TMC PULSE

t m c » p u l s e | f e b r u a r y 2 0 1 9 t m c » p u l s e | f e b r u a r y 2 0 1 9 30 survival outcome, but also length of stay in the hospital post-transplant and how quickly a patient is able to get back on their feet and get back into the swing of things as far as their life is concerned," said Jeff Dreyer, M.D., medical director of heart failure, cardiomyopathy and cardiac transplantation at Texas Children's. Hickman will continue to be monitored over the next several months and will need lifelong follow-up care, Dreyer said, but the frequency of her visits will eventu- ally drop to just three a year—two in clinic and one for a routine biopsy of the heart. As Adachi noted, a heart transplant isn't permanent, and the thrice-yearly monitoring helps heart centers like Texas Children's keep an eye on their patients. According to Dreyer, the half-life of a trans- planted heart is approximately 15 to 16 years, meaning that in that period of time, about half of patients will need another heart. Texas Children's has already implanted another Jarvik 2015 in a different patient suffer- ing from heart failure, again with expanded use approval from the FDA. That patient, like Hickman, is recovering well. On Dec. 24, 2018, Hickman's Christmas wish came true, and she was discharged home. As time passes, her transplanted heart will grow with her, and although it won't last forever, science and technol- ogy are evolving quickly—and who knows what therapies will exist in the future to save her life once again. "We're buying time," Dreyer said. "Medicine changes. I can't exactly predict where things will go, but what I do know is that the way we practice medicine today isn't the same as what we did 10 years ago or 15 years ago, and so I imagine that innovations will likely occur over the same period of time going forward that will very significantly alter the clinical course or prognosis of our patients." The VAD not only improves survival out- come, but also length of stay in the hospital post-transplant and how quickly a patient is able to get back on their feet and get back into the swing of things as far as their life is concerned. — JEFF DREYER, M.D. Medical director of heart failure, cardiomyopathy and cardiac transplantation at Texas Children's Hospital failing heart on a VAD to show some signs of recovery—and that the younger the patient, the greater the chance that a heart in failure may recover on this kind of support. "Most heart centers don't pro- vide the pediatric patient with an opportunity to recover," Adachi said. "If you transplant so quickly, you may miss the opportunity to see some signs of recovery, which is why we like to wait at least three months." Adachi noted that in Hickman's case, they chose not to wait three months since it was only the second time ever the device had been implanted in a patient—the first being in Italy not long before—and the first time the device was used as a bridge to transplant. Still, Adachi anticipates that the Jarvik 2015 will do well in the upcoming multi-in- stitutional clinical trial—in which Texas Children's is participating— and hopes that it will soon become widely available and lead to a world- wide shift in clinical management of pediatric patients in heart failure. Buying time On Nov. 23, 2018, the day after Thanksgiving, Hickman received a new heart—then proceeded to amaze everyone with her swift and steady recovery. "The VAD not only improves "Our center is known for making pediatric patients better while wait- ing for a transplant," he said. "Unlike most other centers, we intentionally wait before moving forward with a transplant after we implant an internal device. We usually wait at least three months with an internal pump before activating the patient on the transplant list, and not a lot of pediatric centers are doing this— they want to get to transplant as soon as possible, which is primarily driven by the sense of urgency to avoid potential complications with VAD support." Texas Children's recognizes the benefit in waiting—the benefit in re-establishing healthy blood flow and all that comes with that, but also the rare benefit of rehabilitating a failing heart, Adachi explained. Such a practice is possible at Texas Children's, which has the world's largest pediatric VAD program, because the team is able to provide stable outpatient management. "Occasionally, someone will recover while waiting, and trans- plantation becomes unnecessary," Adachi said. "And recovery is very, very important, particularly in a pediatric patient, because while heart transplantation is great, it's not really a permanent solution." Adachi explained that it takes at least two or three months for a Above: Hickman gets a ride to the playroom at Texas Children's Hospital. Below: Adachi in his office at Texas Children's.

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