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A Bridge to Life — What’s New in Heart Transplants and Post-Transplant Care

The world’s first totally implantable artificial heart should soon give patients with heart failure who do not qualify for live transplants another chance to live.

The artificial heart, called AbioCor, is intended for patients with both right- and left-sided heart failure whose other medical and surgical treatment options have been exhausted, says Jennifer Joiner, RN, MSN, CCRN-CSC, clinical nurse educator for Cardiac Surgery, Critical Care, Robert Wood Johnson University Hospital, New Brunswick, N.J., one of four AbioCor Centers in the country.

“Rather than tell patients that nothing else can be done, we are excited to have the opportunity to put the choice back in the patients’ hands; they can decide how much more they want to do,” says Joiner.

According to AbioCor’s manufacturer, the device is designed to allow patients to remain mobile and live productive lives. Equipped with an internal motor, it is able to move blood through the lungs and to the rest of the body, simulating organ perfusion that a real heart provides. All parts are implanted in the chest, eliminating the risk of infection from exposed external hardware, adds Joiner.

Ready to Go

Although none of the four national AbioCor Centers has yet performed the artificial heart transplant, healthcare providers stand at the ready.

Special nurses’ preparation includes seminars on the theoretical work, as well as hands-on practice that correlates AbioCor settings with patient symptoms and troubleshoots possible patient problems. “Only experienced nurses who have top-notch critical thinking and assessment skills and have taken classes to care for patients with other types of ventricular assist devices are eligible to care for these patients,” says Joiner.

“Initially, the postop nurse-to-patient ratio will be three to one for seven days, which shows the intense patient care needed,” says Sabriye Bright, RN, head nurse. One RN will provide direct patient care; another will manipulate the machine settings; and the third will focus on medication and blood product administration.

AbioCor representatives provide 24-hour on-site, post-implant support, as well as troubleshooting of device waveforms in real time via remote monitoring from the home office in Massachusetts.

Complication rates can be as high as 40% for stroke, and hospital stay is estimated at three months or more. The current generation device is large, so it does not work for many smaller-framed men and women.

The average life span for patients with AbioCor is up to 18 months. “Eighteen months sounds like a short period of time, but how does one measure time when you are facing certain death?” says Joiner. “We are providing an opportunity for the patient to have an active life again, to feel great, and to see and do things otherwise impossible, such as attending a wedding or seeing a new a grandchild,” she says.

“Hopefully in the future, as devices get smaller, more efficient, and last longer, we may find patients living with biventricular heart failure out in the community for 10 and 20 years,” says Joiner. “We stand on the threshold of possibilities for the future,” she says.

On the Post-Transplant Side

Candice Carr, RN

As treatment for patients with heart failure has improved with medications, such as beta blockers and new pacemakers, a new blood test, the AlloMap molecular expression test, shows promise of countering organ rejection after transplant, says Birgit Jorgensen, APN, chief nurse practitioner, Center for Advanced Cardiac Care, NewYork-Presbyterian Hospital/Columbia University Medical Center.

At NewYork-Presbyterian Hospital/Columbia University Medical Center, patients ages 15 or older who have had transplanted hearts for more than two months may join a clinical trial for the screening blood work that can detect the rejection process before it actually occurs.

AlloMap is non-invasive compared to the current gold standard, heart biopsy, which detects rejection via catheterization, says Jorgensen. AlloMap measures the body’s immune response to a heart transplant by evaluating the degree of activity of genes in white blood cells associated with the immune system pathways involved in acute cellular rejection.

“Results of AlloMap are listed numerically, with higher numbers such as 34, signaling the possibility of an acute organ rejection,” explains Candace Carr, RN, BSN, CEN, CCRN, Clinical Research coordinator at the Heart Failure Treatment and Transplant Program at Newark Beth Israel Medical Center, an affiliate of the Saint Barnabas Health Care System. “Conversely, if the number is too low, the patient may be too immunosuppressed and an adjustment of the medications may be warranted,” Carr adds.

Rather than focusing on a specific number or one test result, healthcare providers look at the patient’s baseline and a trend. “Patients differ and are treated accordingly as individuals, using a holistic approach. AlloMap is a potential breakthrough in post-heart transplant management, but it is not meant to be used instead of a biopsy at this time,” says Carr.

During heart biopsies, the tissue is sent for evaluation and grading of rejection cells. The grade and overall heart function determine the type of antirejection treatment patients will receive. Depending on the healthcare facility, biopsies are typically performed weekly for the first month postop, then bimonthly, and slowly tapered over time.

“This AlloMap clinical trial at NBIMC is a wonderful opportunity for patients to possibly decrease the number of heart biopsies under a controlled, very supervised environment,” says Carr.

At NBIMC, Allomap follows the same post-transplant standard of care as those who are in the biopsy arm of the study and who are one year post-transplant. The test is given every six months for three years and then annually. After participating for two years, patients return to annual heart biopsies.

“Heart biopsies will probably never be totally eliminated as an antirejection standard,” says Carr. “In the future, biopsies may decrease with the integration of AlloMap,” she says.

What One NP Says

When asked what has changed the most in the field of heart transplants, Birgit Jorgensen, ANP, chief nurse practitioner, Center for Advanced Cardiac Care, NewYork-Presbyterian Hospital/ Columbia University Medical Center, responds, “It is the number of patients living longer and waiting for donor hearts.”

“Heart transplant is a great lifesaver, but the result for patients is another form of chronic illness,” says Jorgensen. Nurses help patients learn to live a normal life through education and support. Jorgensen lists some of the important issues to be included in postop education as susceptibility to infection; chance of heart rejection; importance of a healthy diet; and possible side effects of medications.

“Nurses help patients with the difficult adjustment period after this life-changing event, ” says Jorgensen. The best day for nurses is when they see patients more relaxed and confident, devoid of some of the stress that the journey brings, and able to go on that first vacation, she adds.

“Caring for patients with heart transplants means participating in the rewarding transformations — through the patients’ ordeals and on to better health,” says Jorgensen.

Lorraine Steefel, RN, DNP, CTN, is a senior staff writer for Nursing Spectrum.

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By | 2020-04-15T15:20:20-04:00 March 9th, 2009|Categories: National|0 Comments

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