Q&A: Stanford Children’s heart transplant patients ‘not just surviving but thriving’
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Key takeaways:
- Over 50 years, Stanford Medicine has conducted 568 pediatric heart transplants.
- Seth Hollander, MD, credits the program’s successes to its robust pretransplant care and team-based approach.
Stanford Medicine Children’s Health this year celebrated 50 years of pediatric heart transplants and more than 35 years of pediatric lung transplants, according to a press release.
Since its first pediatric heart transplant in 1974, Stanford’s heart transplant team has achieved various milestones in the treatment and care of young patients, according to the release. This includes performing more than 560 pediatric heart transplants and providing more than 200 ventricular assist devices (VADs) to extend patients’ lives until they receive a donor heart.
Healio spoke with Seth Hollander, MD, pediatric cardiologist and medical director of heart transplantation at Stanford Medicine Children’s Health, about Stanford’s pediatric transplant milestones and the future of heart transplants.
Healio: How would you describe your approach to pediatric care, and how has this approach contributed to Stanford becoming one of the leading pediatric heart transplant centers?
Hollander: We are strong believers that every child who can benefit from a heart transplant should get one. We take on very high-risk cases, often cases that have been declined by other centers because they have complex congenital heart defects, multiple prior surgeries or other comorbidities. As a result, we do a lot of transplants, more than 20 per year, which for a pediatric program is a very high volume.
Another way is through excellent pretransplant care. We have a great team that supports and rehabilitates sick patients while they’re waiting for transplant, including by using VADs. This approach allows us to take kids who would otherwise not survive to transplant and not only bridge them, but help them prepare for transplant with good physical therapy, rehabilitation, nutritional rehabilitation and psychological preparation, all of which you need to have a good transplant outcome.
I personally hate the term “waitlist.” We don’t believe that our patients are waiting; we believe that our patients are actively preparing for transplant by getting stronger, both physically and psychologically.
Thirdly, we have a very aggressive, what we call “start with yes” approach to accepting donors. About 40% of hearts that are offered for transplant are not accepted by any center, but we take these hearts and have demonstrated in research studies that we can get kids off the transplant list faster without negative posttransplant outcomes.
Transplant is a multidisciplinary, multispecialty approach of medical doctors, surgeons, nurses, physical therapists, psychologists, social workers, nutritionists and pharmacists. In working together to take this high-risk but aggressive approach to transplantation, we’re able to do a lot of transplants with excellent outcomes.
Healio: What are some notable things that are possible in pediatric heart transplantation now, that weren’t 50 years ago?
Hollander: Transplantation has advanced dramatically since the first adult transplant in 1967 and the first child transplant in 1974. We are now transplanting kids with a wide variety of heart problems. We are supporting smaller and more complicated children with VADs, which allows us to better support them while they’re waiting for transplant. We have also made great inroads into the world of multiorgan transplant, with three combined heart-with-kidney transplants and 18 combined heart-with-liver transplants providing excellent outcomes.
We’re also seeing as the original transplants get older, kids are going on to need their second heart transplant. We’ve done 28 re-transplants or second heart transplants, which historically have had very poor outcomes, but our re-transplant patients are doing very well.
We now think of transplant very differently than we used to. Previously, it was really a matter of keeping patients alive. If your patients didn’t have rejection and they survived, then you went home thinking you did a good job. Now, because survival is so much better, we focus on not just surviving but thriving, and that’s very different than how it was even 25 or 30 years ago.
Healio: How does Stanford’s Pediatric Advanced Cardiac Therapies care model work?
Hollander: The Pediatric Advanced Cardiac Therapies, or PACT, program, which we have had for about 20 years, focuses on patients who have heart failure and often have advanced heart failure care needs. Kids who have heart failure and those who’ve had transplants are often thought of as being in separate phases of care — and are often taken care of by different doctors. But, of course, these things are all occurring in the same patients over time. We focus not on the phase of care, but on the patient having a health trajectory as a seamless continuum. We have specialists in heart failure and specialists in transplant but we’re one team and we always think of the patient as one person who needs our care at different stages.
Healio: What advances in pediatric heart transplantation do you expect to see in the coming years?
Hollander: Additional noninvasive assessments — such as that we can now sample the blood for signs of rejection instead of having to sample the heart, or using imaging techniques that don’t require radiation — are all good for the patients.
I’m very excited to see us move more into what’s often called precision or personalized medicine. Currently, all patients receive more or less the same immunosuppression to prevent rejection. But we are learning that every child is different based on genetic factors, their innate immune systems and how they process medications. We’re going to continue to move in the direction of finding the right “medication cocktail” based on the individual.
I think of two moonshot goals for transplant I would love to see happen in my career. One is the 3D printing of organic hearts, which we are working on here at Stanford Children’s through Stanford’s Basic Science and Engineering program. We have a talented researcher who is working with a large team and has already begun the process of 3D printing hearts from stem cells, such that maybe someday if you need a heart transplant, you wouldn’t get it from a donor but you would literally get it from yourself after your replacement heart was grown in the lab with your own cells. That would be one of many potential ways we could hopefully do transplant without immunosuppression.
In addition, there are also scientists here at Stanford and Stanford Children’s working out ways to manipulate the immune system, such that the donor heart and the recipient body learn how to tolerate each other better. That’s already been demonstrated in kidney transplant and in the lab, and there are active collaborations underway to see if we can make that possible for our transplants.
Healio: How might care of pediatric patients with heart failure evolve in the coming years?
Hollander: On the heart failure side, newer, smaller VADs are enabling patients to wait for their transplant on an artificial heart pump at home.
We’re also improving advanced heart failure care in special populations, including those who historically may have not been offered heart transplant, like kids with Down syndrome or Duchenne muscular dystrophy.
We’re also making a lot of inroads into our understandings of the genetics of heart failure through our cardio-genomic service. Can we figure out what causes certain children to have heart failure and can we intervene early on, such that we prevent the heart failure from progressing and making the transplant itself not necessary?
Healio: Can you share a story that stands out in your mind that reveals the successes and challenges of pediatric transplants?
Hollander: In the 50 years that we’ve been doing pediatric heart transplants, we have done 568 heart transplants, with our latest patient currently out of the hospital and recovering. What’s also remarkable is that our 18th transplant is also out of the hospital and thriving. This patient is still alive, 40 years after their heart transplant. They are a parent, successful in their career and a high-performance athlete. I find it remarkable and inspiring that I can talk to a patient who got their transplant 3 weeks ago and another who got their transplant 40 years ago.
The biggest challenge is that waitlist mortality is still too high. Infants waiting for heart transplants represent the highest-risk group out of any population waiting for any organ, and I find that unacceptable. For me, that is one of the great challenges over the next several decades: How do we make transplant accessible to everyone who needs one?
Healio: Is there anything you would like to add?
Hollander: The first U.S. adult heart transplant took place here at Stanford University in 1968. That patient lived for less than 3 weeks. To be the steward of a heart transplant program that’s been around for 50 years, and to see patients living for decades after transplant is something I take great pride in.
I think of every day after heart transplant as a miracle day. If you’ve been doing heart transplants for 50 years on 540 different patients, you have to wonder how many miracle days have we provided? I did the math for every patient. We have provided more than 1,731,000 miracle days since 1974. That’s a lot of days and a lot of joy. It’s something to be very proud of.
My goal and my hope is that whenever I pass this heart transplant program on to the next director, that they will have the same sense of pride in stewarding this historic program, and that I will pass it to them in better form than I acquired it.
Reference:
- Stanford Medicine Children’s Health celebrates decades of excellence saving young transplant patients. https://www.prnewswire.com/news-releases/stanford-medicine-childrens-health-celebrates-decades-of-excellence-saving-young-transplant-patients-302193763.html. Published July 11, 2024. Accessed July 24, 2024.
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