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A Tale of Two Transplants

09/01/2016

From left to right: Cardiac Surgeon Gregory S. Couper, MD; Cardiothoracic Surgeon Yong Zhan, MD; Senior Cardiothoracic Surgeon Hassan Rastegar, MD; Chief, Cardiac Surgery Frederick Y. Chen, MD, PhD; and Senior Cardiothoracic Surgeon Kenneth G. Warner, MD.

Easter Eve, 2016, two Tufts Medical Center patients received phone calls that would forever change their lives. That night, March 28, a pair of donor hearts became available, meaning it was go-time for both Delphine Andrews’ and Orrin Reed’s long-awaited cardiac transplants. 

Delphine’s ringing cell phone found her already at Tufts MC with her children and grandchildren. She had recently been admitted due to blood-thinning medication levels gone haywire. On the transplant waiting list since 2011, Delphine, 55, was happy to hear Dr. David DeNofrio, Director of the Heart Failure and Cardiac Transplant Center, announce her wait was over. 

David DeNofrio, MD is the Director of the Heart Failure and Cardiac Transplant Center at Tufts Medical Center in downtown Boston, MA.

Orrin’s call arrived at his home in Sandia, NH—a two-hour drive from Boston. “We thought it was Tufts calling to remind me I had an appointment Monday morning,” says Orrin, 58. Instead, “it was Dr. DeNofrio calling to tell me he had a transplant for me.” He and his wife, Jean, had anxiously anticipated this moment since Orrin landed on the heart transplant list the previous May. Still, mixed emotions flooded Orrin. “I thought I was going to be sick, I was [so nervous].” 

The ticking clock

There is no time to waste when a donor heart becomes available. “A heart transplant is an urgent operation for which we have about six hours’ advance notice,” says Dr. Gregory Couper, the Tufts MC cardiac surgeon who performed Delphine’s procedure. This urgency mandates rescheduling other appointments and operations, and often, the on-call surgeon meets the patient for the first time just before arriving in the OR. 

Such was the case with Dr. Couper and Delphine, as well as Orrin and his doctor, Senior Cardiothoracic Surgeon, Dr. Hassan Rastegar. “I generally go in before the operation, introduce myself, talk to the patient and the family, and go from there,” says Dr. Rastegar. 

Both doctors are quick to point out, however, that a cardiac surgeon is assigned to meet each transplant patient during the preliminary evaluation process, at a pre-op visit, and/or while waiting on the list—it’s simply luck of the draw as far as who is available and on-call when an organ finally becomes available. 

It takes a village

As recently reported by The Boston Globe, Tufts MC performs the most heart transplants in New England and has managed as many as four in one day. Doctors Rastegar and Couper agree on what uniquely equips their hospital to tackle this relatively rare occurrence of simultaneous procedures. “It’s all about the team,” says Dr. Couper, “and everyone being committed to the transplants.”

“We have a bunch of dedicated surgeons here who have been doing this for a long period of time,” adds Dr. Rastegar, citing himself, Dr. Couper, and Senior Cardiothoracic Surgeon Dr. Kenneth Warner as the three cardiac surgeons who conduct the bulk of Tufts MC’s roughly two to six heart transplants each month. 

Delphine and Orrin—strangers, thus far unaware of their parallel paths—rolled into their respective operating rooms within six hours of each other, requiring four complete cardiac teams to manage their overlapping procedures. Two teams are necessary to complete each transplant, explains Dr. Couper. While one cardiac surgeon and resident or physician’s assistant (PA) retrieve and preserve the donor heart, another cardiac surgeon oversees the recipient side of the procedure with the aid of a PA, three or four anesthesiologists, and several scrub nurses. 

Both doctors report that the average transplant takes about eight surgical hours, sometimes more. “We take our recipient to the OR about four hours before the new heart comes,” says Dr. Couper—in part, due to concern over how long the donor heart is traveling in the cooler without blood supply. The first 60 to 120 minutes of surgical prep are devoted to administering anesthesia and applying all appropriate monitoring lines, after which, “it can easily take a couple hours of surgery to be ready to put the new heart in.” 

And yet, Dr. Couper continues, “because we can’t control the process at the donor hospital, sometimes we’ll just wind up sitting there, waiting” for the organ’s arrival. On top of this, “we’ve also been fielding and coordinating things the night before,” as logistics typically managed by transplant nurse coordinators on weekdays are handled by on-call physicians over the weekend. All in, Dr. Rastegar calculates an approximate 16-hour span between breaking news of an available heart to transplant completion. 

The procedure is further complicated when ventricular assist devices (VADs, or surgically implanted, battery-operated heart pumps) must be removed. “Over 90% of patients have an LVAD [the most common type] when they get into the operating room,” says Dr. Rastegar—as was true for both Orrin and Delphine. 

Lengthy transplant lists are partly responsible for this high incidence of VAD implantation, particularly in New England, adds Dr. Couper. “It’s difficult to wait long enough to get a transplant without requiring an LVAD first.” 

New leases on life

“I felt like a new man right out of surgery,” recalls Orrin. After living with his LVAD for nearly a year and experiencing an infected driveline (the cord connecting internal pump to external battery source), which hospitalized and bumped him to the highest priority transplant status in December 2015, “I was relieved I wasn’t hooked up to anything…and I could sleep on my side again.” 

Orrin’s recovery progressed faster than anyone expected. “The day after my surgery, they had me walk 15 to 20 feet. The following day, they had me walk to the nurses’ station. After three days, the physical therapists said, ‘You don’t need us anymore,’” he laughs. “They all said I was a freak of nature because I was doing so well and looking so good. Ten days after the transplant, I was released—a free man. The day I got home, I took my own shower,” for the first time since the LVAD was implanted—a moment Orrin both joked about and relished. 

“I’m just grateful,” says Delphine, whose faith has always been a dominant theme in her life. Upon waking post-surgery, “when I realized where I was and what had happened, I opened my eyes and I said, ‘Thank you, Lord, for this heart.’ I felt his spirit. It was so awesome.” 

Looking back

Delphine’s transplant marked her fourth major cardiac surgery in five years, following three LVAD implantations due to two device complications—a potential risk for any patient. As a result, her cardiac team prepared her for a more challenging transplant and potentially longer recovery. 

Hassan Rastegar, MD is the Senior Cardiothoracic Surgeon at Tufts Medical Center in downtown Boston, MA. “Every time you operate on a patient, the body heals by forming scar tissue,” explains Dr. Couper, who has performed hundreds of heart transplants. Tissues surrounding the cardiac muscles of patients undergoing second open heart operations are “a little more hardened than the first time around. But when you get to the third and fourth, the scar tissue is profound. It just makes the surgery riskier and can take much longer.” 

“The doctors said the next months won’t be easy for me,” Delphine acknowledges, “and it will take time to rehabilitate myself. I’ve been healing fine,” though she admits, “I’m swollen, tired, and lazy, with no energy. I’ve had a problem going up stairs.” And yet, she says, “I wouldn’t trade this transplant for anything in the world.” 

Orrin feels the same way. “I’ve got a new life—a second chance. I’m not gonna blow this second chance.” 

Jean confirms: her husband does not exaggerate. “When we first got to Tufts MC and had his LVAD done,” she says, “one of the doctors turned around and said, I would have given him 90 days” to live without the device. 

Delphine’s original condition was even more dire. After not feeling right for weeks following a congestive heart failure diagnosis in 2010, she scheduled a second opinion visit at Tufts MC, and “the day I went for the appointment was the day they kept me. They said had they let me go home, I would have died by the weekend.” 

Attitudes of gratitude

For her transplant and past five years of treatment, Delphine gives major kudos to her cardiac care. “The doctors, nurses—my team—are awesome up at Tufts. That’s my home away from home. We are one big happy family.”  

Orrin’s sentiments exactly. “They treat you like family,” he says. “From the doctors down to the techs. They’re all wonderful. They’re so caring. All of them. I don’t care if it is a two-hour ride for us—I’ll go down to Tufts, no problem.” 

In June, Delphine and Orrin finally had the opportunity to meet, swap stories, and congratulate each other on their new, functioning hearts. “It’s awesome how far modern technology has gotten us,” marvels Delphine, adding that she hopes to encourage young people to become organ donors. 

As for Orrin, “I just want to tell people on an LVAD, there’s an end to the tunnel. There is. Just remember that.”