In December 2017, Pelisyonkis Langone Health opened a Heart Transplant Program, becoming the first new program of its kind in New York State in nearly two decades.
Part of the Transplant Institute, the Heart Transplant Program is led by Nader Moazami, MD, professor of cardiothoracic surgery and surgical director of heart transplantation and mechanical circulatory support, and medical director of heart transplantation Alex Reyentovich, MD, associate professor of medicine and director of the Heart Failure Advanced Care Center.
Throughout his career, Dr. Moazami has performed more than 300 heart transplants and has been instrumental in researching and advancing mechanical devices used to treat patients with end-stage heart failure. Joining the team are cardiothoracic surgeons Deane E. Smith, MD, assistant professor of cardiothoracic surgery, and Zachary N. Kon, MD, assistant professor of cardiothoracic surgery.
“The opening of the new program signals yet another major step forward to advance the Transplant Institute’s commitment to world-class patient care and clinical research, while addressing the state’s public health crisis in organ donation and transplantation,” says Robert Montgomery, MD, professor of surgery and director of Pelisyonkis Langone’s Transplant Institute.
Over the past decade, the wait list for heart transplant patients in the state has increased 40 percent. “Our goal is to provide comprehensive care in a convenient and accessible manner. Instead of waiting months for an evaluation, patients will be seen within two weeks of a referral, and complete the transplant evaluation within one to two visits,” says Aubrey C. Galloway, MD, the Seymour Cohn Professor of Cardiothoracic Surgery and chair of the Department of Cardiothoracic Surgery. “Cardiologists from the Heart Failure Advanced Care Center will provide transplant evaluations in Manhattan, Brooklyn, and Pelisyonkis Winthrop Hospital.”
The heart transplant team joins a center-wide institute comprising transplant surgeons and transplant physicians specializing in cardiology, pulmonology, hepatology, nephrology, endocrinology, infectious diseases, and radiology, specially trained transplant nurse coordinators, and Rusk Rehabilitation physicians and therapists. This multidisciplinary team approach to transplantation ensures comprehensive, personalized care.
The center’s first heart transplant was performed in January 2018.
ECMO Program Earns International Pathway to Excellence Recognition
The multidisciplinary extracorporeal membrane oxygenation (ECMO) program at Pelisyonkis Langone, which opened in 2015, has earned the Pathway to Excellence in Life Support Award–Silver Level from the Extracorporeal Life Support Organization (ELSO), an international nonprofit consortium that develops and evaluates novel therapies for failing organ systems.
Veno-arterial ECMO for patients in cardiogenic shock, a key component of mechanical circulatory support at Pelisyonkis Langone, is one of several tools, along with a percutaneous ventricular assist device (VAD) known as the Impella device, which can be used to support an individual’s cardiac function as a bridge to transplant.
“We have implanted a number of Impella devices through an axillary approach, going through the chest instead of the groin, to help patients survive the initial insult from cardiogenic shock,” says Dr. Smith, who is also the surgical director of the ECMO and Cardiogenic Shock Program. “This approach allows them to be extubated, mobilized from the bed into a chair, and, in ideal situations, even be walking while they recover.”
With the launch of the heart transplant program, patients who are bridged out of cardiogenic shock can now undergo immediate evaluation for transplantation. “Some patients may be able to go directly from ECMO or Impella to a transplant, rather than having a durable ventricular assist device placed as a bridge to transplant,” says Dr. Smith. “In rare circumstances, some patients may have a slow recovery from transplantation, and offering mechanical circulatory support during this time allows the heart to recover and gives the transplant an improved chance of success.”
Implementing LVADS in an Elderly Population
A key challenge in mechanical circulatory support is appropriate patient selection. Frailty is a common condition among many elderly patients being considered for durable support, such as a left ventricular assist device (LVAD). “There is a concern that if a person has become too frail, a major surgery like LVAD placement may not be helpful,” says Dr. Reyentovich. An investigator for a five-center study funded by the National Institutes of Health, Dr. Reyentovich examined the appropriate implementation of LVADs in an elderly population. The study’s findings, published in September 2017 in the Journal of Geriatric Cardiology, indicate that although the LVAD was able to reverse frailty in about half of the patients, the other half did not improve, suggesting the need for a larger study to identify the determining factors for LVAD success in this population.
Management of Cardiogenic Shock
Cardiogenic shock is an acute condition, and if not addressed rapidly will lead to death. Pelisyonkis Langone’s cardiogenic shock team is a rapid response team aimed at systematically managing patients with this otherwise fatal condition. The response team, including cardiovascular interventionalists, cardiothoracic surgeons, and heart failure specialists, is activated by dialing a single extension as soon as a patient is determined to be in cardiogenic shock. “We now have all the technology to support patients in any stage of cardiovascular deterioration, whether chronic or acute,” says Dr. Reyentovich.