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- This is Chris Sosa with the Becker's Healthcare Podcast.
I'm thrilled today to be joined by Amanda Vest, md,
medical Director
of the Cardiac Transplant Program at Tufts Medical Center.
Dr. Vest, thank you for joining us today.
- Thank you for having me, Chris.
- Dr. Vest, could you please introduce yourself
and tell us a bit about your background?
- Yeah, certainly. I'm a heart failure
and transplant cardiologist,
and I lead the Advanced Heart Failure Program here at Tufts
Medical Center in Boston.
I'm originally from the uk and I trained in London, Boston
and Cleveland, Ohio.
Currently I mostly see patients with heart failure,
cardiomyopathies transplantation,
and mechanical circulatory support.
Another area of interest for me is the treatment of obesity.
I medically treat obesity in patients with heart failure
and also co-direct the clinical nutrition course here at
Tufts University School of Medicine.
And actually my research area is in nutrition, metabolism
and body composition
and for example, learning how to help patients
with skeletal muscle wasting
who have heart failure as a condition.
But super excited to join you today to talk on some
of these transplant topics.
- Wonderful, thank you Dr. Va.
So looking at the, the bigger picture here, so
what would you say are the three biggest
issues in cardiology?
I know that's a lot, so, so take that as you will.
- Yes, absolutely.
Well, I come at it with a bit of a transplant lean,
but I'll start on the prevention end.
And because I am interested in nutrition
and obesity, I think it's such an exciting time in terms
of understanding
how we prevent people from developing cardiovascular
diseases, specifically including, uh, heart failure
because obesity is a major risk factor for it with our, um,
newer medications that treat metabolic health.
So particularly the GLP one agonist.
We've had some really interesting data lately
with a select study at American Heart Association,
and I think there are huge opportunities there
to help our populations of patients with diabetes
and obesity from developing cardiovascular disease at all.
In terms of the heart failure realm,
I think there's a lot more that we still have to do
for timely diagnosis
and implementation of our medical therapies
for people with heart failure.
We have about 6.7 million American adults living
with heart failure at this time.
Um, and not all of them are picked up in a timely manner,
and unfortunately not all of them are treated
with the therapies that we know can be lifesaving
and that can help recover their heart.
So, uh, there's a lot more there
to be done in collaboration across primary care, cardiology,
um, and, uh, uh, medical, uh, specialties.
But lastly, getting to the transplant area,
it's such an exciting time to be in heart transplantation
because we've really been able to optimize, uh, access
to heart transplantation, build up the volumes
of transplantation in the United States over the last few
years, and really start to look at the way
that we manage patients longer term
after a heart transplant, for example,
innovating in the ways that we surveil for rejection, um,
and bringing it back again to metabolic health.
Thinking about how do we keep these patients surviving
and thriving for the long-term after a heart transplant.
- Dr. Wess, I'm glad you mentioned the collaboration aspect.
What do you see as the biggest challenges as far as
that element is concerned and how can they be overcome?
- Right. I think we're really in a phase now of trying
to break down the silos between, um, primary care
and those who specialize in cardiology.
In endocrinology and nephrology, we're hearing a lot about,
um, metabolic kidney, cardiovascular health,
and it really takes people working across those domains,
collaborating together, um,
and, um, using often common medications to
gain in multiple areas of a patient's health.
So we saw this a lot as the SGLT two inhibitors became, um,
proven and approved for patients with heart failure
with reduced ejection fraction
and also preserved ejection fraction
that no longer was this group of medications,
just the domain of the endocrinologist.
But now it was very much the domain of the cardiologist
and the primary care provider treating patients
with heart failure and furthermore,
has benefits in chronic kidney disease as well.
Um, similarly, we are seeing now in the GLP one
and GIP GLP one agonist medications,
the opportunity not only to treat the type two diabetes,
but also to treat obesity and of course optimize metabolic
and cardiovascular health.
So it really brings all those subspecialty, uh,
and general medicine groups together to center
around the patient and figure out what's gonna be right
for them for their long-term cardiovascular wellbeing.
- Another sort of big picture question here for you, Dr.
Vest. So when you see the evolution of heart, heart care,
I should say mm-hmm, the next 18 months
or so, two, three years, what do you think is going
to be the biggest trend that is coming the way of
that specialty?
- Oh, so many exciting developments
with medications and devices.
Um, but perhaps I'll focus on my area of transplant.
It's really been, uh, a fantastic few years of innovation
in the way that heart transplantation is done
and how we care for the patients afterwards.
And an area that's been particularly interesting
is the clinical trial and subsequent adoption
and clinical practice of donation
after circulatory death, DCD, which is a type of heart donor
that wasn't previously standard, um, in the United States,
but which has helped us to transplant more patients, um,
and get very good outcomes
and was facilitated by the development of new technology for
the, um, optimization of a donor heart graft
and the transport of it to the recipient hospital.
And there are a number of other innovations ongoing at the
moment with slightly different devices that seek
to really revolutionize the way that we, um, uh,
manage that heart and transport it in
after procurement to get it in the best states
for a transplant surgery.
So I think this is a very exciting area as we think about
how can we make sure that we get access to
as many heart transplants of excellent quality
for our patients on the wait list, knowing
that unfortunately we still have approximately 9%
of patients who are listed for transplant
ultimately passing away without receiving a heart.
And so the race is really on to figure out
how we can bring heart transplant to those who need it.
- Uh, Dr. VAs, could you elaborate a little bit on some
of the technology that you find most exciting?
- Yes, absolutely.
Um, so the donation
after circulatory death, um, option really came about
because of a type
of equipment we call the organ care system.
Um, the uh, system
that was developed in a clinical trial over the last couple
of years is made by a company called Edix
and allows us to take a heart, um, even one
that has stopped beating, which is the case
with DCD transplantation, which we thought used
to render the heart inappropriate for transporting
and uh, transplantation given that it had stopped beating.
But we now know we can place
that heart onto the organ care system
and perfuse it with blood and electrolytes, warm it
and get it beating again in such a way
that we're not only able to improve the quality of
that organ, but also assess it whilst it's on the platform.
So this has opened up, uh, the option of, uh,
DCD transplantation,
which probably adds somewhere in the realm of another,
about 15% volume
of good quality donor hearts being
available to our patients.
And furthermore, starts to give us more flexibility about
how we can transport hearts over longer
geographic distances.
No longer are we beholden to the cold static storage of a,
a lowly cooler, which used to be the way
that we brought hearts to the recipient,
but now we have platforms where we can keep that heart, uh,
in good shape over a longer period as we bring the heart,
for example, from coast to coast.
In the US there are a number of other technologies
that are being developed.
Uh, we can do DCD transplantation using something called
Norm Themic Regional Perfusion, uh, which utilizes some
of our ECMO technology in circulating
blood outside the body.
We have other options for cold static storage, for example,
building on the idea of a heart on ice in the cooler,
but regulating the temperature throughout the organ in a
much more uniform way that's achieved
by a device called the Sherpa Pack from Paragons,
and allows us to monitor the temperature, um,
during a period of transport of the organ, uh,
with some early data from our team at Tufts, uh, suggesting
that that heart can be transported a little further
and longer and still be of good quality.
Another device that's coming into trials is something called
the Ex Vivo, um, device
where the heart is continuously perfused
and a, a cold eight degree Celsius oxygenated
cardioplegic nutrition hormone solution.
So not yet available, um, or FDA approved in the us
but coming into trials
with some exciting data internationally,
- 15% Dr.
Vest, that seems like no small number when it comes
to the number of hearts that are available for transplant.
- Absolutely. Um, expanding access
to heart transplantation is so important.
Um, and looking to, uh,
utilize all available hearts is absolutely key to that.
A lot of work has gone into the concept of how do we
optimize hearts, um, ensure that any, um,
possible donor is being considered for donation,
but certainly using DCD hearts, being able
to be geographically more flexible
with these organ preservation and transport systems, um,
and also using hearts, for example, from donors
who have Hepatitis C, which has become standard
of care over the last decade, are all strategies
that incrementally add up to bring more heart transplants
to the patients who need them.
And amazingly, we're now at more than 4,000 heart
transplants a year in the United States.
Um, so really, uh, increasing on that volume
and simultaneously, of course,
many people doing excellent work on enhancing the equity
and access amongst populations to this lifesaving resource.
- Dr. West a little bit on the flip side
of this conversation that we've been having
for the last few minutes, uh,
what would you say makes you a little bit nervous and
or what would you like to see improved as far as
your specialty is concerned?
- Yes. Well, with all these wonderful technologies
that has come, of course, the potential for increasing cost,
um, so that has certainly been something that, uh,
many programs have had to look carefully at.
And I think we'll see a lot more over the next few years
about thinking about cost effectiveness
and how we can, um, geographically share hearts
and get them where we need them to be,
but be smart in our resources.
And already a lot of work is going on to, um, really think
through the systems of care whereby teams are, um,
located in hubs and sent out to recover hearts
and bring them back to the center that needs them.
So a lot of good work there.
We've also got really exciting technologies
for monitoring patients after heart transplantation.
So for example, the surveillance
for rejection has traditionally been, um, the biopsy,
which goes into the right side of the heart
and takes a sample of myocardium
to be examined under the microscope.
But we've got real opportunities now to do a lot more
of the surveillance less invasively using
donor derived cell-free DNA,
which is a blood test currently commercially available
on next generation sequencing
that quantifies the donor derived cell-free DNA,
and can use single nucleotide variations
to give a ratio of that
donor derived cell-free DNA coming from the heart versus the
total pool of DNA that comes from the recipient's body.
Um, when the heart is under stress, such as during a episode
of rejection, the donor derived fraction
that's coming from the heart increases
and that can help us understand
that the heart is having some difficulty
and needs further investigation.
Or on the flip side, that the heart is actually doing well,
um, has a low donor drive cell-free DNA level, um,
and that the patient can continue their medications
and continue in the direction they're going.
But you asked about the challenges
and it can be quite difficult to, um, roll out some
of these changes in care across programs.
Caring for patients
with heart transplants is incredibly complex.
Um, it's a high risk situation where we need a high burden
of proof that changes in our protocols
are safer and effective.
And so we have seen some differences in the speed
with which these new technologies are adopted
across different programs.
Um, and I think coming together
as a community providing educational resources
and disseminating the data that's coming
through from research studies can be very helpful
in getting pat in getting programs to the point
where they're comfortable, uh, taking on some
of these newer innovations for patients
with heart transplantation.
- Doctor, I did wanna ask you a little bit about a that, uh,
your health system had early this year where you had a
transplant candidate who received a heart
after seven months in the care of the hospital.
So can you take me through just a little bit about how
that process went
and what was it like, what it was like
to finally tell this person, Hey, we have a heart form?
- Yes, absolutely.
Our, um, patients do sometimes wait a very long time
for heart transplantation, which can be an incredibly
challenging journey for them and their family.
Um, these days, many of our heart transplants occur
for patients who are supported on temporary mechanical
circulatory support, so heart pumps that are, um,
optimizing the blood flow around the body
and for which the patient needs
to stay in the intensive care unit.
We, um, try to get the patient as active
and up moving around as much as possible during this period,
but still it's very challenging to be confined
to an intensive care unit for a long period of time, um,
often with lots of medical and emotional ups
and downs along the way.
So it's one of the greatest privileges of my job to be able
to talk to a patient about receiving a match, um,
and help them to get through to realizing all those future
goals and, um, achievements
that they're looking for in their life.
Just the nicest thing.
So, um, certainly, uh, a, a challenging process
for many of our patients,
but really delightful when we're able
to give people a new lease on life.
And really wonderful
that this year we've had a very busy year
at Tufts Medical Center.
We're not quite through 2023,
but we've done 56 heart transplants this year,
which actually equals our record in the New England region
that we set back in 2016 for the most number
of heart transplants in this region in a year.
So hopefully we'll be able to keep moving forwards
and offer this gift of life
to even more patients on our waiting list
as we wrap up the year.
- Dr. West, thank you so much for being so generous
with your time and insights today.
We can't wait to share them with our audience.
Julie, uh, thank you again,
and we look forward to connecting with you soon. Thanks
- For having me, Chris.
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