THIS MONTH'S FOCUS:

BASIC SCIENCE
HEART FAILURE & TRANSPLANTATION

(PDF VERSION)

Many thanks to Howard Eisen & David Nelson for coordinating the content for this month's issue.




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VINCENT'S TRADITIONAL SEASONAL SENSE

Again, it's that time of year. It's now a tradition for this season to shop to give, celebrate, eat more after Thanksgiving and in the Links review another great masterwork of classical music to rekindle the heart and soul. In regards to stoking the flame, Gustav Mahler supposedly stated "Tradition is not to preserve the ashes but to pass on the flame." In this final issue of 2016, our inimitable Senior Associate Editor, Roger Evans, delivers an insightful exposé on the definition of a Cardiothoracic Transplant Surgeon - the maestro of heart and lung replacement and transplantation. Such a maestro is at the helm of rather suddenly and deliberately (hmmm is December 7 on my mind?) turning around the state of the sufferer into a more vibrant human with better quality. In keeping with quality, Joshua Mooney gives of us the important message of "Quality and Value in Lung Transplant" transcending beyond the embracing charge of the ISHLT in terms of quality and value for its members and patients. We feel the burning torch of the eagerness of Nikita Desai's interest in "A Career in Lung Transplantation - A Fellow's Perspective." How can the value of such desire be measured for the ISHLT to prove its worthiness than to lay a path for our future and future members other than by reading Nikita's article?

For added value on the donor side, an ever-increasing need and important update on donor research and potential unmonitored donor adverse effects is reported by David Nelson through an "Update: Institute of Medicine Donor Management Research Study." Also, Jedediah Lewis of "Organ Preservation Alliance shares with us the initiatives from the White House to reduce the organ shortage in his article on "Taking Aim at Organ Preservation Constraints to Revolutionize Transplant Logistics." Next, Yasha Kresh, Pablo Huang and Howard Eisen provide us a brilliant, detailed and penetrating explanation with a Shakespearean twist on the protective effects of spiral flow generated by torsional contraction in their summary on the "Functional Architecture of the Heart: Torsional Contraction and Spiral Flow" - "To Swirl or not to Swirl, it's no longer the question." Another always reliable Senior Associate Editor, Pam Combs plucks the human emotion yearning to go home, when our VAD patients say, "I just want to go home?" in her brief missive - "The Return Home: VAD patients transitioning home."

It was the great maestro and composer, Gustav Mahler who was yearning to go home - Vienna - when he was dying from rheumatic heart disease complicated by subacute bacterial endocarditis from Streptococcus viridans. It should be no surprise that Mahler, probably an expert on grieving and suffering through experience from the deaths of his eight brothers, 5 in infancy and three before adulthood; had a morbid obsession with pain, sorrow and death reflected in his music. Not to mention the death of his oldest daughter, named after his insufferable mother, Marie. How he coped with it, hard work and great expressionistic music as summarized in the Editorial's Corner - "Gustav Mahler: Ahaseurus - The Wandering Jew." Along with his great compositional works, he left us with, "If a composer could say what he had to say in words he would not bother trying to say it in music."

Happy Holidays!

Vincent Valentine, MD
Links Editor-in-Chief



IN THE SPOTLIGHT:


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What Is a Cardiothoracic Transplant Surgeon?

Roger W. Evans, PhD

I frequently recruit transplant surgeons for transplant centers. For the most part, the recruitment of abdominal transplant surgeons is unambiguous, and relatively straightforward. I can easily describe the position for which I'm recruiting. However, when it comes to so-called "cardiothoracic" transplant surgeons, there is considerable confusion. In this regard, when describing transplant surgeons who have something to do with the chest, people often interchangeably use the following terms: cardiac, cardiovascular, thoracic, cardiothoracic, and cardiopulmonary. In my opinion, it's time to eliminate the ambiguity, and avoid the confusion. I recently completed a thorough review of the surgical staffing for all adult lung transplant programs in the United States (U.S.). In doing so, I found considerable diversity. First, let me begin with the obvious. In the United States, a lung transplant surgeon is any qualified and appropriately credentialed surgeon who performs lung transplants at a lung transplant center approved by the United Network for Organ Sharing (UNOS). Read more →



ISHLT NEWS AND ANNOUNCEMENTS:



Call for Council Vice Chair Nominations for BSTR, ID, MCS, PATH, PEDS & PHARM Councils

We are calling for nominations to become a part of these important and exciting Councils beginning in April 2017. The role of Council Vice Chair is a two year position and transitions to Council Chair in April 2019 and Council Past Chair in April 2021 for a total time commitment of 6 years. Self-nominations are accepted.

If you would like to nominate someone or yourself, please send the following information by December 15, 2016, to Megan Barrett at megan.barrett@ishlt.org:

We will be conducting the election for Council Vice Chair online in February 2017.




SPECIAL INTEREST:



Quality and Value in Lung Transplant

Joshua Mooney, MD

links imageDuring the 2016 ISHLT Annual Meetings President's Report a call was made to the society to "embrace the role of improving quality and value in the treatment of heart and lung failure." These terms, quality and value, have permeated healthcare discussions, news, and policy over recent years becoming widely accepted and emphasized metrics for healthcare performance. This development provokes questions for those in the field of thoracic transplant about how we should respond to the evolving focus of quality and value in healthcare delivery. The lung transplant community has responded to date by acknowledging the resources associated with lung transplant and has worked to understand high resource events, such as the index transplant hospitalization and readmissions. In 2016 alone, the number of publications on resource utilization and readmissions in lung transplant grew exponentially from prior years. Read more →



A Career in Lung Transplantation - A Fellow's Perspective

Nikita Desai, MD

links imageAs I entered my fellowship, eager to immerse myself in the knowledge of pulmonary physiology, critical care, and advanced lung disease, I was struck by the unexpected and often frustrating role of managing my patients' expectations. Rarely did a patient walk into my Monday afternoon clinic with a complaint I could definitively cure. Most of the time I was counseling patients on their new diagnosis of a chronic, irreversible disease with difficult to manage symptoms. I found myself wishing I could do more, and that my paltry offerings inhalers, influenza vaccines, and pulmonary rehabilitation felt surprisingly inadequate. It wasn't until my rotation in lung transplantation that I was able to offer hope, however slim, to the patient with end stage lung disease. Suddenly I saw that patients who were substantially limited could finally be able to do things we take for granted: grocery shopping, attending a baseball game, traveling to visit family. Read more →



Highlights of the European Society for Immunodeficiencies Meeting

Javier Carbone, MD, PhD

links imageThe 17th Biennial Meeting of the European Society for Immunodeficiencies (ESID) was held in Barcelona, Spain on 21 - 24 September 2016. Basic and clinical research in the field of primary immunodeficiencies (PID) was covered at this year's meeting from diagnostic immunology, to genetics and the immunobiology of immunodeficiency, immune dysregulation and inflammation. These topics together with other advances in the area of tolerance induction and new insights into cellular therapies were discussed through distinct keynote lectures, symposia, educational workshops and meet-the-professor sessions. Thymic function can be determined by T-cell receptor excision circle (TREC) analysis. A perspective on newborn screening in the United States was presented by Jennifer Puck, from the Department of Pediatrics at the University of California, San Francisco School of Medicine. Read more →




FOCUSING ON HEART FAILURE & TRANSPLANTATION:



Update: IOM Donor Management Research Study

David P. Nelson, MD

links imageAs previously reported in Links, two HRSA funded donor management research consensus conferences were held in Crystal City, November 2014 and Philadelphia, May 2015 to define barriers to donor management research and explore their possible solutions. The conferences recommended that a national oversight board be developed to assess ethical and scientific merit and provide safety monitoring for these studies and observed that the existing network of regulations which safeguards us from human research abuse is a misfit for donor related research in the complex context of organ allocation. In response to efforts of the consensus conferences and others the Institute of Medicine (now National Academy Medicine) has initiated a study to "examine the ethical, policy, regulatory, and operational issues relevant to the conduct of research involving deceased organ donors...that aims to increase the quality and quantity of donated organs". Read more →



Taking Aim at Organ Preservation Constraints to Revolutionize Transplant Logistics

Jedediah Lewis, JD

links imageLast June, the White House convened the first Organ Summit, bringing together many stakeholder organizations across transplantation to discuss ways to reduce the organ shortage [1]. The Organ Summit heavily emphasized the promise of research and development to provide solutions for patients on the transplant waitlist, unveiling new initiatives aimed at organ preservation, tissue engineering, donor management, bioartificial organs, and reconditioning of marginal organs, among other topics [2]. Among the initiatives announced by the White House was the upcoming Summit on Organ Banking through Converging Technologies, organized by the Organ Preservation Alliance [2]. The Summit is part of a growing research effort aimed at dramatically increasing preservation time and quality for transplant organs, combining advances in ex vivo perfusion, cryopreservation, hibernation and related areas that have occurred in recent years [3-5]. Read more →




FOCUSING ON BASIC SCIENCE:



Functional Architecture of the Heart: Torsional Contraction and Spiral Flow

J. Yasha Kresh, PhD, FACC, FAHA
Pablo Huang, MS
Howard J. Eisen, MD

Most, if not all, treatment modalities to correct and/or replace cardiac structural abnormalities are rooted in representing the heart as a pressure generating source for propelling blood circulation. Not until very recently has the helical structural arrangement of the cardiac muscle and the torsional dynamics (twisting and untwisting) of the ventricles during ejection and relaxation gained wider recognition and clinical impact. Much of this occurred in the past decade with the advent of sophisticated non-invasive dynamic 3-D imaging (i.e., Echo, MRI) of the blood-flow velocity patterns, exhibiting spiraling / vortical streamlines emanating from the ventricles. The specific molecular signaling pathways and significance (adaptation, pathogenesis) related to the more complex, momentum imparted, spiral flow in normal physiology and its alteration in heart failure leading to the onset of vascular pathophysiological states (atherosclerosis, thrombosis) needs to be fully elucidated. Read more →



The Return Home: VAD Patients Transitioning Home

Pamela Combs, PhD, RN

links imageHow many times have we heard a VAD patient say "I just want to go home?" And we typically respond with an objective, well-scripted response as why the patient can't go home "now" but that indeed the team's plan aligns with their request. The key to the patient/caregivers' adjustment of living at home with the VAD involves processes, communication, extensive planning to name a few, but what is the return home experience like for the VAD patient? Though the VAD team may celebrate the newly implanted VAD patient's discharge home, the work is only beginning. In general, the VAD team's perspective regarding the VAD patient's outpatient life consists of clinic visits, telephonic triage, support meetings, and facetime monitoring. The patient's transition home involves a noticeable change in daily routine and resumption of activities. Read more →




EDITOR'S CORNER:

Gustav Mahler: Ahaseurus - The Wandering Jew

Vincent Valentine, MD

links imageThis is the sixth consecutive December in which the Links steers our attention to Great Musical Composers and how they enhance our cultural and creative side of what we do for and in the ISHLT. (see 2011, 2012, 2013, 2014, and 2015. From Dvorak, Beethoven, and Mozart to Berlioz and Tchaikovsky, we turn to a summary on the life and works of Gustav Mahler encompassing a personal expression of his inner world characterized by a sense of alienation and loneliness. This sense relates to our theme of Volume 8 as we gain a better handle of what our patients deal with while suffering from a failing heart and/or failing lungs. Mahler was once quoted - "The symphony must be like a world: it should contain everything." In his symphonies and song cycles, Gustav built a complete world, involving every kind of human experience, from childlike innocence and wonder to anguish and despair. To achieve this, he wrote music for a huge orchestra, sometimes with voices added. He pushed musical form to the limit with exciting new harmonies. Read more →





Contact

Vincent G Valentine, MD
Editor-in-Chief
vgvalent@utmb.edu


Editorial Staff


"It's not just a question of conquering a summit previously unknown, but of tracing, step by step, a new pathway to it."
— Gustav Mahler

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Disclaimer: Any opinion, conclusion or recommendation published by the Links is the sole expression of the writer(s) and does not necessarily reflect the views of the ISHLT.