesthesia. “It’s a fail-safe system,” Zusman said. “You don’t put a person at risk for general anesthesia until you know you’re going to go ahead with the surgery.”

Once the aorta of the donor heart is cut, the surgeons begin a race against time. They have exactly four hours to implant the new heart. No more. In medical terms they are now on “ischemic time,” the time when a heart is cut off from its blood supply. Cardiac experts figure that such a heart can survive for four hours without damage. Beyond that time, there are no guarantees, Raney and Zusman said.

Raney estimated that if the donor heart is acceptable, he can remove it in a 35-minute surgical procedure. Then it will be a matter of plunging it into a saline-filled, blue Playmate carrier packed with ice and rushing it to Hoag.

Once the heart arrives at Hoag--but not a moment before--the transplant recipient will be placed on a heart-lung bypass machine, Zusman said. He and Raney recited several horror stories about transplants--by one account, the helicopter transporting the donor heart had crashed just as the recipient’s chest was opened up.

Also, there reportedly was a situation where a heart surgeon’s jet refused to start and the governor of North Dakota mobilized an F-4 fighter plane that was on alert for the North American Aerospace Defense Command to rush the donor heart to its recipient.

So Raney and Zusman don’t take chances. “We’ll open up the patient as the surgeon with the donor heart walks in the door,” Zusman said.

The actual transplant surgery would be far less complicated than many coronary bypass operations, Zusman said.

Though the entire surgery is lengthy, involving slowly sedating the patient, putting him on the heart-bypass pump and carefully monitoring his condition, it takes perhaps five minutes to remove the damaged heart, then another 40 minutes to sew the new heart in place.

The surgeons’ first view of the damaged heart is sometimes startling.

A normal heart is “about the size of a man’s fist,” Raney said, but a damaged heart could be swollen to five times that size--perhaps “the size of a cantaloupe or even bigger. . . . And there are times when we go in and you can barely see it move.”

Working together as quickly as they can, the surgeons will remove the damaged heart, then implant the new heart. “One of us will sew in one side; one of us will sew in the other,” Raney said.

Once the heart is implanted and the new heart started beating, a new phase of heart transplant surgery begins.

Now the surgeons’ job is to prevent infection. Working with critical care nurses, cardiologists and a Hoag pathologist, they will give the patient massive doses of immunosuppressive drugs to prevent his body from rejecting the new heart and monitor him closely for signs of rejection.

Actually, the monitoring process will last months and years after the surgery. At any time after the transplant, the recipient could reject his new heart, Raney and Zusman said. “The incidence of rejection is high. We tell everyone they are going to have rejection,” Raney said.

Added Zusman, “They’re never out of the woods.”

Superficially, Hoag’s new “transplant room,” with its pink draperies, lounge chair and private bathroom, resembles a typical private room at the hospital.

But the room has been specially designed for infection control. Special ducts filter the air in this chamber. It has a glass-walled anteroom--a nursing station at which, in the first day after the transplant, two critical-care nurses will monitor the transplant patient 24 hours a day.

The room also has strict rules about who may enter.

In the first days after the transplant, nurses must clean it daily with a germicidal solution because hospital housekeepers will not be allowed inside. And no one with a cold may enter because a transplant patient is on a heavy dose of cyclosporin, steroids and other immunosuppressives to lessen his chance of rejection, and so is at high risk for infection.

A major concern for those who tend the patient here is rejection. To find out if that is occurring, Zusman and Raney plan to biopsy the new heart every week for at least eight weeks --threading a thin instrument through their patient’s jugular vein and snipping off several small pieces of heart muscle.

The procedure is uncomfortable but not very painful, the surgeons said.

Pathologist Lloyd Silverman, who from 1963 to 1969 was at Stanford performing heart pathology on Dr. Shumway’s transplant patients, will do the analysis.

If rejection occurs, the patient may not notice it because his new heart has no nerve endings and so does not feel pain. But Silverman will be able to detect it under his microscope. He can see the lymphocytes “invading the heart and attacking the heart muscle. You see cells beginning to surround the small vessels of the heart and infiltrate between the muscle and you see some signs of destruction of the heart and muscle,” Silverman said.

But rejection is a spooky business. It can happen overnight. “Within 24 hours, a person can look fine and have a temperature of 98.6--and he can die within 24 hours,” Zusman said.

When it occurs, Raney and Zusman sharply increase the patient’s dose of immunosuppressives. If that doesn’t work--and that is rare, the surgeons said--they might have to do a second heart transplant.

Zusman and Raney figure their first patient will stay in this isolation room for about a month. After a couple of weeks, he will be able to leave the room and, clad in mask in gown, take walks along the third floor of the hospital. In fact, part of his therapy in the hospital’s cardiac rehabilitation program is to take those walks to condition his body again.

Should Have Good Life

If all goes well, the transplant patient should be able to go home after a month. He will be on immunosuppressives and monitored closely for the rest of his life, Zusman and Raney said, but odds are he should have a good life; he may be able to return to work, to choose what he wants to do.

Though there is never a point in a heart transplant case when you can claim victory, Raney said the transplant team at Sharp sometimes celebrated with a quiet dinner when one of the patients had lived a year.

“When you’re done and the patient is doing well, you feel good,” Zusman said. “And when someone is doing poorly, you feel terrible about it.”

An Elating Experience

Mostly though, a successful heart transplant is an elating experience for the patient and the entire transplant team. Raney recalled the reaction of one of his first heart transplant patients at Sharp the morning after the surgery. “He said, ‘My God, my hands are warm and my feet are not blue anymore.’ ”

With Hoag at full capacity, hospital staff are using the transplant room as a recovery room for other surgery patients, but as soon as a donor heart is found, its occupant must leave.

So for now, the room is still waiting for its first transplant patient. The drama of a heart transplant has yet to begin.

Times librarian Daniel J. Crump contributed to this story.

ANATOMY OF A HEART TRANSPLANT

THE SURGERY

Harvesting the donor heart

1. Regional Organ Procurement Agency in Los Angeles indicates a donor heart is available at a hospital in Southern California. The donor, probably a traffic victim, has been declared “brain dead.”

2. A cardiac surgeon opens the donor’s chest with a sternal saw , then examines the donor heart to see if it contracts correctly when it beats. If the donor has been in an accident, the surgeon also checks to make sure that the heart is not bruised.

3. In a 35-minute procedure, the cardiac surgeon flushes the donor heart with cardioplegeia a solution to make it stop beating, then carefully removes it.

4. The donor heart is placed in a saline-filled, ice-packed container and cooled to about 4 degrees centrigrade. Then it is rushed to the transplant recipient’s hospital.

Implantation of the donor heart

1. As soon as a cardiac surgeon signals that the donor heart is suitable, aides wheel the transplant recipient into the operating room. The anesthesiologist places the patient in deep sedation, inserts a catheter next to the heart and carefully monitors fluid pressures in the recipient’s damaged heart. He tries to keep the heart and other organs going until the donor heart arrives.

2. As soon as the donor heart arrives at the operating room, the transplant recipient is placed on a heart-lung bypass machine. In that procedure, a cannula--or tube--is placed in the damaged heart’s aorta and two more cannulae are placed in the heart’s atrium passing into the venae cavae. As soon as the bypass machine begins oxygenating the transplant recipient’s blood, surgeons clamp the aorta of the damaged heart, cut off the venae cavae and remove the heart.

3. Surgeons cleanse the donor heart in a saline solution, then begin implanting it, starting by opening the donor’s pulmonary veins in the heart’s left atrium. The donor heart’s left atrium is then sewn to the recipient’s left atrium. Surgeons then connect the right atrium, reconnect the aorta and reconnect the pulmonary artery.

4. With the heart implanted, surgeons make sure the heart has no air in it. Then a technician weans the recipient off the heart-lung bypass machine and blood rushes into donor heart. The heart begins beating. Surgeons control any bleeding and then close up the patient’s chest. The patient is transferred to the recovery room.

Sources: Drs. Aidan Raney, Douglas R. Zusman, Charles P. Stinmann; “Techniques in Cardiac Surgery” by Dr. Denton Cooley; World Book Encyclopedia.

CARDIAC BIOPSY

Approximately one week after surgery, a cardiac biopsy is performed using a local anesthetic. An instrument the size of a pinhead is introduced via the jugular vein, and a tiny sample of heart muscle is analyzed for signs of rejection. The biopsies are performed on a weekly basis for about three months, then monthly, then bi-monthly, then every 90 days.

Sources: Drs. Aidan Raney and Douglas R. Zusman; “Cardiac Surgery,” edited by Dwight Mc Goon.

SURVIVAL RATES*

Survival is expressed in terms of a given time period after the heart transplant surgery.

1967-1977: data from 206 cases

30-day survival rate: 82%

60-day survival rate: 69%

90-day survival rate: 61%

1978-1984: data from 1,245

cases

30-day survival rate: 86%

60-day survival rate: 80%

90-day survival rate: 77%