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Heart Transplant in Children: What Can Be Done While Waiting for a Transplant [Transcript]

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Dr.  Luca Vricella talks about pediatric heart transplants at Johns Hopkins.Dr. Luca Vricella talks about pediatric heart transplants at Johns Hopkins.
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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

Describe what you do.

My name is Luca Vricella and I currently head the pediatric heart transplantion 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.

What conditions cause a child to need a heart transplant?

So the conditions that require heart transplantation in the pediatric age group are different if you look at patients who are in the early infancy than older patients in the pediatric age group. So when you are considering infants, or neonates, you are mainly dealing with congenital heart disease – things that they are born with and require surgical intervention early on. And sometimes these surgical inteventions fail because of, you know, a variety of reasons - you’re born with a single ventrical, or basically what you’ve done so far does not help the heart any more. So those conditions we usually transplant patients, anywhere from infancy to usually seven or eight years of age. And those are patients that typically will have a condition that they are born with. So they have congenital heart disease as their main indication for transplantation.

When you move into the older pediatric age group – so teenagers and adolescents and from eight years on – the indications do change. And a lot of these children are perfectly fine until then, and then they have something that happens – a viral cardiomyopathy – the get, their heart enlarges…clearly with no reason. They get restrictive cardiomyopathy. So these patients have a different indication – they’ve never had surgery before and they come in with sudden failure or progressive decline of their function.

What would you tell a patient’s family who has just been told their child needs a heart transplant?

So when we reach criteria for transplantation of patients in the pediatric age group, we have to consider what the patient has to be told according to the age group – of course what you tell to a teenager will be different from what you tell to a seven year old child. Then of course, what you tell the families. For parents this is a very stressful and emotional time in their lives. So the way that I approach the families about this particular problem is to give them hope. At that point, it’s an almost hopeless situation, but what I tell them is that pediatric heart transplantation is a very consolidated form of therapy, that it’s been around for, you know, forty years. But at the same time I tell them we’re not only changing, you know, the heart, we’re changing the quality of life for this patient. Because what we want to do is for their child to go back to having a perfectly normal life. The difference is the medications they are on. But their level of activity of what they can enjoy and do over time is just the same as any other child.

What options are there for keeping a child stable while they wait for a heart transplant?

One of the most recent developments in pediatric heart transplantation has been that of the introduction of mechanical support of children. So the pediatric age group, from neonates all the way to adolescence, we have now assist devices. These are basically artificial hearts that allow for us to support the patient from the time of decline of their physical condition to the time of heart transplantation. Without a device, a lot of these patients would not be alive. They would not reach a heart transplantation.

So these are devices that we need to get approval for. These are devices that are, of course, very expensive, and not every center does this kind of particular operation. So, I think, one of the things that we do here is provide comprehensive care for these patients. We have a very, you know, very well run pediatric heart failure program, which includes assist devices, ECMO [Extracorporeal Membrane Oxygenation], heart transplantation, and complex congenital heart surgery. So we cover all bases from neonates to basically when you’re 18 and then beyond in the adult heart transplant group.

Currently, we have a program that provides comprehensive care for patients in the pediatric age group. And what we can provide these patients with is assistance – so mechanical assistance, artificial hearts basically, that will bridge them to transplantation. And this true for patients all the way from neonates to patients who are 18 years of age or older. So there’s a variety of assist devices that are available to patients now that were not available ten years ago, especially in this smaller, you know, subset of patients.

How are assist devices implants?

When a device is indicated, it is an open heart surgical procedure. We have to actually enter, you know, through the sternum and connect the heart to these devices. So the devices are usually, especially in the smaller age group, are pericorporeal, they are just pulsatile machines that are right there, that are connected to the heart but come out through the skin because there’s not enough room.

So we’ve had success with these and we’ve had patients who are bridged to transplantation successfully after a long period of time. So it’s not only that we support patients acutely, but we can actually bridge them to transplantation over months. It takes a very strong team to do this.

Why do you do what you do?

Pediatric heart transplantation is a relatively smaller part of what our team does. We care comprehensively for all sorts of congenital heart disease in patients. And some of them will actually need transplantation. So we’re a busy heart transplantation service, but it’s a smaller part of the big picture.

Personally, I’ve been involved in heart transplantation for twenty years. And as a medical student, I actually came from Italy to the United States, just to see the guy who fathered heart transplantation in neonates, Len Bailey of Loma Linda operate. And I was just struck – it was the most amazing thing I’ve ever seen. I remember coming off from the airplane. Two days later I was scrubbing in for a heart transplant for a neonate. And it was a magical thing. And to this day, when you take the clamp off and the heart starts beating again, it is magical. And it’s rewarding and it’s wonderful and it’s an amazing thing that happens.

Why should a parent come to Hopkins for treatment of pediatric heart conditions?

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.

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