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A Matter of the Heart

DR. ABBAS ARDEHALI HAS BEEN A LEADER IN RESHAPING THE MEDICAL COMMUNITY'S APPROACH TO TRANSPLANTATION IN OLDER ADULTS.

MedMagSpring10-Dr. Abbas ArdehaliOn a Wednesday Morning at Ronald Reagan UCLA Medical Center, Abbas Ardehali, M.D., leans over a patient in the O.R., delicately removing the scarring inside her damaged heart. The director of the UCLA Heart and Lung Transplant Program is not only mending two of the woman’s heart valves, he also is redoing a coronary bypass she had a few years before. Except for the steady beeping of monitors and the rustle of nurses fetching instruments, the brightly lit room is quiet, the atmosphere calm. When Dr. Ardehali addresses his team, he is polite and direct.

Dr. Ardehali has done this surgery countless times. It is tricky, to be sure, but it’s hardly his most complex procedure. that would be the double-lung transplant he performed two nights before on a 46-year-old man. The surgery, which began at 4 a.m., after the donor organs arrived from saddleback hospital in Orange County in a limo – it was too foggy to fly them – lasted until 1 p.m. the next day.

Yet there is one aspect of this morning’s surgery that is unusual: The woman on the table is 80 years old. When she arrived at UCLA, she was in heart failure. Because of her age and chronic medical problems, her own surgeon considered her too high-risk for surgery. Not Dr. Ardehali.

“We don’t get too many healthy 80-year-olds,” he says with a warm smile on the morning of the woman’s surgery, sitting in his tidy office on the sixth floor of the center for the health sciences building. Dressed in a lab coat, scrubs and New Balance shoes, the surgeon is fielding calls from colleagues as he waits to hear if the woman is ready for the operation to begin.

Given her condition, it’s hard not to wonder why he accepted her case. for Dr. Ardehali, that decision reflects his deeply felt philosophy of medicine. “I’m willing to take the risks,” he says. “at UCLA, I feel we have a commitment to expand the horizons of the field.”

And then he adds: “The alternative would be consigning her to death."

OVER THE LAST DECADE, a dramatic change has swept the field of heart and lung transplantation: The number of older people receiving the lifesaving gift of a transplant has increased. As one of the few physicians in the United States with specialties in both medicine and surgery, Dr. Ardehali has been a leading innovator of this development. Since 1999, when he became head of UCLA’s program, the Iranian-born surgeon has performed dozens of transplants on older patients, with significant results. In a 2008 study of 50 patients who received lung transplants at UCLA between 2000 and 2006, Dr. Ardehali and his colleagues found that patients 65 years and older had nearly identical three-year outcomes as those who were younger than 65 years of age.

Peers in the field have taken notice. “He is widely regarded as an excellent surgeon and an innovator in the field,” says Kenneth R. McCurry, M.D., surgical director of heart and heart/lung transplantation at the Cleveland Clinic.

Historically, those who were 60 years or older found it nearly impossible to get a transplant. The reasons were many. Older patients didn’t tolerate immunosuppressive drugs well. They had problems with organ rejection. Add to those reasons various medical problems like high blood pressure or stroke, and their chances of survival were considered poor.

But there also was a generalized attitude within the transplantation community that younger patients, with many years of life potentially still ahead of them, should get preference. Didn’t they, after all, have the most to gain?

It was a philosophy Dr. Ardehali didn’t share. “It’s the only area in medicine where we ration care,” he says. “The rationale is there is a limited organ supply – organs should be transplanted to younger patients who are more likely to have a better outcome. However, at UCLA we continued to ask how can we improve access to transplantation for older patients without affecting organ availability for younger recipients?”

As transplant surgery got safer and patients were surviving longer and leading healthier post-transplant lives, the attitude began to change, and it was Dr. Ardehali who helped pave the way. He also took the lead in another breakthrough for older patients. He began to offer them organs that were older or slightly damaged or that might have been rejected as unusable because of the donor’s uncertain health, significantly increasing the supply of donor organs.

In a recent case, a 20-year-old donor was suspected of having died from IV-drug use. After numerous tests, Dr. Ardehali and his team believed the young man’s lungs were healthy. When he offered them to two older recipients, explaining the donor’s history, “One patient agreed, and now is home and off oxygen. The other patient decided not to accept the organ.”

In such a grave situation, how does he know the right thing to do? “I cannot make that decision for them,” says Dr. Ardehali, a slight, handsome man with thinning black hair. “You have to rely on the patients and their families. I need their help so we can make the best decision together.”

In addition to his work in the O.R., Dr. Ardehali is also an active researcher. He’s the principal investigator for the U.S. clinical trial of the “heart in a box” — a machine that can preserve a still-beating heart in isolation for hours until it can be transplanted. Besides UCLA, the trial is being held at four other transplant centers: Columbia University, Cleveland Clinic, Washington University and the University of Maryland. If successful, the new technology could break down the geographic barriers to transplantation, making it possible for donor organs to be transported anywhere in the country where a patient is in need.

With today’s technology, a heart must be delivered to the recipient within six hours for it to remain viable for transplantation. And many organs are, for a variety of reasons, thought to be too fragile for transplantation. in 2006, for example, 64 percent of donated hearts were not used because they were considered too weak or otherwise imperfect. The “heart in a box,” however, could sustain an organ for up to 24 hours, and further opens the door to salvaging some hearts that were previously deemed unusable, giving more desperate patients much-needed hope.

AS A BOY GROWING UP IN TEHRAN before the Islamic revolution, Dr. Ardehali was fascinated by medicine. he vividly remembers hearing the stunning news in december 1967, when South African surgeon Dr. Christiaan Barnard performed the world’s first heart transplant. “That was one of the moments in my background as a child that affected my career goals,” he says.

Dr. Ardehali’s family placed a tremendous value on education. His father, who received his Ph.D. from Clark University in Massachusetts, was an economist for one of the leading banks in Iran. But Dr. Ardehali particularly credits his mother for his drive and that of his five siblings to do something meaningful with their lives. Long before the 1979 revolution overthrew the Shah and sent tens of thousands of Iranians fleeing abroad to escape the repressive theocracy that followed, Dr. Ardehali knew he would finish his education in America, just as his father had done.

In 1976, when he was 16 years old, he left Iran and moved to Fall Rivers, Mass., to live with a family who were friends of his father. Although his english was good, the Iranian teenager definitely stood out among his all-white catholic schoolmates. But in his characteristic upbeat way, he downplays any difficulties of the transition: “It was a different culture, but after going to the prom, I felt pretty acclimated to the system.”

But as his new life unfolded in America, tragedy struck his family in Iran. His grand-father died of a heart attack. And his grandmother, to whom he was especially close, died suddenly in her early 50s when her pacemaker malfunctioned. Their deaths were a terrible blow. Yet in one sense, their deaths also were a catalyst to eventually motivate the disciplined and intellectually gifted student to focus on afflictions of the heart.

He almost took a different path. Engineering had also intrigued Dr. Ardehali. After earning a master’s degree in chemical engineering from Rutgers University, he decided to apply to the Ph.D. program at Stanford University and to several medical schools. When he was accepted to every one, it produced a crisis of sorts. “My thought was, where could i see myself happiest?” Dr. Ardehali recalls. In the end, the heart won out.

He earned his medical degree at Emory University in 1986 and went on to specialize in internal medicine and cardiology at UC San Francisco. In 1990, he came to UCLA, where he completed residencies in surgery and cardiothoracic surgery. It was at UCLA that he first saw desperately sick patients get well seemingly overnight – all because of a transplant.

After years of training, the young doctor found his calling. “It’s an awe-inspiring moment to look into a human being’s chest after you have taken out that person’s heart and to see the new heart you have placed there beating,” he says.

Asked what drives him, Dr. Ardehali’s wife, Mitra, says it’s not only his high expectations of himself. “He is constantly thinking of the patient,” she says. ”He is just really dedicated to what he does.”

THAT DEVOTION and Dr. Ardehali’s stellar reputation have drawn people from across the country to the program at UCLA. Patients like Ed Griganavicius, who came to Dr. Ardehali after more than two years of grappling with a potentially fatal heart condition.

Griganavicius owns an IT company in Orange, Calif., with an emphasis on healthcare. In the summer of 2006, the avid backpacker and climber was just 42 when his heart rate began soaring to 220 beats a minute. Like his mother, who died of the disease, Griganavicius was diagnosed with cardiomyopathy, a condition where the heart muscle is inflamed and doesn’t work as well as it should. In January 2007, after several harrowing trips to the emergency room, Griganavicius had a pacemaker defibrillator put in. “Unfortunately, it was shocking me,” he says. It was only later, after he’d been stabilized, that he learned he was in heart failure. He was also told he should get a heart transplant.

Shortly thereafter, Griganavicius’s wife, Lisa, gave birth to their daughter. It was bittersweet for Griganavicius; by the time his child was a few months old, he was so weak that it was hard for him to carry her.

In the meantime, Griganavicius was methodically comparing transplant programs. He was particularly impressed by Dr. Ardehali’s depth of experience and success with patients. “UCLA pretty quickly became the place to go,” he says.

In September 2008, Griganavicius met with the heart-transplant team, which included a cardiologist, a psychologist, a social worker and the transplant coordinator. Dr. Ardehali participated in the evaluation, too. In spite of his difficulties, Griganavicius was still too healthy to qualify for the transplant list, but he entered UCLA’s cardiomyopathy program. In November 2009, his condition worsened, and he was admitted to the hospital and placed near the top of the transplant list.

When word came, in January, that a donor heart was available, Griganavicius contemplated the upcoming surgery, and the thought of his own heart being lifted out of his chest. He wasn’t afraid. “I had done everything I could,” he says. “I had found the right place. I had the support of my family.” He was confident he was in good hands. “The fact you have a team of professionals that you truly believe in — that helped to alleviate any fear or uncertainty,” he says.

The surgery to replace Griganavicius’s dying heart went perfectly. Five hours later, he was off the respirator, and a few days later, he was up and walking.

As Griganavicius recovered in the hospital, his new heart beating away in his chest, Dr. Ardehali came by to check on him. How was he feeling, Dr. Ardehali asked. Was he eating? Getting any sleep? How was his state of mind? “It was about my overall well-being, not just the disease itself, but my entire quality of life,” Griganavicius recalls.

On January 21, eight days after his transplant, Griganavicius returned home. That first day, he walked up the stairs of his two-story house. For the first 24 hours, his daughter, now 2 ½ years old, wouldn’t let him out of her sight. Six weeks out, he’s working again. Under his doctor’s supervision, he’s also planning some trips. His heart is doing beautifully. “Everything is firing on all cylinders,” he says. “I’m just grateful that i got a second chance,” he says. “And that second chance is because of two reasons: the fact we have a donor program and somebody donated their heart to me, and the fact I had the best medical team I felt I could have gotten.”

It’s no wonder Dr. Ardehali feels so passionate about his work.

“I couldn’t have chosen a better profession,” he says. “The concept of having a direct impact on someone’s life and being able to see it within hours or days, it’s even highlighted more. These are patients who otherwise had no chance.”

Mona Gable is a freelance writer and journalist in Los Angeles.

 





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