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Featuring Luca Vricella,MD, Associate Professor of Surgery, Assistant Professor of Pediatrics, Chief of Pediatric Heart and Lung Transplantation, Assistant Director Pediatric Cardiac Surgery
My name is Luca Vricella and I currently head the pediatric heart transplantation and pediatric heart surgery program at Johns Hopkins. It’s a busy service, we do about 300 cases a year. We’re one of the leading centers on the East Coast in regards to pediatric heart transplantation.
So heart transplantation is a very orchestrated effort. It takes time for these cases to take place and there’s a donor team and there’s a recipient team. Sometimes you’re on both sides of the fence. I a lot of times will go and retrieve a heart and then implant it, which translates into, for me, a twelve to sixteen hour operation. For the patient, it depends on what kind of procedure the patient has had before. If the child has never had an operation before, then the operation could be less than four hours. If the child has had multiple operations before, then the operation may be six or eight hours.
So the length of the operation varies according to what the prior operations have been in this particular child. Some of them can be extraordinarily complex and then reconstruction can be very difficult. So it’s very…it’s actually very good or useful for a surgeon who understand congenital heart disease to do a case like this. Because we know how to treat or palliate these conditions very early on in life. We’re the ones who have to take everything down and then put it back together. So we really understand how these things need to be done. That’s why it’s really good to have a congenital heart surgeon do pediatric heart transplantation.
The recovery of these patients varies according to how they came in. if they came in an extremist, they are bridged with a device, or they are on ECMO [Extracorporeal Membrane Oxygenation], it may take some time, you know, to recover from the heart transplant. If you come in and you’re, you know, sort of an elective case, that you’re at home on a fusion and you come in here and get a heart transplant, and you’ve never had surgery before, you could be home in a week. So it varies according to the complexity of the operation that was done before, and the status of the patient when they arrive to the hospital.
Usually the scar that is present after surgery is a midline incision. Some of these children will have already had one, and we’ll just go through the same one. Some of them never had one, and sometimes you do have small incisions down towards the lower part of the chest, especially if they have an assist device in place.
Pediatric heart transplantation is a very consolidated form of therapy for heart disease. And the…not only do you change quality, but of course you have a big impact on longevity of these patients. And quality of life is basically they go back to doing things that every child does. They participate in sports, they do well in school. I mean, I enjoy personally, as a physician caring for these patients, to get feedback about what happens later on in their lives. How active they are and how they can participate in everything in their childhood. In terms of how well they do long term, it depends on at what age they receive their transplantation and if they’ve have prior surgery. So let’s say, infants for example, and small children will do better the adolescents. And if you look at the median survival- so that point in which 50% of patients will, unfortunately, have died, long term - for an infant, it’s about 19 years. And for an older child, an adolescent, it’s about 13 years. But if we take away the early mortality, so that portion of patients that die in the first year, where the mortality after heart transplantation is more pronounced, the survival is more around 20 – 22 years – the median survival. So it’s a long term proposition. And most important, it’s an amazing quality of life that these patients have. That’s why it’s important to have families who are compliant and follow medications. Because without their support, and the support of a big team, this would not be a long term proposition.
Retransplantation is a reality in the care of these patients and currently it’s about two to four percent of all transplants that are performed in children that are retransplantations, whether they happen right away because you have acute failure or later on, it’s a small but growing population of patients. And what we’ve seen is that once you actually transplant them again, their overall survival is comparable to what happened before. So when you retransplant these patients, you almost set the clock back, then you know, you take it on from there.
A patient should come to Hopkins because we provide comprehensive care for patients of pediatric heart failure. And we can provide them with any form of assist device and any form of surgical treatment of their disease. And it’s not only complex neonatal heart surgery, but it’s also implantation of a mechanical assist devices or artificial hearts. And then, of course, heart transplantation. We offer the full spectrum of therapy for these patients.