Stanford Health Care’s Department of Cardiothoracic Surgery completed ten heart-lung block transplants in 2018 – more than any other group in the world. By comparison, the facility with the next highest total conducted five.
“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.”
This achievement, particularly with such a challenging procedure, is emblematic of the work being done by cardiovascular surgeons and cardiologists at Stanford Health Care. Taking on the most difficult cases – even relatively rare ones – raises the bar across the board.
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. There are many considerations.
“These are the sickest patients, and it’s a little bit tricky to decide on both heart and lung,” says Yasuhiro Shudo, M.D., Ph.D. 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 effectively coordinates their care from start to finish: surgeons, critical care specialists, pulmonologists, pharmacists, case managers, social workers, nutritionists.
“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.”
Because Stanford performs more of these procedures, the 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.1
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 heart-lung transplant candidates from outside institutions, potentially because they know that Stanford is doing the most heart-lung transplants. They prefer to transfer the patient to Stanford because they know we do a lot of these heart-lung transplants. In addition, 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, M.D., Ph.D., conducted the first adult heart transplant in the U.S. in 1968. Thirteen years later, Bruce Reitz M.D., led the world’s first heart-lung transplant. That legacy continues today, as Stanford specializes in multiorgan transplantation: lung-liver, heart-liver, and heart-lung.
It also means not standing pat. 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. “So, 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, it also increases quality throughout the system.
The Pillars of Academic Medicine
In addition to increasing its complement of surgeons, Stanford Health Care has added residents, training the next generation of surgeons, cardiologists, electrophysiologists, and other specialists.
That growth extends to research as well: from pure molecular and cellular biology through translational, animal, clinical database, health policy, and health economics. The goal is to advance the life sciences across the board to give surgeons and cardiologists around the world better tools to make the right recommendations and perform their work even more precisely.
“We have a lot of operations that we understand how to perform, understand the anatomy and physiology of humans,” says Woo. “But what is poorly understood is the biomechanical engineering underlying these operations. We’re trying to learn why these operations work. What are the mathematical, physics, and engineering principles behind why these operations work and how can we further enhance these operations?”
That spirit informs the entire cardiovascular practice at Stanford. By performing heart-lung block transplants and other challenging procedures, the team gains skills and knowledge that can be applied to all procedures.
“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.”
(1) Shudo, Y., Kasinpila, P., Lingala, B., Kim, F. Y., & Woo, Y. J. (2018). Heart–lung transplantation over the past 10 years: An up-to-date concept. European Journal of Cardio-Thoracic Surgery, 55(2), 304-308. doi:10.1093/ejcts/ezy253.