Mending Broken Hearts

Step inside the operating room at Cedars-Sinai for two heart valve procedures and a transplant.

Christine Moore's new heart, shown covered in its thin layer of epicardial fat, will represent the hospital's 40th transplant of 2012. In eight to nine days, Moore should be able to leave the hospital; full recovery will take about two months.

In Pictures: Heart Surgery at Cedars-Sinai

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Two days after surgery, Trusel is wearing makeup and walking around the intensive care unit with her nurse for exercise, clearly no longer troubled by a lack of oxygen. In fact, she takes her laps so quickly the nurse repeatedly urges her to slow down.

It was 3 o'clock Wednesday morning when Christine Moore of Orange, Calif., 62, got her summons. She packed her bag and headed with her husband to the hospital. "There was no traffic," says Moore, a part-time receptionist at the Orange Senior Center. "We made it in an hour."

First diagnosed with an irregular heartbeat in the 1980s, Moore had a stroke in 1996 and about 10 years ago began experiencing edema, the swelling characteristic of a failing heart caused by excess fluid trapped in the tissues. She controlled the swelling using diuretics well enough until last year, when Jon Kobashigawa, her cardiologist, suggested she might be ready for a heart transplant. Moore's condition, known as restrictive cardiomyopathy, isn't completely understood, but it means that her heart just doesn't stretch properly. The situation became dire in April, after Moore gained 27 pounds of fluid weight and had trouble breathing. She was moved to the top of the transplant list of patients with type B blood in need of a small heart.

As Wednesday dawns, Moore settles in with her husband for a long day of waiting, with no food or drink. "I'm very thirsty and my mouth is bored," she observes. Her new heart will be coming from another state, and the retrieval must be coordinated with the surgical teams for the other people receiving organs from the donor. Surgeon Danny Ramzy must fly to the donor's hospital, remove the heart, and fly it back to Cedars-Sinai.

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Finally, at 6:30 p.m., Moore is asleep on the table and Trento has made his first incision. Her sternum is cut with a saw, her rib cage pulled open, and her blood is soon circulating through the heart-lung machine. Ramzy is expected to return just before 7:30, and, right on time, he delivers the donor heart on ice in a red cooler. At 7:35, Trento frees Moore's own sick heart and puts the new one in its place. He attaches the five major channels that bring blood into and out of the heart: the left atrium, the inferior vena cava, the pulmonary artery, the aorta, and the superior vena cava.

Trento, 61, has been performing heart transplants almost half his life, beginning 15 years after Christiaan Barnard pioneered the procedure in 1967 in Cape Town, South Africa. That patient, a man in his mid-50s, lived for 18 days before dying of pneumonia contracted while on immune suppressant drugs to keep his body from rejecting the heart. By 9:30, the highly practiced Trento has completed one of his fastest transplants ever. In eight to nine days, he says, Moore should be able to leave the hospital. Her full recovery will take about two months.

To make her immune system as hospitable as possible to the new heart, Moore will at first take a relatively new mix of anti-rejection drugs that includes tacrolimus, mycophenolate, and prednisone, and after six months just tacrolimus and mycophenolate at reduced doses. A 2006 study led by Kobashigawa, director of Cedars-Sinai's heart transplant program, found that this combination significantly lowered the odds of rejection compared to standard treatment with cyclosporine. Cedars-Sinai claims one of the lowest first-year rejection rates in the country at 5 percent.

At the moment, about 3,200 people in the United States are on the waiting list for a heart transplant. Here in Region 5 (California, Utah, Nevada, New Mexico, and Arizona), the median time on hold is 108 days. Various factors push people higher on the list: They are in the hospital, or taking high doses of medication, or require mechanical pumping help from a ventricular assist device or a full artificial heart. Each week on Friday, the Cedars-Sinai transplant team gathers to present new candidates and discuss the condition of the people already on the list. It's at these meetings that people who have recently faced health setbacks get promoted closer to the lifesaving operation.