World Heart Day
Sunday 29th September was World Heart Day. But sadly, despite the fact that we’re better than ever at treating people with heart problems, the number of people waiting for a heart transplant has reached a record high - and doubled in a decade. Sai Bhagra is a cardiologist from Royal Papworth Hospital, one of the country’s leading transplant centres...
Sai - As you said, Chris, heart failure is becoming a growing epidemic. It is the end stage of all heart conditions. And we've got very good at treating heart attacks, and as a result you have patients who have heart pumps that are not working as well as they would have, and they've lived longer. This number is growing, there's about 60,000 new cases added in annually in the UK alone. 10% of these will progress into advanced heart failure, and transplantation is a treatment option for a select few of these.
Chris - So there's a range of different conditions which can result in heart failure, and some cases of heart failure, we just run out of road when it comes to drugs - and we only have one option, which is to put a new heart in these people.
Sai - Putting a new heart is an option for not everybody, unfortunately, because we have an organ availability and patient demand mismatch.
Chris - So how do you make that decision?
Sai - We assess the patient to see if they’re sick enough to need a transplant. Transplantation comes with its own issues: it has a mortality rate of 10-15% in the first year. So what we're looking to see: is the patient sick enough to need a transplant, but well enough to survive the operation.
Chris - And what's actually involved in doing a cardiac transplant?
Sai - What we do first is assess the patient with heart failure to see if they are suitable to go onto the transplant waiting list, and then it's a matter of making sure the patient remains stable and well enough for their operation. The waiting time on the routine transplant list in the UK is up to two and a half years, so patients can die waiting for a transplant. And the patients who get successfully transplanted end up having 14-15 years added on to their life, of good quality.
Chris - And how do you decide which heart goes in which person?
Sai - Well the heart has to be matched to the patient. So the heart has to be functionally normal - it has to have no structural disease - it has to match on blood group, it has to match on size and tissue typing. It's only then we tend to use the heart for the particular recipient.
Katie - Sai, Chris mentioned that the wait for a heart transplant has reached a record high. Why are waiting lists so long at the moment?
Sai - The waiting lists are long ‘cause we don't have enough hearts to go around.
Katie - So what can we do then?
Sai - Well, what we can do is get more people to express their intent to donate. The laws are changing, it's going to be an opt-out scenario come spring next year.
Chris - At the moment we assume someone is not a would-be donor. And we're going to start assuming, if someone is a potential candidate donor - they've got what looks like a healthy heart, something else has gone wrong with them - they’re heart donor until proven otherwise.
Sai - Unless they have explicitly said that they do not want to donate.
Katie - But is it that simple though? Because from what I understand, you also need to get the consent of the family. Is that correct?
Sai - I think the family consent is still key. So if people are wanting to donate, then the key thing for them to do is to express it, express their intention to their family so that the families can respect their wishes.
Chris - And if you have a potential donor, how do you decide that their heart is worth transplanting?
Sai - It's assessed on multiple parameters. We look at it on echocardiography, we look at it on imaging to see how it's working, we assess it haemodynamically. If it passes those tests we then look for coronary disease, and if it's still working well then we use it in our recipient.
Chris - Because in recent years the liver doctors who are doing transplants have been able to enormously widen the pool of livers they can use, because they've been able to rescue organs that they previously would have discarded by, for instance, putting them in an organ bath and perfusing them and giving them some recovery time before they chuck them into a new patient. Is there anything similar for cardiac transplantation that could be used to widen the pool of organs you have there?
Sai - So we are attempting to widen our pool. At Papworth we have the world's leading experience in using hearts that have been taken from donors whose hearts have stopped beating. Conventionally hearts are from people whose hearts are still beating and they are ... brain stem dead, but using a DCD heart - where the heart’s obtained after the heart stopped beating - we recondition the heart on the OCS machine…
Chris - What’s OCS?
Sai - It’s the organ care system, it’s similar to what the liver and the kidney teams are using. And we find that at Papworth, we have roughly increased our transplant numbers by 40%.
Katie - What is the outlook for somebody who's had a successful heart transplant? How long could they expect to be around for?
Sai - So what we state is, if you have survived the first year - which is where the mortality rates are the highest - then you're looking at an average of 14-15 years post-transplant, half of our patients will be alive at that stage. Our longest survivors, out at 35 years post-transplant now.
Chris - I think, was that a lady? Because I think she...
Sai - A man.
Chris - Oh, a man. There was definitely someone I saw give a talk, and they were inspiring.
Sai - It's 40 years since we started transplantation at Papworth.