House with a new heart

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57 heart transplants and 15 implanted portable pumps supporting the work of this organ – this is the record of the Institute of Heart Diseases of the University Hospital of Wrocław since the start of the heart transplant program in February last year until in the first days of June this year. USK remains the only center in the region where both procedures can be performed.

The latest generation HeartMate III pumps, with which the patient can simply go home and live normally for a long time, in Poland have the right to implant only transplant centers. These devices are treated as a gateway to heart transplantation and their purpose is to allow the patient to remain in at least satisfactory physical condition until targeted surgery. Supplementing the transplant program with new methods of mechanical support allows USK to meet the needs of the most seriously ill cardiology patients throughout Lower Silesia, and even the nearest cardiology centers outside of the border of the Wrocław Voivodeship.

The development of medical technologies and the introduction of new drugs in recent years have improved treatment options for patients with severe heart failure. Although heart transplantation remains a salvation for some of them, in some cases mechanical cardiac work support devices are used. These possibilities are used above all in situations where, for various reasons, there is no chance of a rapid transplant: there is no compatible donor or the patient himself has contraindications. Mechanical cardiac assist devices (including ECMO), which have been used for many years, allow the patient to safely wait out the worst moment, but must remain under intensive supervision in the hospital when connected to it . The advent of small implantable titanium pumps has considerably changed the quality of life of patients awaiting a transplant.

Bridge to transplants

– The HeartMate III pumps, which we began to implant in the fall of last year, have the advantage for the patient of allowing him to leave the hospital shortly after the intervention, sometimes after a week – says Prof. Michał Zakliczyński from the Department of Heart Transplantation and Mechanical Circulation Support at the Institute of Heart Diseases, USK.

– After the procedure and several days of rehabilitation, the patient can simply go home, be active and, above all, be independent and independent of the help of others. The devices are small and during surgery they are placed near the tip of the left ventricle. The pump replaces the function of the inefficient chamber. It is powered by batteries, via cables led outside, easy to hide under clothing. The only thing the patient needs to remember is to take care of the power cord (the so-called lifeline) and charge the battery.

– Each of the two batteries of the device lasts 17 hours – explains Jakub Jankowski, coordinator of the mechanical support program at the Heart Disease Institute of USK. – Whatever the patient’s activity, he can supply his pump safely under normal conditions. The manufacturer of the latest pump model has changed the design of the device, eliminating the disadvantages of previous types. The technology is amazing. The pump impeller spins at speeds of up to 9,000 revolutions per minute, providing blood flow of up to 10 liters per minute.

The devices are designed for many years of operation, but legal regulations also decide how long they will support a diseased heart. In some countries, implantable pumps can be used as targeted therapy. The patient then receives the device not only as a bridge to the transplant, but instead of the procedure. In others – such as Poland and Great Britain – the method is authorized for patients who have already qualified for a transplant, but who for some reason cannot receive it. Most often it is associated with such a poor biological state of the body that there is a risk of failure of the transplant. Another common reason a pump will be implanted is that a matched donor is unlikely to be found. This is the case, for example, in the case of heavy patients, for whom the waiting time for an organ of the appropriate size is sometimes very long. There is a real risk that the patient will not see it. Then the pump saves him. In addition, sometimes thanks to its use, the patient’s condition improves so much that there is a chance to avoid transplantation.

They just won’t swim

One of Jakub Jankowski’s tasks as program coordinator is patient contact. He encounters various reactions.

– After the implantation of the pump, patients generally feel an immediate, often dramatic improvement – explains the coordinator. – It has happened that a patient who was eagerly awaiting a transplant, after having implanted HeartMate III, did not want to hear about it again. Because why undergo a difficult and painful procedure, with the need to use immunosuppression for the rest of his life, when a small device in the heart allows him to live practically without restrictions? Aside from extreme sports, a pump patient can do virtually anything except swim in open water due to its power. A shower is possible thanks to the waterproof bag in which the batteries are placed. At the other extreme, we have patients who are downright dissatisfied when offered a pump they’ve never heard of before, but have been focusing on a new heart for a long time. You have to explain to them exactly what it is about and that in a given situation it is the best, if not the only, solution for them.

Patients are also informed of the profile of complications associated with each therapeutic alternative. It is often the high risk of side effects that determines the choice of treatment method – in the case of transplantation, we must take into account the effects of many years of weakening of the immune system by immunosuppressive drugs, which additionally have their own side effects, and in the case of pumps – the need to use strong anticoagulants that reduce the risk of ischemic stroke, but increase the risk of bleeding. Sometimes the possibility of self-care of the socket, so that it does not become infected, obviously exceeds the capabilities of the patient. Therefore, the first instruction on pump operation, including basic manual steps related to battery, controller, and dressing replacement, occurs prior to implantation and is part of qualification. Ultimately, the patient must give informed consent to any type of surgery offered by specialists. No one will transplant anyone’s heart or put in a pump against their will.

– However, we always offer the patient what suits him best – underlines the prof. Michał Zakliczyński. – Whether it is a transplant or mechanical support of cardiac work is determined by medical considerations in specific circumstances. Transplantation remains the method of choice in the treatment of severe heart failure.

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