2018 was a history-making year for the Department of Cardiothoracic Surgery. The Department completed 10 heart-lung block transplants, twice as many as the next highest volume center, which performed five such procedures in 2018.
“To the best of our knowledge, Stanford is the highest volume program in the world. And during the past five years, our patients have had a 100 percent one-year survival rate,” says Joseph Woo, M.D., who heads the Department of Cardiothoracic Surgery. “We have outstanding physicians, surgeons, nurses, health care providers and administrative leadership, and they all contribute to that success.”
A Rigorous Approach
Potential candidates suffer from a variety of conditions: cystic fibrosis, congenital heart disease and other cardiorespiratory conditions, and the system must flex to meet each person’s individual needs.
“These are the sickest patients, and it’s a little bit tricky to decide on both heart and lung,” says Yasuhiro Shudo, MD, PhD, clinical assistant professor of Cardiothoracic Surgery. “We need to consider donor availability. For heart-lung block, we need three separate organs en bloc from the same donor, which is pretty challenging.”
Heart-lung block transplants require a large multidisciplinary team to manage the many moving parts. Clinicians, case managers and others collaborate closely to determine each candidate’s suitability for the procedure and ensure they are fully prepared for their surgical and post-operative marathon, which will impact their lives long after the actual procedure has been completed.
The surgery generally takes between four and six hours, depending on the patient’s condition and medical history. Recipients who have had previous cardiothoracic procedures or complicated congenital abnormalities often require more time. The heart is connected to five blood vessels, while each lung must be attached to three. The surgical team takes special care that none of these connections leak and no nerves are damaged during the procedure.
Stanford succeeds at higher acuity cases, like these, by refining all aspects of care. Improved surgical approaches have combined with advances in organ preservation, immunosuppression and mechanical circulatory support systems. Patients do well because the team of surgeons, critical care specialists, pulmonologists, pharmacists, case managers, social workers and nutritionists effectively coordinates their care from start to finish,
“We have been good at optimizing recipients medically and physically prior to surgery,” says Shudo, “building specific protocols for donor selection, pioneering improved donor organ procurement and preservation techniques, as well as improving recipient surgical techniques and developing excellent collaborations with post-op care.”
Stanford performs more of these procedures than other centers, so its team has the experience that often leads to positive outcomes. Clinicians in the ICU know the specific dangers these patients face after surgery, which gives them an advantage when providing post-operative care. This also applies to nurse coordinators and pharmacists, who are well-acquainted with medication protocols to control the patient’s pain, reduce infection risk and allow the body’s immune system to accept the new organs.
This approach has generated long-term success over the past ten years. In a paper published in the European Journal of Cardio-Thoracic Surgery, Shudo, Woo and colleagues showed that more recent transplant patients have higher acuity, but technical refinements have kept pace, delivering excellent results. Stanford conducted 49 procedures between 2008 and 2018 and had a 100 percent one-year survival rate. Long term, the median survival was 10.3 years. This is particularly significant, as the majority of patients were under 50 and, if healthy, would have many years of quality life in front of them.
“Many institutions may hesitate to conduct heart-lung transplants,” says Shudo. “We have several referrals of candidates from outside institutions, potentially because they know that Stanford is doing the most heart-lung transplants. Based on our recent excellent results, we are expanding the inclusion criteria. We recently performed heart-lung transplants in patients with complicated congenital heart conditions.”
Carrying it Forward
Stanford Health Care has a long history in transplant medicine. Stanford surgeons, led by Norman Shumway, MD, PhD, conducted the first adult heart transplant in the U.S. in 1968. Thirteen years later, Bruce Reitz MD, led the world’s first heart-lung transplant. That legacy continues today, as Stanford specializes in multi-organ transplantation: lung-liver, heart-liver and heart-lung.
In recent years, the hospital has added complex valve repair to its repertoire. “We are repairing all the valves inside the heart instead of replacing them,” says Woo. “Patients get to keep their own living tissue, which is much better long-term.”
Stanford surgeons have also adopted more advanced approaches to conduct coronary artery bypass grafts, such as arterial conduit procedures and robotic bypasses. The team has also embraced transcatheter valve technology, which allows specialists to replace heart valves in patients who could not tolerate having their chests opened for surgery.
In addition, the Department of Cardiothoracic Surgery has grown its numbers to meet demand from California, Nevada, Oregon and other regions. Higher surgical volume does not just improve heart-lung block outcomes, but also increases quality throughout the system.
“As our hospital gets larger—we have a brand-new building opening up this year—we are going to have the capacity to undertake even more operations, both the most difficult and the routine,” says Woo. “Patients have come to recognize that the place that provides the most complex care can also deliver the simpler procedures extraordinarily well.”