Stephen Large, Papworth Hospital Cambridge
Heart failure is when the heart simply canít pump enough blood around the body, and itís so prevalent it costs 2 percent of our GDP! Transplants come from people who are brain dead, with permission of the families, and taken off life support. Stephen Large, a surgeon from the world-leading transplant centre, Papworth Hospital in Cambridgeshire, may have discovered something which might improve peopleís chance of getting thrown this lifeline in the first place.
Stephen - We look at heart failure in sort of stages if you will, and weíre looking at patients for heart transplantation who are stuck in the severe category of heart failure. So theyíre breathless at rest or theyíre persistently tired. Their exercise ability is very, very limited; their lives are so contained, dreadfully contained by the restrictions of their heart failure, theyíre pump failure, despite best medical therapy, and those are candidates for transplantation. And, of course, we find that the younger people tend to do better with transplantation than older folk, which is a little ironic because heart failure is an age-related issue. We heard today in this conference, 20% risk of heart failure developing in those over the age of 65, and thatís a daunting prospect as you approach 65 - not great.
Georgia - In terms of actually taking the heart out of someone who no longer needs it, I suppose, and putting it into someone who does. This sound incredibly difficult. How long have we been able to do this and what are the success rates?
Stephen - Well, I was a secondary school student when this whole area exploded and, of course, Christian Barnard hit the press in '67 with his transplantation of Wychenzky. There was a big flurry of transplantation after that and folk didnít understand really the ups and downs of immune suppression because, of course, you have to damp down the recipient of the heart's immune system, otherwise theyíll reject it, like any foreign protein. So we have to get the patients to have immune suppression so they tolerate the new heart and it keeps them going, and very effectively so too. As we saw again from statistics today, survival moving from a 50/50 chance of those with severe heart failure of 1 year to 50/50 survival after transplantation of 13 years, which is amazing, absolutely incredible therapy. And not just survival but, of course, a quality of life benefit hugely impressive.
Georgia - So how does one of these transplants work? Well, last year, BBC Radio 5 Live made history and did a live recording from one of these operations, and weíve got a clip here that give you a small idea of just how incredible these procedures areÖ
Chris - So this is my first look proper into the operating theatre and you can see Steveís head right in front of me just coming out of the top of the bed. Various tubes connected to the top of his head and coming out of his mouth as well. And if I just come over to my right as well, pretty much the most important machine in here which is effectively doing the job of Steveís heart, working out the circulation of Steveís blood around his body whilst his heart can no longer do so. One, two, three surgeons right next to Steve and doing all of the main work, and then we have a perfusionist here whoís operating that machine I was talking about thatís doing the work of Steveís heart, and then the anaesthetist just to the left as well. And they know that theyíve got a long road ahead.
Letís have a quick word with Laura who is the transplant coordinator. So just tell us where we are at the moment because theyíve been working for some time already? What stage are we at here?
Laura - Weíre at the stage where weíre preparing to explant the heart here from Steve, so heís on the bypass machine now. So Mr Howell is just loosening the heart and preparing to take it out properly and in the background we are waiting for his new heart to be delivered to us. So weíve got the timings quite strict and weíre hoping that will happen within the next half an hour.
Chris - And when you say the timingís quite strict. I mean itís actually incredibly tight isnít it? Itís effectively a race against time?
Laura - Yeah. Itís a four hour window that we have when we stop the circulation and the blood supply of the old heart and transport it on ice and need to be reperfused in Stevenís body. So itís crucial and, obviously, youíve got transportation time to factor into that as well.
Chris - Just as a reminder, at this moment in time, weíre heading to a critical stage here, arenít we now?
Laura - Yes, itís crucial now because weíre getting anxious that the heart will be on itís way to us and we need to make sure that weíre ready because we just want to cut down the amount of time that the heart is on ice as much as possible.
Chris - Well the heart has just been taken out. Iím going to come round this way because the heart has just literally been taken out. You might have heard the surgeon, Neil Howell, just say the heart is out so that everybody in the room knows. And here it is on a table in a plastic bowl. Itís quite a sight, itís quite a size, itís bigger than I would have thought, and itís just made a movement there completely independently from Steveís body as well. Now what they will be doing at the moment is preparing Steve's body for when the new heart arrives and in front of me, effectively, is a man who, at this moment in time, does not have a heart in him, which is quite a thing to consider. And also to look at what is now going to be his old heart in front of me and, again, as I look, itís still moving even though itís no longer in Steveís body, which is quite a thing to see and Iíve seen that happen about 6 or 7 times now. That will now go for various tests and now we await the arrival of the new healthy heart....
Neil Howell - how are things going here?
Neil - Well theyíre going pretty straightforward really. So you can just see in here at the moment when we look in, this is the cavity thatís left by the heart being removed and you can see what a huge space there is there. And you can see down here weíve got what we call the cuff, so this is the residual heart tissue, the residual blood vessels that weíre going to sew the new heart into. Weíve got absolutely everything prepared, weíre all ready. Iíve got my first suture already placed at the top of the left atrium so, the second the heart comes in, I can take it out, inspect it and start implanting itÖ
Chris - So the box has been opened. Thereís some paperwork and such like in the top and then itís full of ice. The ice being scraped back . Ice as you would picture it a cool boxÖ
And one of the team here rooting through that ice. Whatís happening - what's it protected by?
Neil - Okay. So this is the standard way of protecting the heart when itís getting transplanted so itís triple bagged and literally just packed in ice. So this is when the coordinators get a little bit stressed and they donít like it. What theyíre doing is cutting through the first bag without trying to cut through the second or the third bag. And what theyíre going to do is theyíre going to open this up and then Iím going to reach my hands in into the sterile interior of this and Iím just going to lift the heart out. Then weíll move it to this bowl over here. So as soon as I see what I want to see which is that bit there and this goes into an empty bowl at this stage just because thereís a lot of water.
Chris - Whatís the heart floating in there?
Neil - Itís just some saline, so salt water
Chris - Picking the heart out there, orientating it around.
Neil - Thatís where itís going to sit so..
Chris - I mean this is absolutely amazing stuff to see. The work theyíre doing here where theyíre just treating this heart with great care but, at the same time, preparing it in order to put it in. So here we go thenÖ
Neil - Okay, so first stitch goes inÖ
Chris - Just to tell our listeners now. Neil Howell has got his instruments deep into Steveís chest bringing the heart into that cavity that we talked about and now the heartís sitting inside there. As I said, that area about the size of a small football. Quite whitish walls around his chest and some more ice thrown into the area as well just to keep that heart as cold as possible even though itís now sitting loosely in Steveís body. And Mr Howell just trying to manipulate the heart to try and move it into the correct position. Heís got both of his hands in Steveís chest now which he was talking about earlierÖ
Neil - What Iím trying to now is just open up because Iím doing a sort of upside down anastomosis right at the back of this guys chest . So what I need to be able to do is just to.. Thank you, trying to drop the instruments.. Is to try and now see what Iím doing because as I do this anastomosis I gradually see less and less of what Iím doing. Iím just trying to keep in the same position really. Iím just opening up the donor left atrial cavity so I can see where I am stitching. You know thereís lots of old phrases in surgery and one of them is ďif you can see what youíre doing itís generally an easy thing to do.Ē And half the problem, I think with surgery, is just not being able to see what you're doing half the time.
So the heart is no completely finished. You can see the heartís just starting to beat so we've connected half the joints and the heartís just starting to beat
Chris - Mmm. And thatís quite a sight isnít it? From the heart being brought in completely still in ice and now we see the new heart inside Steve pumping. Pumping away.
Neil - Itís not pumping. So itís not doing any work - itís beating.
Chris - Itís beating. Yes, okay, I see the distinction.
Neil - At the moment thereís not a lot of blood going to this heart because itís all going round Ruthyís machine. But itís starting to beat and that is a good sign.
Georgia - That was Chris Warburton following Steveís transplant. But people like Steve are often sat on the waiting list for donations for months, even years. Back to Stephen LargeÖ
Stephen - The central issue here is really the huge imbalance between the supply of hearts for transplantation and the need for it. Weíre an ageing population, the need is going up, and the number of organs available is actually going down. Why? Because public health is so good. People are wearing crash helmets, theyíre driving at sensible speeds. Itís a demonstration of fantastic outcomes from public health.
So weíve been looking at alternatives. And so what weíve been doing in Papworth is to ask the question, what about those poor folk who have no therapeutic outcome for their devastating brain problem and treatment is withdrawn at the relative's request and the intensive cares request. And for a number of years now those folk who have treatment withdrawn, their hearts stop and they have gone forward for organ donation.
And up until recently the question of using the heart from such donors hasnít been an issue but weíve pushed and said these are appropriate hearts, and weíve shown that in modeling in rat and a pig model, theyíre going to be very appropriate hearts. Perhaps even better than the current ones we use. And so we started a program after ten years of justification on the 28th February 2015. Hugely exciting and to date the country has transplanted 23 hearts. The majority at Papworth and 4 from our sister hospital in Harefield, and this is a hugely exciting development. We think that at least 50 further heart transplants will be offered to program through this development, so itís pretty exciting stuff. But the frustrating thing is the demand is still so much greater and I think, sadly, that demand will always be greater than supply whatever fabulous innovations we come up with
But, in the meantime, letís encourage everybody, everybody to get onto the organ donations register. Opt in and help somebody.