As a young man lingered near death — his heart barely pumping, other organs also failing — about two dozen members of the University of Kansas Health System’s multidisciplinary team debated what to do.
Was he too sick for anything but palliative care? No-one wanted to tell the 30-year-old patient that.
Should he be transferred to a more seasoned heart programme, one experienced in treating such high-risk patients? Perhaps.
Or should they take him into surgery, implant a device to help his heart pump blood, try to nurse him back to better health and then — likely many months in the future, if he survived — give him a new heart?
At that point, the University of Kansas Hospital had implanted only one such device, and it went to a low-risk patient after careful planning. The hospital hadn’t transplanted a heart in more than two decades, after shuttering its first programme when news leaked that it had been turning away hearts for months while still adding patients to its transplant waiting list.
Now, several years into its transplant restart effort, health system officials wanted every step to go right. Those gathered in the conference room discussing the high-risk patient knew his case could derail their momentum if things went badly.
Yet he also represented the reason the KU Health System was getting back into the heart transplant game.
“We can do this,” said surgeon Travis Abicht, who had transplanted 16 hearts during his final year at Chicago’s Northwestern Memorial Hospital, which he left in 2015 to become the KU Health System’s surgical director of heart transplant and mechanical assistance.
Abicht, a former surgical resident at KU Hospital, brought along heart failure specialist Andrew Sauer to be the health system’s medical director for heart transplant and advanced heart failure. Co-workers since 2010, both had felt the timing was right to move to the KU system.
And at this moment, in March 2016, both thought the timing was right to operate. This was a young patient, and if they could get him back on his feet, he could thrive.
“It wasn’t a matter of questioning whether it was appropriate to do,” Abicht recalled recently. “We needed team buy-in … first and foremost for the patient but also for the group.”
They got it.
Since receiving a left ventricular assistance device 10 months ago, Zach Engelken has turned 31, gotten engaged and received a healthy heart.
Around KU Hospital, he is “No. 4” — the fourth heart recipient of the new programme. The first patient received his heart in October, the second in December, the third and fourth this month. Once the hospital conducts 10, it will have enough cases to seek final certification.
The KU Health System joins St. Luke’s Hospital — which performed 44 heart transplants last year, the most in this region — as the only Kansas City-area hospitals performing adult heart transplants. Children’s Mercy Hospital, which did three transplants in 2016, launched a paediatric programme two years ago.
Last year, the area shipped about half its donor hearts to other regions. A second local transplant programme should help keep some of those here, Abicht said.
The move also adds Kansas City to the list of similar-sized metro areas — including Cleveland, Milwaukee and Indianapolis — with two heart transplant programmes. Plus it fills a void in Kansas, which has not been home to a heart transplant programme since a Wichita hospital ceased doing the procedure in 2009.
Nationally, a record 3,191 patients received new hearts in 2016. More than 4,000 others remain on waiting lists, including four at KU Hospital and 16 at St. Luke’s.
Engelken hopes someday to meet his donor’s family.
“I’m very grateful,” the Seneca, Kansas, resident said last Wednesday, eight days after transplant surgery, as he rested in a fourth-floor hospital bed.
When Sauer knocked on his door and reported that tests on the new heart looked good, Engelken smiled.
“It’s got a good strong beat, compared to my old one,” he said. “I can tell. Oh, yeah, it feels great.”
The hospital closed its original heart transplant programme in 1995 after a Kansas City Star investigation revealed serious problems.
The hospital rebuilt by upgrading the quality of its personnel and heart treatment facilities. The transplant programme is the final piece of that rebound. When KU Health System officials announced their plans in 2012 to renew the transplant programme, Abicht already was paying attention.
As a teenager, he had watched heart procedures at the Wisconsin hospital where his father worked as an anaesthesiologist. He had marvelled at how surgeons could stop and start a heart, and how a bypass machine could keep a patient with no pulse alive. Later, when the surgeon visited the patient in intensive care, it seemed almost as if the surgery never had happened.
It’s an incredible profession, Abicht said.
“You see people at their worst, when they are at their most vulnerable. And you do something that essentially takes them from death’s doorstep to back to being themselves again.”
He drew inspiration from KU Hospital staff while in his general surgical residency here. He’d already earned his undergraduate degree from the University of Kansas and stuck around to attend KU’s School of Medicine. So even after he went to Northwestern, where he learned from some of the best in the country, he felt a strong tug to return to Kansas.
When the first transplant surgery day arrived in October, part of the KU Hospital team went to another hospital to remove the heart from the donor. Others prepared to work on the recipient. Co-ordination is key, Abicht said.
Though a transplant patient might be in the operating room for six to eight hours, the furious part of the procedure — removal of the old heart and insertion of the new one — takes 60 to 90 minutes.
Little about the operation has changed over the years, Abicht said.
Much has changed, however, when it comes to heart assist devices like the one Engelken received last March. Decades ago, any such device would have been large and cumbersome. But as the devices have gotten smaller, surgeons have increasingly relied on them, often as a bridge to keep patients alive while awaiting a new heart.
The device’s pump sits next to the heart, inside the patient’s chest. A cable extends from the pump out through the skin and connects to portable batteries or an electrical outlet.
Before Engelken received such a device, his left ventricle — the heart’s main pumping chamber — was pushing out only 5 percent of the blood inside it with each contraction. A normal ejection fraction is 55 to 70 percent.
Doctors aren’t sure what caused Engelken’s heart to decline so rapidly. He started feeling sick only about a month before turning deathly ill.
Even with the mechanical assistance, he moved to the top of a three-tier transplant list in November. Most patients who reach that designation are so sick that they have to be hospitalised in intensive care, sometimes staying there many months until a heart becomes available, if they get one at all. Because of the assist device, Engelken waited at home.
When his telephone awakened him at 12:40am January 17, he saw the 913 area code and knew what it meant.
“Well, Zach, I think we found you a heart, and Dr Sauer is pretty confident in it,” said the caller, transplant coordinator Joey Crane. “He would like for you to start making your way here.”
Engelken and his fiancee quickly started the two-hour drive to Kansas City.
“I know what it takes for you to get a call like that,” he said. “Another family has to go through a tragedy for another family to gain from it.”
Tests showed his new heart humming exceptionally well, ejecting nearly 70 percent of blood with every beat.
Depending on whether Engelken likes big trucks or fast cars, he either got an 18-wheeler or a Ferrari, Sauer said.
“That heart is a really good heart,” Sauer said. “It was a good match for him.”
‘Pretty amazing gift’
Many times, a transplant recipient’s path to the operating table takes much longer than Engelken’s. Because those patients’ hearts fail much more slowly, cardiologists can try other treatments first.
That happened with transplant recipient No. 3, a 49-year-old married father of two high-schoolers in Higginsville, Mo.
Kyle Warren first arrived in Sauer’s office in August 2015 seeking a second opinion. Sick since the fall of 2013, he’d learned in January 2014 that he had an enlarged heart and an ejection fraction of 30 percent. His doctors ordered a pacemaker and defibrillator. At each new doctor’s appointment, Warren and his wife, Jill, expected to hear he was getting better. Instead, he’d be the same, or worse. Eventually, shortness of breath robbed him of his quality of life. When he took his son deer hunting last fall, he had to stay in the truck because he couldn’t walk to the tree stand.
Sauer suspected an inflammatory condition, even though biopsies came back negative. He prescribed steroids and other aggressive therapies. Yet Warren got sicker, eventually quitting his job as a state road worker.
Doctor and patient remember well the moment they knew his treatment course had veered down the transplant path.
“I think you were pretty upset,” Warren recalled to Sauer during a recent checkup.
“It felt like failure,” Sauer said. “It felt like we had let you down.”
In December, Sauer had suggested Warren enter intensive care to await a heart. But Warren wanted to be home for the holidays. And he wanted to watch his son’s first wrestling match of the year on January 4.
He’d come in after that, they decided. The morning after Christmas, Warren sat at his kitchen table, physically spent. There would be no attending his son’s wrestling match. He and his wife headed to the hospital.
His ejection fraction had dropped to 10 percent. His left ventricle was twice its normal size, and his heart looked more like a basketball than the football shape it should have resembled.
“Without a transplant, he would have died,” Sauer said. “He was in the final stages of a very advanced disease.”
Doctors moved him to the top tier of the transplant waiting list, where the Warrens expected him to stay for two to three months.
Silently, Warren worried that he wouldn’t get to walk his daughter down the aisle. In a Facebook post, Jill Warren asked for prayers — not just for them, but for the family who would have to give up a heart.
Ten days later, nurses told Warren he couldn’t have breakfast. He finally fished the reason out of doctors later that morning.
Warren tried calling his wife. Unable to get through to her phone at the Higginsville bank where she worked, he sent a text: “I know why I can’t eat.”
She called him.
“They think they have a match.”
“Are you kidding?”
Both choked up as they sat there, phones to their ears, unable to speak.
The next day, January 5, Kyle Warren received a new heart. An examination of his old one revealed inflammation, as Sauer originally had suspected.
Since the surgery, Warren’s shortness of breath and fatigue have vanished.
He now walks three times a day, trying to rebuild his stamina. Like all recipients, he takes medicines to prevent rejection. Doctor visits punctuate his calendar.
Jill Warren finds herself brainstorming ways to encourage organ donation.
Kyle Warren finds himself dreaming again about the future.
“Transplant is a pretty amazing gift for the patients that have the right criteria,” he said. “It’s a gift from a donor to a recipient. It’s a gift from the community.
“No matter how many times I’ve participated in heart transplantation, I find it to be miraculous every time, because you watch a heart come out of one person and go into another and start up as if it didn’t even know there was a change.”
The patients know. —The Kansas City Star/TNS