A Cut Above

At many hospitals, cardiac transplants are a rare and dramatic event; at Vcu’s Pauley heart center, “they’re a routine thing for us,” said dr. Vigneshwar Kasirajan, Pauley’s chairman of cardiothoracic surgery and director of heart transplantation and mechanical circulatory support.

The routine begins like this: When a good donor match is identified for a patient, the surgeon on call contacts the transplant coordinator. The coordinator works out the logistics with the organ procurement agency and the hospital’s staff, and then assembles the operating, critical care, and ICU teams. Two surgeons and their assistants scrub in for every transplant, along with a team that comprises cardiac anesthesiologists, operating room nurses, and perfusionists to operate the heartlung machine. One surgeon travels to the donor hospital to procure the heart. After returning to VCU, the surgeon makes any needed repairs to the heart before surgery. When the heart is ready, the surgeons can begin the transplant.

Once a heart is removed from a donor, the transplant team has only a four-hour window of time in which to work.

“That time frame is very critical. If you cross four hours, the outcomes are definitely worse,” said Dr. Kasirajan.

But with their experience, and their routines and procedures already in place, the VCU transplant team swings easily into action.

“Everybody knows exactly what their roles and responsibilities are, and there’s not a lot of hand wringing,” he said. “And I think that’s important, because if it’s not routine, and everything is a big production, there’s more room for error.”

Donor hearts can become available at any time; the hospital has even performed two cardiac transplants in a single day. A transplant surgeon’s life is composed of late–night phone calls, long and unpredictable hours—and unimaginable rewards.

“I did a transplant on Sunday on a woman who had been in the hospital for a long time,” he said. “It was very gratifying to see her get a heart, get well, and go home.”

“Vig,” as he is often called, grew up in india, the son of a cardiologist and a homemaker.

“My dad was a cardiology fellow in the United states in the 1960s, and he was at Maimonides [Medical Center in Brooklyn] when the first human heart transplant in the United States was performed by Dr. Adrian Kantrowitz,” said Dr. Kasirajan.

He grew up listening to his father’s stories of heart surgery and transplantation. “It was a big thing,” he said. “The ’60s and ’70s were when heart surgery was rapidly exploding, and it was very exciting.”

Inspired by his father, Dr. Kasirajan attended Madras Medical College in India. As a young medical student, he watched his first open heart surgery. That’s when he decided to become a cardiac surgeon.

“I saw the heart and it was kind of bouncing in and out,” he said, his eyes lighting up. “It was beating—it was actually beating. It was a dynamic organ.”

He went on to serve his fellowship in cardiothoracic transplantation and mechanical assist devices at the Cleveland Clinic Foundation and remained there for his residency in thoracic and cardiovascular surgery.

He has helped to create a vibrant environment at VCU, where he has been since 2003.

“Vig has been very instrumental in the resurrection of the heart transplantation program here,” said Dr. Keyur B. Shah, Medical Director of the Mechanical Circulatory Support Program.

In addition to his work with transplant patients, Dr. Kasirajan is at the forefront of a new frontier in cardiac surgery that includes artificial hearts and mechanical assist devices.

In 2006, he led the first surgical team on the East Coast to implant the SynCardia Total Artificial Heart, the only device of its kind approved by the FDA Since that time, he has implanted a total of 50 of the devices, and his work has helped establish VCU as one of the leaders in the realm of artificial hearts.

Data presented to VCU by SynCardia last fall establishes Dr. Kasirajan’s reputation as “one of the best total artificial heart surgeons in the world,” said Dr. Michael Hess, Director of Pauley’s Heart Failure Program. “He now has the largest and best experience with the SynCardia total artificial heart.”

Artificial hearts enable patients to improve their health, and even prolong their lives, as they await cardiac transplantation. The current wait time for a donor heart is six months to two years or more, depending upon the patient’s priority status.

Patient care plays a critical role in recovery. After receiving an artificial heart, the patient is transported first to the ICU and then to Pauley’s special device-dedicated, stepdown floor. Working in the unit are biomedical engineers and nurses specially trained to take care of patients with artificial hearts, left ventricular artificial devices (LVADs), and other heart–assist technologies.

As patients recover on the step-down floor, they begin to get stronger almost immediately. “The artificial heart has dramatically improved patient outcomes,” said Dr. Kasirajan. “We went from taking really sick patients who might have had only a 20 to 30 percent chance of survival to over 85 percent survival to transplant,” he said.

Based upon his experience and success with artificial hearts, Dr. Kasirajan was selected to be the lead investigator of a national clinical trial for the freedom driver, a small, portable air compressor that keeps artificial hearts pumping.

“With the Freedom Driver, the goal is to take selective patients who meet the criteria and ultimately let them go home to wait for a transplant,” he said. “Until now, when a patient went on an artificial heart and was waiting for a transplant, they couldn’t go home because they were attached to a large driver.”

VCU’s large driver, “Big Blue,” weighs more than 400 pounds. The Freedom Driver, by contrast, weighs about 14 pounds and can fit in a backpack.

Six patients at VCU have received the device, and “the ones that have been able to go home have been very happy, because a lot of them have spent months in the hospital,” he said.

“The device could lead to tremendous savings in health care costs,” he said. For instance, before the Freedom Driver, “we had one patient who was in the hospital for over 400 days, waiting for a transplant.”

Not everyone can receive an artificial heart; only those who are candidates for donor hearts. The devices are approved only as a “bridge-to-transplant.”

LVADs, on the other hand, can be either a “bridge-to-transplant” or a “destination therapy.” That means patients can live with the implanted device instead of continuing on to a transplant. LVADs are small, batteryoperated pumps that patients can recharge off their car lighters.

“We have a number of patients living at home with LVADs who don’t want a transplant because they’re doing really well on them,” he said. To qualify for an LVAD, the right side of the patient’s heart must function well. As its name implies, the left ventricular assist device supports primarily the left side of the heart.

The movement from large, pulsating pumps like the HeartMate XVE to smaller, quieter, continuous flow machines like the HeartMate II “is perhaps the single most important surgical advance [in treating advanced heart failure],” he said.

Dr. Kasirajan is part of a seven-surgeon cardiothoracic team that treats patients at both VCU and the Hunter Holmes McGuire Veteran’s Hospital. Their busy practice performs about 1,000 cardiac procedures each year, from valve repairs and coronary bypasses to minimally invasive surgeries for atrial fibrillation. They implant about 60-80 mechanical assist devices like LVADs, artificial hearts, and other temporary devices each year.

“We offer a comprehensive list of options for patients requiring heart surgery,” he said.

With its Medical College of Virginia campus, VCU operates the longest-running cardiac transplant program on the East Coast and the second–oldest in the nation. The program began with the hiring in 1965 of Dr. Richard Lower, an early pioneer in cardiac transplantation, who performed Virginia’s first human heart transplant in 1968. The university was also the site of the state’s first heart-lung transplant in 1986.

“VCU is very rich in the history of transplantation. I’m very fortunate to be here,” said Dr. Kasirajan.

He hopes to see donor heart transplantation move further along the continuum. “Candidly, transplantation has not changed a lot since Dr. Lower started doing it,” he said. For instance, “we’re still limited to four hours of time, from the time we take out the heart to the time we put it in. It limits us to donors who are within 800 miles.”

He would like to see devices developed that can prolong the time a heart can be safely preserved. Additionally, he is interested in testing donor hearts prior to transplantation and an organ donor waiting list that considers antigen matching.

“Heart transplantation is still evolving compared to liver and kidneys and other organs because we match hearts based only on blood type,” he said. “But that is probably going to change very dramatically in the future as we learn more about organ preservation and matching.”

He also believes that, ultimately, artificial hearts will be approved as destination therapies for many patients who are not optimal candidates for transplantation.

He is impatient for these changes, and that’s why he enjoys working at VCU. “In additional to doing clinical work, being here gives us an opportunity to participate in some cutting edge research with people in other specialties,” he said. “We have a lot of opportunities to collaborate with them and come up with new ideas.”

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