The Heart of the Matter

Transplants have been responsible for saving the lives of those on the brink of death. William Baumgartner of Johns Hopkins explains the role his department has played in mending some broken hearts.

In 1944 Johns Hopkins doctors opened door for today's heart surgery

“It is one of the amazing things about this place. There are experts almost around every door or within every office”
-William Baumgartner, The Johns Hopkins University School of Medicine

Johns Hopkins medical center’s heart transplant program is recognized as one of the country’s leading centers in the surgical treatment of heart failure. It has a long history with transplant patients and has been undertaking these complex operations since 1983. In fact, it was the first hospital in the US to complete a domino donor transplant in 1987. The completion of this complex procedure helped put Hopkins on the map as a center for transplantation.

“The patient in question needed a heart-lung transplant,” says William Baumgartner, Vincent L. Gott Professor in Cardiac Surgery at the Johns Hopkins University School of Medicine and the Cardiac Surgeon-in-Charge at the Johns Hopkins Hospital, recalling the groundbreaking operation.

“Back in the early days it was believed that the best operation for a person who needed lung transplantation was to use the heart and both lungs, even though the heart, in this particular case, belonged to the recipient with cystic fibrosis. The patient actually had a pretty good heart. The process involved taking the heart and lungs from a donor; then the heart and both lungs were transferred into the patient who had cystic fibrosis. The heart was then taken from the cystic fibrosis patient and given to the patient who only needed a heart transplant. The name coined for the procedure was ‘domino donor transplant’.

Baumgartner arrived at Johns Hopkins in 1982, a year after the first successful heart-lung transplant operation was first carried out by his friend and colleague, Bruce Reitz at Stanford University Medical Center. Following his arrival, Baumgartner set up the Johns Hopkins heart transplant program, which took a year to develop. “In those days,” he recalls, “there weren’t any well established transplant organ procurement centers. We had to develop most of it within the institution. However, it gave me a great opportunity to immerse myself in transplantation.” Currently the lung transplant program, led by Dr. Ash Shah, implants single and double lungs for patients with end-stage lung disease, with few recipients actually needing heart and lung transplantation.

Across the country, the number of heart transplants is now relatively static, a trend which is also apparent at Johns Hopkins. Baumgartner points out, however, that the center does have a number of patients who are treated with various new medications, some with biventricular pacing, and others undergoing fairly standard operations like mitral valve repair. Still others are treated with surgical ventricular restoration, a procedure developed by Dr. Vincent Dor in Monaco, during which patients who have suffered a myocardial infarction have the scars removed from their hearts, thereby allowing them to pump blood more efficiently.

In common with many institutions which have heart failure programs, under the leadership of Dr. John Conte, Johns Hopkins has a very active ventricular assist device program for certain patients who deteriorate while they’re on the heart transplant list. “We use one of these artificial devices to bridge a patient to transplantation,” says Baumgartner. “If patients decompensate while they’re waiting for a transplant, we put this in to tide them over. We also have approval from CMS to use a permanent device for certain patients who are not transplant candidates.”

Baumgartner keeps in contact with many of his past transplant patients. He explains how rewarding it is to hear from them about their progress: “There are a number of transplant recipients who are still alive between 15 and 22 years after their operation, whom I still correspond with – they send me cards, or I see them from time to time. The field of cardiothoracic surgery is a very gratifying one where you can really help patients and, over a period of time, make a difference in their quality of life.”

Neurological protection

Baumgartner has conducted studies into neurological protection in cardiac surgery, an area of research that has had continuous funding support from the National Institute of Health over the past 15 years. Although he did all his early basic science work in the field of transplantation, defining the mechanisms of neurologic injury fascinates him. “Sixteen years ago,” he says, “A cardiac fellow by the name of Mark Redmond arrived at the department with a keen interest in neurologic research. We had achieved a certain amount of success in preserving hearts for transplantation. However, Mark identified that not much inroad had been made to protect the brain. I agreed with him that he had a very compelling argument and was something we needed to look into.”

There is certain receptor in the brain known as NMDA that if over-stimulated can cause brain cells to die. Decreased oxygen causes over-stimulation by one of the neurotransmitters (glutamate). This pattern of neuronal cell injury is called excitotoxity.

When they began to look up information about NMDA receptors, Baumgartner was thrilled to find that an expert in this area worked at Hopkins. “It is one of the amazing things about this place,” he enthuses. “There are experts almost around every door or within every office. Dr. Michael Johnston is a pediatric neurologist and neuroscientist and was happy to work with us. That was the start of it. We now have about a dozen different collaborators involved in this research that has been ongoing for 16 years, and we recently received NIH approval for five more years.”

“We are trying to figure out what exactly is the mechanism of neuronal injury. One of them is stroke. This often happens when a fragment is dislodged from the heart or aorta that then causes an occlusion of an artery. As a result, the part of the brain supplied by the artery dies.”

In addition to stroke, there are also other subtle changes that occur in the brain when there’s decreased blood supply. The center now has a drug that researchers think might be beneficial for patients undergoing certain operations and they are about to start a pilot study clinically, based upon this lab work. It will be particularly used in aortic operations, performed by faculty within Cardiac Surgery led by Dr. Duke Cameron, Director of the Broccoli Center for Aortic Diseases. “We’re also now looking at the genomics of this problem to see if we can more accurately define the mechanism. One day it may be possible to identify which patients might be more susceptible. This is an area that is going to take several more years of research, but it’s where we’re going.”

Challenges

One of the most frustrating aspects of Baumgartner’s work is when a breakthrough in the lab does not translate to the patient. Another challenge for him is how to support the young faculty that he has on his staff. “They have bright ideas, but it is hard these days to obtain an NIH grant. The budget of the NIH has been flat for several years. Unless you have preliminary data, obtaining a grant is virtually impossible. There has to be some kind of funding mechanism to provide support for these young investigators who have really bright ideas.”

Baumgartner recalls that when he first started in the field, the reimbursement for clinical services was such that at the end of paying all the expenses and salaries, there would still be enough money left over to go towards funding new research. He laments the fact that the reimbursement rate has been decreased by over 50% over the last 10 to 15 years, so by the time bills and salaries have been paid, they are almost at a break even point.

“We try to help our young faculty through philanthropy,” says Baumgartner. “We have grateful patients who are interested in helping us make a difference. We use this money to help our young faculty develop the preliminary data they need so they then can apply to the American Heart Association or NIH.”

Another area of involvement for Baumgartner is researching whether stem cells may be an effective treatment for patients who have neurological injury with cardiac surgery. Although the first experiments have not been done yet, the team is already gearing up to apply for another set of funding. This might be particularly applicable in pediatric heart surgery where stem cells from cord blood could be grown and infused at time of operation. Dr. Luca Vricella, Chief of Pediatric Heart Transplantation will be the director of this clinical program if the basic research shows promise.

On the horizon

The hopes Baumgartner has for the department are based upon the missions of Johns Hopkins to provide excellent and quality patient care, and to do this through supplying them with cutting edge and innovative therapies. He is proud that the department is exploring new ways to treat patients through minimally invasive approaches and through different operative techniques like SVR, and he would like to apply cellular therapy for patients with heart failure in the near future. “If you operate on a patient who has heart failure, maybe it will be possible to harvest their own cardiac stem cells ahead of time, grow them and inject them into the heart directly when you’re operating on the patient for another problem such as a bypass operation, a mitral valve repair or a ventricular assist device implant.”

Due to the rapid evolution of technology, Baumgartner is optimistic that operations through smaller incisions will become more viable in the future. Dr. David Yuh, Director of this Program at Johns Hopkins, has performed several of these procedures with and without robotic assistance. Most importantly, he would like to ensure that junior faculty members have every opportunity for advancement, so that they can go from assistant to associate and then to full professor. These opportunities were readily available to him 20 years ago and he would like to insure these opportunities continue for the next generation.

The final mission of the department is to train the future leaders in cardiothoracic surgery, an area in which they have already had a great deal of success. “Two-thirds of our graduates, and we graduate two a year, go into an academic cardiothoracic surgical practice,” explains Baumgartner. “Long term, a little over 50% continue in an academic practice, and about 28% of our graduates have become chiefs of divisions or departments. We hope to be able to continue to produce the next leaders; it’s a terrific feeling to see how these young kids go on to do really great things and I’m proud we have had an input into their education.”

William Baumgartner is the Vincent L. Gott Professor in Cardiac Surgery at The Johns Hopkins University School of Medicine and the Cardiac Surgeon-in-Charge at The Johns Hopkins Hospital. He is also Vice Dean for Clinical Affairs and President of the Johns Hopkins Clinical Practice Association, the organizational body representing more than 1700 full-time practicing physicians at Johns Hopkins.

After joining Hopkins in 1982, Baumgartner reinitiated the medical center’s heart transplant program, now recognized as one of the country’s leading centers in the surgical treatment of heart failure.

Steady hands is certainly a must in cardiac surgery, but what other characteristics make a good surgeon? We asked William Baumgartner, cardiac surgeon in charge at the Johns Hopkins Hospital, for his views.
First, you must establish yourself as someone who can operate properly and have complete competency in your operative procedures. A humble approach to what you do is also very necessary. Most successful cardiothoracic surgeons are very hard workers. They’re dedicated to what they do – taking care of patients. You have to have a certain set of interpersonal skills – not just with your patients but with your colleagues.

To get into a leadership position, your focus must shift from yourself to your colleagues and you need to be cognizant of the promotion and advancement of your young faculty. You need to have a certain inquisitive curiosity about science and what you think might be the next best operation or the next research project that might help better the care of patients or provide an answer to a specific question that you have.

In a heartbeat

Some cardiac surgery innovations from Johns Hopkins
In 1944 doctors at Johns Hopkins performed the surgery that opened the door to today’s heart surgery. Working together, the Johns Hopkins Hospital’s chief surgeon, Dr. Alfred Blalock, and pediatric cardiologist Dr. Helen Taussig devised a means for improving the flow of oxygen into the blood by connecting one of the heart’s major arteries with another feeding into the lungs.

Known as the Blue Baby Operation, it brought relief to a young girl plagued with a combination of heart defects that kept her blood so starved for oxygen that her skin was literally blue. In time the procedure not only helped save the lives of thousands of similarly afflicted children around the world, but also opened the door to now-familiar procedures like coronary bypass surgery.

In the 1950s doctors and scientists at Hopkins developed the first cardiac defibrillator and discovered cardiopulmonary resuscitation or CPR. While defibrillators today with their metal paddles are a familiar feature of hospital emergency rooms and ambulances almost everywhere, CPR has been credited with saving hundreds of thousands of lives.

In the 1980s cardiac specialists at Hopkins working with children developed balloon angioplasty – inserting a balloon-tipped probe into the arteries feeding the heart and then inflating it to clear blockages. Like the first open heart surgery pioneered at Hopkins during the Second World War, this new technique quickly became a common procedure for the treatment of adult heart problems as well.

That tradition of pioneering work continues at Johns Hopkins with physicians and researchers working in almost every field related to cardiovascular disorders, from transplant surgery to prevention. The hospital receives more federal research funding than other medical institution in the country and its cardiology department has been specially recognized for its work.

ldimarca@csurg.jhmi.jhu.edu.