Faculty Spotlight: Teresa De Marco, MD
More than 5 million people in the United States have heart failure, according to the Centers for Disease Control and Prevention. Heart failure occurs when the heart cannot pump enough blood and oxygen to support other organs. Common symptoms include shortness of breath during daily activities, having trouble breathing when lying down, swelling in the legs, ankles or lower back, and general fatigue and weakness.
Heart failure can often be controlled through a combination of medications, reducing salt in the diet, and exercise. However, some patients continue to deteriorate despite optimal medical and electrical device therapy and progress to advanced heart failure. “These are patients who are on all the right medications, but can’t walk a block or up a flight of stairs without feeling short of breath or fatigued,” said Dr. Teresa De Marco, medical director of heart transplantation and the director of the heart failure and pulmonary hypertension programs. “Their quality of life is poor, and they have a shortened survival.”
Dr. De Marco encourages physicians to refer patients with heart failure as early as possible, when the progression of the condition may be slowed by medication and lifestyle changes. Even if a patient has advanced heart failure, prompt diagnosis and treatment can improve outcomes. “By seeing patients earlier, we may be able to improve quality of life, and help patients avoid developing additional complications such as kidney failure,” said Dr. De Marco. “If patients do need advanced therapies, earlier referral can help these therapies be more successful.”
Dr. De Marco works closely with Dr. Dana McGlothlin and Dr. Robin Shaw, who are also heart failure specialists, as well as Dr. Charles Hoopes, director of the heart and lung transplant program at UCSF Medical Center.
“We have a really strong team, and we develop an individualized care plan for each patient,” said Dr. De Marco. “We offer the full spectrum of state-of-the-art therapies for patients with heart failure, from oral medication therapies all the way to mechanical support and heart transplant.”
Ventricular Assist Devices
About 20 percent of patients referred to the Heart Failure Clinic are diagnosed with advanced heart failure, and may be candidates for advanced therapies. These include ventricular assist devices (VADs) and heart transplant.
UCSF Medical Center implants 15 to 20 VADs annually. These devices, also known as mechanical circulatory support, supplement or replace the flow of blood generated by the heart. The ventricles are the lower chambers of the heart; a VAD can be implanted to support just the left ventricle, which pumps oxygen-rich blood to the body, or the right ventricle, which pumps deoxygenated blood to the lungs. Some VADs can be used to support both the left and right ventricles at the same time.
In 2008, the Food and Drug Administration approved the Thoratec HeartMate II, a newer type of VAD which is compact enough to fit in the palm of the hand. It is ideal for smaller body types, such as short women who might have difficulty accepting some of the older types of VADs, which are much larger and use bulky pumps. The HeartMate II uses a rotor inside a tube which provides a continuous flow of blood. This device is currently used at UCSF as a “bridge to transplant,” allowing seriously ill patients to improve their strength and health while waiting for a donor heart to become available. This allows patients to go into surgery in the best condition possible, improving their chances of good short- and long-term outcomes.
“There is a whole explosion in the technology of this field,” said Dr. De Marco. “With these new, smaller devices with fewer complications, there is no reason to wait until the last possible moment to implant them. These devices reduce the risk of surgery. They are easier to insert and are less prone to malfunction than the older VADs.”
Dr. De Marco anticipates that UCSF will be approved to implant the HeartMate II as “destination therapy” sometime early next year. This means it could be used to improve quality and length of life for patients who are not good candidates for heart transplant, such as those who are older or have other conditions that would negatively impact the outcome of heart transplantation. Patients can live with VADs for several years; many who were hospitalized and near death can return home and resume daily activities. Because VADs help the heart pump oxygenated blood to the rest of the body, patients feel more energetic and healthy than they have for months or years.
Critical patients may need other interventions to stabilize them before receiving a VAD or transplant, such as extracorporeal life support (ECLS). ECLS is similar to a heart-lung machine, and can be used for days to pump and oxygenate a patient’s blood. This allows the heart and lungs to rest, and buys time while the medical team determines optimum therapy.
Patients might also receive an intra-aortic balloon pump or an Impella. These devices are inserted through a puncture or cut in the femoral artery, at the groin, and are threaded through the arteries up to the heart. The intra-aortic balloon pump sits in the aorta, the body’s main artery. It deflates when the left ventricle contracts, creating a vacuum that helps to propel the blood forward and unloading the left ventricle, and inflates when the left ventricle relaxes (fills), helping to perfuse the coronary arteries.
The Impella is maneuvered between the aortic valve and the left ventricle. Left ventricular blood fills the catheter within which is located a rotor that propels blood into the aorta. This increases blood flow from the left ventricle to the rest of the body, reducing the amount of work the heart needs to do and increasing the amount of oxygen the body receives.
Two new investigational mechanical circulatory devices are currently under study in the United States. The HeartWare Left Ventricular Assist System is a small, implantable centrifugal blood pump. Also, the SynCardia Total Artificial Heart replaces the pumping function of both the right and left ventricles. “This area of development is very exciting, providing more potential options to patients with advanced heart failure,” said Dr. De Marco.
UCSF also has an outstanding heart transplantation program, performing about 20 heart transplants a year – more than 250 since the program’s inception. “We have excellent outcomes, despite caring for some of the sickest patients,” said Dr. De Marco.
One-year patient survival rates for heart transplant are 95 percent, and three-year survival rates are 87 percent, which are among the best in the Bay Area. Dr. De Marco attributes this to several factors. “We are highly experienced in the management of patients,” she said. “We have an inpatient service which includes hospitalists, heart failure fellows, experienced heart failure attendings, and close surgical collaboration. We also have an incredible team of nurses, coordinators, pharmacists, dieticians and social workers, as well as excellent cardiac anesthesiologists and perfusionists.
“Also, the same team of doctors follows patients all the way through, from the pre-transplant evaluation, during hospitalization for transplant, and after they are discharged for post-transplant care. That allows us to provide superlative continuity of care.”
The waiting time for a donor heart ranges from weeks to a few months for the sickest patients, and months to years for other patients. Under national regulations, hearts must go to the sickest patients first in a given geographic area. Many factors contribute to the actual wait time, including medical urgency, the recipient’s blood type and body size, and the length of time the recipient has been actively on the waiting list.
Once an appropriate donor heart becomes available, patients go immediately to UCSF, where they are prepped for the transplant surgery. Patients are put on a heart-lung bypass machine and ventilator. Surgeons make a major incision down the chest, remove most of the old heart, and transplant the new heart.
The transplant team cares for the patient before and after surgery. The new heart is supported with intravenous medications during the first three to five postoperative days to assure protection of all vital organs.
The team also provides long-term follow-up, monitoring heart function and immunosuppression medications needed to prevent rejection of the donor heart, as well as medications to prevent infection and treat high blood pressure. UCSF is currently participating in clinical trials sponsored by the National Institutes of Health to observe and prevent long-term development of accelerated cardiac allograft vasculopathy of transplanted hearts – disease of the coronary blood vessels – that limits long-term survival after heart transplantation.
UCSF is also a leader in offering dual-organ transplants. Significant kidney disease has traditionally disqualified patients from receiving a heart transplant, because diseased kidneys can lower the chances that a heart transplant will be successful in the long run. Yet heart failure often contributes to kidney dysfunction due to inadequate blood supply to the organs.
UCSF heart and kidney transplant specialists work closely to help patients in need of both a new heart and kidney successfully receive a dual transplant. “One of the distinguishing features of our program is that we create opportunities for transplantation, rather than limiting them,” said Dr. De Marco. So far, UCSF has performed 20 heart-kidney transplants, with heart and kidney transplant surgeons working side by side in the operating room. One-year patient survival rates are comparable to patients who receive a heart transplant alone. UCSF has also performed 10 heart-lung transplants.
Whether a patient receives one organ or two, Dr. De Marco and the rest of the transplant team are committed to caring for that individual for life. “Once patients come under our care and eventually undergo a heart transplant, we are in it for the long term,” she said. “They become like part of our family, and we are rooting for them every step of the way.”