Sharp, UCSD Doctors Hope to Do 1st Heart-Lung Transplant Within 2 Months
Doctors at Sharp Memorial Hospital and UCSD Medical Center hope to do their first human heart-lung transplant within two months, pushing into a relatively unexplored frontier of transplantation.
If successful, the heart-lung program eventually could lead to unilateral lung transplants, making San Diego the second city in California and one of a handful in the nation where that experimental operation is available. In 1987, there were only five lung transplants done in the United States.
However, San Diegans’ hopes could be dampened by two immediate obstacles: how to finance the effort, and the new UCSD medical dean’s push for a long-term transplant strategy.
“The question is, what do we want to do in terms of the whole transplant program?” said Dr. Gerard N. Burrow, who took over as medical school dean in March. “Is the direction we want to go off in . . . a major academic transplant program?”
Burrow said he expects the university to have answered that broad question within three to four months, as part of its continuing look at problems in the liver transplant program.
All four liver patients died, and the program was suspended in February. That left UCSD’s surgeons doing transplants only of kidneys, corneas and, in a program based at Sharp, hearts.
Despite Burrow’s four-month timetable for the overall look at transplants, doctors at Sharp and UCSD hope to do their first heart-lung operation within two months, said Dr. Rob Adamson, co-director of heart transplantation at Sharp and an assistant professor at UCSD.
“At first we will just try to do one of the lungs and the heart, or a double-lung and the heart,” Adamson said. The more experimental operation of transplanting lungs by themselves will come later, he said.
“I would hope to be on line within a couple of months,” Adamson said. “It’s difficult to make an institutional marriage. Right now, we’re working out funding and a cooperative agreement between the two institutions.”
The nine-doctor team of surgeons and lung and heart specialists has concluded that each institution would have to kick in $500,000 for the first year of a program, after which it is hoped that the program will be self-sufficient, Adamson said.
This would be a major commitment from UCSD, which now mainly lends its name and status to the Sharp program. No university money is now put into heart transplants, said Pat JaCoby, spokeswoman for UCSD Medical Center.
As the UCSD experience of losing at least $320,000 on liver transplantation illustrated, however, breaking even is far from certain in a new transplant program.
The $150,000 lung operation is considered so untested that its costs generally aren’t covered by private insurance companies. State medical programs, such as Medi-Cal, won’t reimburse for transplants at a given institution until it has a proven track record.
So, at UCSD, the cost of two out of four liver transplants was borne by the hospital. At Sharp, it took 3 1/2 years to meet the state requirements for Medi-Cal funding.
A Seattle researcher who has followed the development of heart transplant programs nationwide questioned the wisdom of starting a heart-lung program in a financially tight environment. For instance, UCSD lost $1.9 million last year and Sharp $900,000 because of unpaid medical bills for uninsured accident victims they treated in their trauma units.
“From an institutional standpoint, it’s very expensive. And, from a financial standpoint it’s very risky,” said the researcher, Roger Evans, a medical sociologist for Battelle Seattle Research Center. “I think that, realistically, they’re probably making a mistake if they really have that level of an indigent health care problem that they’re trying to contend with.”
Not only would a lung program require an infusion of cash at a time when hospitals already are short of money but the demand would come when doctors can expect their lowest success rate. Only about 60% of lung recipients now live more than a year, Adamson said, and a new transplant program can expect its percentage to be significantly lower.
Indeed, it was a string of early fatalities that led to the suspension of UCSD liver transplants and eliminated the program that Sharp had briefly in 1983-84.
“It’s going to be a few bleak years where the results aren’t as good, and aren’t where we’d like it to be, before it gets better,” Adamson said. “It’s more than a philosophical issue right now. It’s a financial one.”
Heart-lung transplants, which numbered 41 last year in the United States, remain experimental and without the one-year success rate of more than 80% in heart transplants. Most of them are done at Stanford University and the University of Pittsburgh.
Lung transplants are even rarer, with only five done last year in the United States. The University of Toronto in Canada has led the way internationally in lung transplants.
Lack of Donors at Stanford
At Stanford University Medical Center, where doctors have performed 53 heart-lung transplants since 1981, doctors have wanted since late last year to transplant individual lungs. But the program has yet to treat its first patient because of a lack of donors, a spokeswoman said.
Unsuccessful lung transplants occur largely because of excess bleeding and failure of the new lungs, Adamson said. It also is harder to find lung donors than heart donors because a traumatic accident that leaves the heart undamaged can still cause lung bruising or infection and make the lungs unusable, he said.
Nevertheless, lung transplants would offer hope to a broad group of patients who now have no medical alternative. The Sharp/UCSD program would at first concentrate on heart-lung transplants in patients whose faulty lungs have irreparably damaged their hearts. Later, double- or single-lung transplants would give new hope to patients with conditions such as cystic fibrosis and emphysema.
Despite the technical obstacles, Burrow said he thinks the next organ transplantation effort in which UCSD might get involved would be for lungs. In the longer term, pancreas transplants would also be a possibility, he said.
As for liver transplantation, that ambitious effort remains on hold both as part of the investigation into its track record and because of Burrow’s push for a review of UCSD’s transplant efforts overall.
Dr. Ruud Krom, head of liver transplantation at the Mayo Clinic in Rochester, Minn., visited UCSD recently to review the program’s records along with another outside expert, but the results of the inquiry are being kept secret. Dr. A. R. Moosa, head of surgery at UCSD, did not return several phone calls seeking comment.
The inquiry has moved beyond the specifics of why the patients died and into the issue of how “enormously expensive” such a program is, Burrow said.
“The question that really needs to be decided is that, given limited resources, should we go ahead and pursue liver transplant,” Burrow said. “The answer may be yes, but we need to step back and look at it. And we need to look at it in relation to heart transplants, future lung transplants, pancreatic transplants.”
