February 18, 2008

A heartfelt response
to a patient’s plight

After a heart transplant patient’s first donor heart was rejected, doctors joined forces to find a way to improve her chances of surviving a second cardiac transplant.

Winsome Smith, RN, (left) and Peggie O’Donnell, RN, (right), in the lab medicine unit of the Yale-New Haven Blood Bank, took an apheresis machine like this one to the cardiac care unit at Yale-New Haven Hospital about 35 times to give Lane plasmapheresis treatments, which took about 90 minutes each.

Last week we ran a story about Kim Lane, a young mother diagnosed with end-stage cardiomyopathy – twice. In 2000, shortly after the birth of her second daughter, Lane had heart transplant surgery. Then, about four years later, after her body rejected the donor heart, she had a second heart transplant. 

Following the failure of Lane’s first donor heart and the realization that she needed a second heart transplant, Lane’s cardiology team took an all-hands-on-deck approach to designing a treatment plan that would reduce Lane’s risk of a second organ rejection. 

“It really was an aggressive plan that integrated several teams of medical professionals from numerous disciplines throughout the institution,” says Heart Transplant Coordinator Joan Amatruda, RN. This plan, initiated pre-transplant and continuing for the first year post-transplant, was aimed at increasing Lane’s chance of matching with a suitable donor and lowering her risk of antibody-mediated rejection following the transplant.

Lane is what’s called a “highly sensitized patient,” meaning that she has elevated levels of preformed reactive antibodies to human leukocyte antigens (HLA), possibly due to a previous exposure to blood products, prior pregnancies or because she received a ventricular assist device (VAD) while awaiting cardiac transplantation. 

Although patients are screened pre-transplant for antibodies that might react to the donor antigens (a process called cross matching), doctors are under tight time constraints. “Because the heart remains viable for only four hours from the time of explant to the completion of the implantation, we are not able to match for HLA,” Amatruda says. In the case of Lane’s first transplant, her doctors believe the donor heart wasn’t a close enough match

To reduce the risk of a second rejection, Lane’s doctors used a PRA (panel of reactive antigens) test to find the closest match, but they worried about how long the search was taking. Lane waited for a heart for nearly six months while hooked up to a heart monitor in the cardiac intensive care unit of Yale-New Haven Hospital. “We knew Kim could die at any moment,” says Stuart Katz, MD, director of the Yale Congestive Heart Failure Program. “It was a very tense situation.”

While Lane waited for a suitable donor, doctors implemented phase one of the plan, which was aimed at reducing the antibodies in Lane’s blood prior to re-transplantation and minimizing the risk of rejection following the surgery. Because heart-rejecting antibodies are found in plasma, Lane’s doctors used a technique called plasmapheresis, run out of the Yale-New Haven Blood Bank, to remove potentially harmful antibodies from her bloodstream.

She underwent the procedure, which is similar to dialysis, about 35 times. Harmful antibodies are removed from the blood’s plasma by spinning the blood at a high speed. Beneficial blood cells are returned to the patient and the antibodies are discarded. During the process, the patient also receives intravenous immunoglobulin, a medication given to supply the antibodies needed to fight infection.

Following the second heart transplant, doctors implemented phase two of the plan, which called for continued plasmapheresis combined with another technique called photopheresis, which is run by the Department of Dermatology.

Under the direction of Michael Girardi, co-director of the photopheresis unit, Physician Assistant Kacie Carlson, (left), Niki Dobbs, RN, (seated), gave Lane multiple photopheresis treatments both before and after her second heart transplant.

Michael Girardi, MD, co-director of the Phospheresis Unit at Yale-New Haven Hospital, oversaw Lane’s photopheresis treatments. “They made the difference in this very-high risk patient’s ability to tolerate another transplant,” he says.

With photopheresis, the patient’s blood is removed from the body. The white blood cells are separated and mixed with certain chemicals and the patient’s plasma. The mixture is then exposed to ultraviolet light before being combined with the untreated blood and returned to the patient. Researchers believe the process alters the properties of the white blood cells in a way that minimizes organ rejection.

It’s been three years since Lane’s second transplant, and so far there have been no serious signs of organ rejection. Katz attributes this to the multidisciplinary effort and state-of-the-art therapies that were available. “Not that many programs have access to these technologies,” Katz says. “We’re just very fortunate to have these things here at Yale and that everyone worked together to bring them to the assistance of this one patient.”

—Jennifer Kaylin

Photos by Jennifer Kaylin

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