Advanced Heart Failure Therapies Program
Heart failure occurs when a heart is unable to keep up with the demands of the body, meaning the body’s demands on the heart outweigh the supply of blood to the body. As heart failure progresses, it causes the heart to weaken and eventually makes everyday activities like walking very difficult.
Early stages of heart failure can be managed with medication and a healthy lifestyle. The condition is considered “advanced” when conventional heart therapies are no longer effective. However, even at this stage, there are still treatment options.
At UofL Health – Trager Transplant Center – Advanced Heart Failure Clinic we diagnose heart failure (HF) and determine the best treatment path for each patient based on their individual case. Our clinic has experts in many different areas, including physicians, coordinators, nurses, pharmacists, dietitians and social workers, who come together to help make the process as effective and simple as possible.
We specialize in helping patients with advanced heart failure that are not responsive to standard medical treatment options, offer a comprehensive treatment approach, which includes medication, device implants such as ventricular assist devices (VADs) or heart transplantation (link to VAD and heart transplant pages respectively), and use advanced technology and are leaders in transplant research.
Learn more about heart failure from our partners at the American Heart Association.
Please call 502-587-4384 to speak with our Heart Failure Therapies Program Coordinator.
If you are a patient and would like to self-refer yourself to our program or are a physician who would like to refer a patient, complete the advanced heart failure referral form.
Ventricular Assist Devices (VAD)
A ventricular assist device (VAD) is a blood pump for those with advanced heart failure that helps the heart send blood to the rest of the body. The device takes blood from a lower chamber of the heart and helps pump it to the body and vital organs, just as a healthy heart would. A VAD may be used if one or both of the heart’s lower chambers, the ventricles, don’t work properly.
Surgery is required to implant the VAD, which can be placed inside or outside the body.
UofL Health – Trager Transplant Center – Advanced Heart Failure Therapies Program uses VADs as:
- A bridge for patients while they wait for their heart transplant
- Permanent support for those who are not candidates for a heart transplant
- Temporary support to see if the heart will recover or heal itself before a transplant is considered
How it works:
A VAD can be a long-term solution to help your heart work better. The basic parts of a VAD include: a small tube that carries blood out of your heart into a pump; another tube that carries blood from the pump to your blood vessels, which deliver the blood to your body; and a power source. The power source is connected to a control unit that monitors the VAD’s functions. Some VADs pump blood like the heart does, with a pumping action. Other VADs keep up a continuous flow of blood.
Types of Ventricular Assist Devices:
The two basic types of VADs are a left ventricular assist device (LVAD) and a right ventricular assist device (RVAD). If both types are used at the same time, they may be called a biventricular assist device (BIVAD). However, a BIVAD is not a separate type of VAD.
The LVAD is the most common type of VAD. It helps the left ventricle pump blood to the aorta. The aorta is the main artery that carries oxygen-rich blood from your heart to your body.
RVADs usually are used only for short-term support of the right ventricle after LVAD surgery or other heart surgery. An RVAD helps the right ventricle pump blood to the pulmonary artery. This is the artery that carries blood to the lungs to pick up oxygen.
Both an LVAD and RVAD (sometimes called a BIVAD) are used if both ventricles don’t work well enough to meet the needs of the body. Another treatment option for this condition is a total artificial heart.
VADs have two basic designs. A transcutaneous VAD has its pump and power source located outside of the body. Tubes connect the pump to the heart through small holes in the abdomen. This type of VAD may be used for short-term support during or after surgery.
Some risks associated with implantable VADs include developing blood clots bleeding, infection surrounding the device, device malfunctions and right heart failure.
More than 6 million people suffer from heart failure with 500,000 new cases each year. More than 250,000 patients a year will die because of heart failure. UofL Physicians’ transplant experts understand the pain, struggles, and frustrations that affect people with heart disease, and those who care for them. We pursue advanced transplant research, develop new technologies, promote enhanced educational programs, and provide the finest pre-transplant and post-transplant patient care available in the region; all of which help decrease the mortality rates and provide life-saving options for individuals suffering from heart failure.
UofL Physicians performed the first adult heart transplant in Kentucky at UofL Health – Jewish Hospital in 1984. Since then nearly 500 heart transplants have been performed, thanks to our dedicated, expert multidisciplinary team approach.
Start here to learn more about different stages of heart transplant:
- Consultation & Evaluation
- Preparing and Waiting for Transplant
- The Transplant
- Life After Transplant
Consultation & Evaluation
From the date you are referred to our program for transplant consideration, it is our goal to have you seen in our transplant office within seven days of the referral, if not sooner. The first phase involves us obtaining as many of your records as possible to have them reviewed prior to your first appointment. During your first appointment, you will meet with the heart transplant coordinator and transplant cardiologist and/or transplant surgeon who will review your medical history. During this first appointment, they provide information regarding transplantation, including potential risks and benefits of having a transplant, as well as an overview of the evaluation process. While not required, many patients find it helpful to bring someone with them to the initial consultation to listen and take notes.
After the review of your records, additional testing will be necessary to determine the best treatment path for your individual case. Based on the condition of a patient’s advanced heart failure, same day testing in our Advanced Heart Failure Clinic might be discussed.
- Blood tests: You will need blood tests to help find a good donor match and help improve the chances that the donor heart will not be rejected.
- Diagnostic tests: You will need tests to assess your lungs as well as your overall health. These tests may include X-rays, ultrasound procedures, CT scan, pulmonary function tests (PFTs), and dental exams.
Meeting the Heart Team
- Surgeon: Evaluate the degree of your heart failure with the transplant team to ensure the best path is chosen for your care. The transplant surgeon will perform your transplant surgery and/or ventricular assist device (VAD) implant, if that option is the best choice for you.
- Cardiologist: Manages your heart failure treatment and evaluates you for transplantation. Following transplant, the cardiologist monitors your health and immunosuppressive medication regimen.
- Coordinator: Organize all aspects of your care before and after the transplant. They educate you about the entire process, coordinate diagnostic testing and help make sure you receive all necessary follow-up care.
- Social Worker: Evaluates your social history and discusses social issues related to cardiac transplant.
- Social worker: Some psychological and social issues that are involved in organ transplant include stress, financial issues, and support from family or significant others. These factors can greatly affect how you do after the transplant. Your social worker can help support your psychosocial needs and address them appropriately throughout the transplant process.
- Registered Dietician: You will meet with a dietician, who will assess your daily diet. The goal is for you to be as strong as possible for surgery.
- Other consults may also be required
Outline of Transplant Evaluation
On this testing day, you will be moving from department to department, and most patients bring someone along to help assist them. Plan on spending several hours on our campus for testing.
Tests may include:
- Chest CT scan
- Myocardial oxygenation tests: These tests are performed to measure the amount of oxygen the heart consumes during exercise. You will walk on a treadmill for approximately one hour while breathing into a plastic tube attached to a machine that measures oxygen consumption.
- Pulmonary function tests: These tests, which take about one hour and involve blowing into a plastic tube, are used to detect lung disease. Specifically, pulmonary function studies detect and measure respiratory function abnormalities
- EKG (electrocardiogram)
- Ultrasound of abdomen
- Heart catheterization: A heart catheterization enables physicians to measure pressures in all four chambers of the heart through the insertion of a thin plastic tube or catheter into a vein in your neck. Patients receive a local anesthetic before undergoing the 30-45 minute catheterization procedure
- Cardiovascular surgery clinic appointment
- Additional imaging/lab tests
- Social work evaluation
- Registered dietitian evaluation
- Transplant education with the transplant coordinator – It is required and very important to bring your support people to this appointment.
Following the evaluation process, results from your medical tests and physical are compiled along with the medical and psychosocial history. A selection committee comprised of heart transplant team members reviews your information and makes recommendations based on your overall health and test results. If treatment options, such as surgery or conventional medical therapy, are not suitable for you based on physical condition, you will be placed on the transplant waiting list.
If our heart transplant team determines a heart transplant is the best option for you, we add you to the current wait list that is maintained by the United Network for Organ Sharing (UNOS).
Preparing and Waiting for Transplant
The wait time for a suitable donor varies for each individual and will be explained fully by the heart transplant team. The team will also describe what to expect throughout the process.
After you are placed on the waitlist, it is extremely important you come to all appointments and take all medications as directed. If there are any changes in your condition while on the waitlist, you will need to inform your transplant coordinator as soon as possible. We also recommend following your dietitian’s suggestions regarding your diet. Participating in daily exercise is also beneficial in helping you be in the best possible condition for surgery.
Once you are placed on the waitlist, you will receive a status depending on the severity of your heart failure. The time people spend on the list varies on many factors, including your blood type, weight, pre-formed antibodies and donor availability. Those with a higher status on the waitlist will likely have a higher chance of receiving a donor heart. If a donor is found to be suitable for you, our team will contact you to schedule transplant surgery.
VAD: A Bridge to Transplant
For many patients, the process of heart failure treatment will include a mechanical assist device to support their heart while they await a donor heart. A ventricular assist device (VAD) may be used to help the current heart function as it is intended while patients on the transplant wait list await a donor heart. This is called a bridge to transplantation.
Heart transplant surgery typically takes six to eight hours. Additionally, patients are monitored for several more hours after surgery in the operating room prior to moving to our cardiovascular intensive care unit (CVICU).
In the CVICU
In the CVICU, you will have many lines and tubes in place; you will be sedated and asleep during this time. There will be a breathing tube in place and IV lines in your neck; there will be a chest tube in place. The average time spent in the CVICU varies, but the average is five to seven days.
The transplant team will update your family following the surgery. Your family will be allowed to see you as soon as you are stable in the CVICU. The CVICU has open visitation hours except for 6:30-8:30 a.m. and p.m.
After the CVICU
Once the transplant team decides you no longer require intensive care, you will be transitioned to our heart transplant step-down unit. Like the nurses in the CVICU, our nurses in the transplant unit have specialized training to care for heart transplant recipients.
Life After Transplant
As you recover from surgery, our heart transplant team will follow you closely. Follow-up care after a transplant is individualized depending on your needs, but you will likely experience the following:
- The first four weeks: You will have biopsies and clinic visits weekly after you go home from the hospital.
- Routine labs: You will have monthly lab testing to monitor anti-rejection medication levels as well as other labs to monitor the effects of the medications.
- Months two and three: We begin spacing out your biopsies and your clinic visits every two to three weeks.
- During the first year: We will see you monthly in clinic visits. You will continue to have periodic heart biopsies and blood testing to monitor for possible rejection.
- Annual testing: Annual testing consists of a heart catheterization to check for the presence of coronary artery disease (blocked arteries), heart biopsy, blood work, bone density scanning and an echocardiogram.
Medications After Transplant
Our transplant team will help you manage and understand your medications following surgery. As a transplant recipient, you will need to take immunosuppressive (anti-rejection) medications for the rest of your life to prevent organ rejection.
Here are some things you need to know about your post-transplant medications:
- These anti-rejection medications suppress your immune system so your body doesn’t reject your transplanted heart.
- Because your immune system is suppressed, you will be more prone to infections, especially during the first year after transplant.
- It is critical that you take all your medications as prescribed.
- You will need to carefully monitor and report any unusual side effects to your transplant coordinator. Side effects vary by dosage and type of the medication. Ask your transplant coordinator or transplant doctor any question you have about your medications.
- Never miss doses of your medications or stop your medications without approval from your transplant team.
- Although your medication regimen will be complex, rest assured your transplant team will teach you what you need to know and how to properly take your medications.
Monitoring for Signs of Rejection
Because your body sees your transplanted heart as a “foreign object”, it may try to reject your heart, much the same way if does with infections. Rejection is not uncommon. The risk of rejection decreases over time but can occur at any time. It’s important to follow all medication regimens and instructions to help prevent rejection and to recognize the early signs of rejection. We are highly skilled in treating rejection if it occurs; the key is to prevent rejection as much as possible.
Symptoms do not always accompany rejection but here are some ways to help identify and manage possible rejection. If you experience any symptoms of rejection, call your transplant nurse coordinator immediately:
- Low-grade fever
- Shortness of breath
- Fast heartbeat or skipping some beats
- Swelling of hands or feet
- Sudden weight gain
- Drop of blood pressure
- Not feeling “quite right” or flu-type aches and pains
Minimizing Infection Risk After Transplant
The same medications that help prevent rejection also increase your risk of infection. For the first 12 months after your transplant, the likelihood of rejection is highest, so you will be taking higher doses of these medications. This makes you even more vulnerable to infections. There are ways to help protect yourself from infection. You will be asked to follow these guidelines:
- Take and record your temperature daily.
- Wash your hands frequently and avoid contact with people who are ill. Alcohol gel is effective in preventing the spread of germs.
- Wear a mask in any crowd. You will be provided with masks to wear when you leave the hospital following your transplant.
- Practice good dental hygiene. You will need antibiotics prior to all dental procedures.
- Avoid contact with dust and dirt, which may carry a fungus that is dangerous to people taking immunosuppressive medications. Do not work in or visit any form of a construction site. Avoid gardening for the first after your transplant.
- Do not have a humidifier in your home.
- Do not use pepper for the first three months after transplant. After this time, you may use pepper, but replace your pepper supply every three months. Old pepper may contain a fungus that is dangerous to people taking immunosuppressive medications.
- You may have a dog, but other pets will put you at risk for infections. Avoid cats, reptiles, and birds.
- Undergo recommended immunizations (e.g., influenza, pneumococcal)
You should call your transplant coordinator immediately if you have any of the following symptoms which could indicate you have an infection:
- Fever over 99°F
- Signs of illness (cold, flu or extreme tiredness, or a cough that lasts more than 2 days)
- Sudden weight gain
- High blood pressure
- White patches on your tongue or mouth
- Cloudy or foul-smelling urine
Patient Story – Heart Transplant Patient Grateful for New Heart
Suffering from heart failure, Lisa Russell knew her heart would not be able to work much longer. She would soon need a transplant. To help her get to that point, physicians at UofL Health – Jewish Hospital implanted a ventricular assist device (VAD) to support her heart in pumping blood to the rest of her body. Three months after her VAD implantation, she received the call that a donor heart was ready and underwent a heart transplantation. Read more of Lisa’s story here.