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Medicine | THE UNREAL WORLD

Transplant drama matches truth -- to a point

June 18, 2007|Marc Siegel | Special to The Times

"Heartland" premiere, TNT, June 18, 10 p.m.

The premise: At St. Jude's Regional Transplant Center in Pittsburgh, transplant surgeon Nate Grant (Treat Williams) is having difficulty finding a heart that is the proper size and match for 14-year-old heart failure patient Leslie Walker. Grant's ex-wife Kate Armstrong (Kari Matchett) is the transplant coordinator, and she approaches the parent of a dying potential donor who turns her down. Walker's mother then attempts to overdose on her daughter's morphine so that her own heart can be used.

Armstrong finally finds a match, Sarah Evans, 24, who is dying from car accident injuries, and obtains consent from Sarah's father. During the transplant operation, however, the harvested heart becomes ischemic (doesn't get enough oxygen), and after the operation, Walker develops an irregular heartbeat, for which she's given mechanical support as well as anti-rejection drugs. Grant considers performing a new transplant, but Dr. Bart Jacobs, former chief of surgery, recommends Grant give the current heart "a chance to take."

Jacobs himself requires a lung transplant due to pulmonary fibrosis; he also suffers from hepatitis C. Grant (who will assume his mentor's position as chief) manages to find a lung through the computer-matching system UNOS (United Network for Organ Sharing), and transplants him as well. Jacobs was deemed a viable candidate for a lung even though his lung CT scan looked bad, because his arterial blood gases and pulmonary function tests were acceptable.

The medical questions: Are organs for transplant so difficult to come by? Does UNOS control the network for available organs? Are transplant coordinators (non-doctors) involved in obtaining donor consents? Would a patient awaiting heart transplant be treated with morphine? Can harvested hearts become easily ischemic as they are transitioned to the recipient, and would they then be treated with more anti-rejection drugs? Are hepatitis C patients routinely included on transplant lists?

The reality: Organs are very difficult to come by, according to UNOS. There are currently more than 96,000 patients on waiting lists, with more than 6,000 transplants and just more than 3,000 donors so far this year. Though UNOS oversees the national database of clinical transplant information, black market transplants (bought and sold organs) are increasingly popular.

And yes, coordinators are often neither physicians nor nurses, just as the show suggests.

It is unclear what is causing Walker's heart to fail, but if it is intractable angina (insufficient blood flow), then part of her pain relief program might include narcotics. Medicines such as morphine decrease the blood volume flowing to the heart, which decreases the amount of work the heart has to do.

Regarding the likelihood of ischemia: To prolong the period of time that donated hearts will tolerate an interrupted blood supply, the organs are cooled and flushed and preserved with histidine solutions. Studies from Germany and elsewhere show that the period of time between removal and insertion should not generally exceed four to six hours, and the donor heart from Sarah Evans doesn't appear to be without a blood supply for anywhere close to that. The show suggests that some operating room error may have caused the ischemia, which is plausible.

The show is misleading, however, in suggesting that a dose of anti-rejection drugs would be given to a transplant patient to treat ischemia. First, anti-rejection drugs are given automatically to transplant recipients. Second, doctors wouldn't give more of them to a failing heart recipient unless graft rejection is the cause -- which in this case, it is not.

Surprisingly, some degree of ischemia may be beneficial. Animal experiments have shown that mild ischemia paired with cooling may help preserve the heart muscle.

Patients are not generally excluded from transplant lists because of hepatitis C, and Bart Jacobs appears to be a reasonable candidate for a lung transplant according to his test results. The treatment of his lung exacerbation with steroids is also realistic.

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Dr. Marc Siegel is an internist and an associate professor of medicine at New York University's School of Medicine. In The Unreal World, he explains the medical facts behind the media fiction. Reach him at marc@doctorsiegel.com.

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