INSINC Insight: Transplant Surgery



Join our informative and interactive session that delivers a deep dive into heart transplants. With perspectives coming from medical professionals on the transplant surgical side, we're also fortunate to have two transplant patients sharing their firsthand experiences. Our panel of speakers include senior trainees and the cardiothoracic surgeons from Freeman Hospital in Newcastle who bring a wealth of field experience along with practical tips and advice to the table. The session will include live Q&A points for participants to engage and ask their queries. A highlight of the session will be a video from a cardiothoracic surgeon, taking you through an actual heart dissection, helping to better understand the heart anatomy and the surgical process of heart transplantation. Whether you're a final year med student or an established practitioner, this session is a great opportunity to stay updated and deepen your clinical knowledge.
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After lots of feedback from last year's series for a talk on Transplant Surgery, we are delighted to be able to offer this as a new topic in this year's lectures!

Throughout this evening you will hear from a Consultant Cardiac Surgeon and Patients about their perspectives on transplant surgery, with plenty of opportunity to ask questions and understand the process of preparing, undergoing and recovering from these operations.

*Due to the sensitive nature of the content covered in this talk, we will not be sharing the recording of the talk from our transplant patient guest speakers.

Learning objectives

1. Understand the anatomy and physiology of the heart and its importance within the cardiovascular system. 2. Recognize the symptoms, causes and impacts of heart failure, and the role of heart transplants in treating heart failure. 3. Learn about the process involved in heart transplantation surgeries from the perspective of a medical professional. 4. Analyze case studies of real patients who have undergone heart transplants and learn from their experiences and outcomes. 5. Engage in discussions regarding ongoing advancements and challenges in heart transplant surgery, reflecting on the ethical and practical questions these pose.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

All right. Hi, everyone. Good evening. Um Welcome, welcome to the second talk of our series. Um So, for everyone who joined us yesterday, we hope that you enjoyed the talk and um got something out of hearing from experiences from a medical student all the way up to being a consultant. Um Today we're focusing on um heart transplants. And so we have a talk lined up from um the transplant surgical side as well as um two transplant patients who will be telling you about their experiences. Um And so if we all introduce ourselves, um my name is I'm one of the mentorship officers, part of the N Sync um Act S committee. Um And it's uh a pleasure to have everyone here today. So, um I'll hand it off to Alana. Yes. Um Hi, everyone. I'm Elana. I am a final year medical student um at Queens University in Belfast and I am a part of the INS team as well. I'm the participation lead. Um And so it's really great to have you all here. And same as last night, please ask all of your questions. We will be monitoring them in the chat. Um and then we'll also be able to um take some questions live as well. So, yeah, just engage and that would be brilliant. Um If I pass that over to um Avril, are you happy to introduce yourself? Next, I go next. So, uh my name is Chris Bay. I'm a senior cardio uh trainee in the northeast. So I'm currently James Cook previously worked at Freeman. Um I was previously an Aortic and transplant uh fellow at Birmingham. Um I worked a lot with uh Miss Booth, whose presentation you're about to see, hopefully that'll answer some questions for you later. OK, great. So what I'll do now is I'm just going to share um a, a video from um Miss Booth. Um And so feel free as Mary is saying to put your questions in the chat, we'll have a question and answer period just after this um video and as well, we'll have another question and answer period at the end of the session. Um And so feel free to engage as much as you can and hope you enjoy the talk. Good evening, everyone. Welcome to the In Sync Insight program on Cardiothoracic. I'm really sorry that I can't be with you tonight. I hope you really enjoy the next 30 minutes or so. When I take you through that one side part of transplantation that we offer as cardiothoracic transplant surgeons and that is heart transplantation. And it's really important that we look at what heart failure is and how it's treated and where transplantation fits. And if this is your first time joining us in the In Sync Insight Program, welcome. And if you were with us last night and I hope you have a fantastic time, please feel free during the presentation to write down any questions that you have. And I know that Chris Bay is with you tonight and he'll be more than happy to answer any questions that you have. I wanted to start off by saying who I am. So my name is Karen. Uh I'm one of the cardiothoracic surgeons. I work at the Freeman Hospital in Newcastle. Uh And I've been at the Freeman's for nine years and I've been a surgeon there as a consultant for seven. I very much remember being the position that you're in. Uh I remember being to get my A levels having thought that I would keep my options open for doing medicine. And I remember not feeling confident enough and not feeling like I was good enough. I didn't know any doctors. I didn't have any doctors in my family that was, and I've done some work experience and I felt that I was not useful, shall we say when I was there and find it difficult to sometimes engage with the staff? Because they were very busy. I also remember being told by a chemistry teacher when I was doing my G CSE S at a parent evening. Although I would make a lovely doctor. Uh, I would never get in. I wasn't going to be able to attain the grades. And I just wanted to say that whatever it is you want to do in life. If you are inspired by what we're telling you tonight or if it's just something you're really passionate about doing medicine, then please go for it. Please remember that everyone's got potential to achieve their dreams. Certainly a lot of hard work along the way. But it's very, very doable. And it's about when you see setback or when you receive rejection, it's about not giving up and it's about carrying on. And that's why Chris and I got where we are today have said that I'm one of the heart transplant surgeons at the Freeman the next 30 minutes in the talk. I really want to take you through what heart failure actually is, what a normal heart looks like, what the normal physiology of the heart is and how is it treated fit and amongst all that, how common is it? What's the operation like? Uh And we've got two patients with us tonight who will be able to talk you through what it's actually like to have one because it's very difficult actually as a doctor to really empathize with someone. If you've not experienced it yourself, we're constantly learning from the people that we treat what it's actually like the experience treatments that we offer. And that really helps us to modify what we do and how we do it. So we're really grateful that they want us to like. So the heart to me when I open up the chest. So I make an incision in the skin and then I use an oscillating saw to be able to open up the breast bone, which is kind of like a flat plate that the ribs attach onto in the chest cavity. Uh Once I use a little bit of spreading action, so I can see as much as I can have to scoop the heart up with my hands because it's living, beating constantly a very, very strong muscle. And you feel that it's extremely slippery because it's constantly moving and BP is very sensitive to any manipulation of the heart itself. It's a very well wheeled machine. Um And it's actually easier to talk through the anatomy of it if we're able to dissect it out. So, just to show you a video now with some G CSE revision, the dissection of an actual heart, porcine heart ap heart, we just refresh our knowledge on that. We'll just go now and watch the video and then we can read this presentation. Hi, welcome to samples for school heart dissection. So today we're gonna be looking at a pig's heart and we're gonna be looking at all the components that make up how this muscly organ works to pump blood around the body. We're using a pig's heart because it's relatively similar in size to an average human heart, which is about the same as your fist. So if we look at this muscly organ, we can see that there are a number of blood vessels coming out of the surface. We're gonna be cutting open into the four different chambers of the heart to look at what each section does. Now, if we look at the outside of the heart, we can see just where the top surface lies is where the atria would have been. These have been trimmed off so that we can see the details of the inner cavity. So we're gonna make our first incision onto this side of the heart parallel to the coronary artery and the coronary artery is the main blood supply to the heart tissue itself. So the heart has its own supply of oxygen and glucose. When we make this incision in here, we're gonna be cutting into the most muscular part of the heart, which is the left ventricle and the left side pumps blood around the entire body out of the blood vessel called the aorta. So our first incision will be parallel to the coronary artery straight through the muscle. You can see as you start to cut it open, it's thick muscle tissue. So it may need more than one cut. Ok. And you can see the depth of the ventricle there, incredibly thick, firm muscular piece of tissue. And we take our scissors and we continue that incision straight up to the top of the heart. And we go into the remainder of the atrium. And we see once we cut this ventricle, open the cavity on the inside and the sheer depth of the muscle tissue, we can also see if we clean away some of the remaining debris. The tendon is heart courts. Now, these are there to attach the heart valve to the tissue of the muscle. And those heart valves are incredibly important in maintaining uni direction and flow of blood around the body. The second incision we're gonna make is going to be into the right ventricle and again, take the scissors to cut up towards the atria. And in there, we can see the right ventricle of the heart, much slimmer muscle wall because the right side of the heart is only pumping blood to the lungs. So the blood is pumped under much lower pressure. So if we go back to the blood vessels that we can see at the top of the heart, we can use seeker or a finger to put a finger down the vessel to see where the chamber ends. So if we go down this blood vessel, it comes out into the left ventricle, the thick chunky ventricle. So that must be our aorta that's gonna pump blood around the entire body. If we were to explore the other blood vessel, which is much thinner, it goes straight into the right ventricle, the thinner, less muscular ventricle. So that must be the pulmonary artery that's gonna transport blood from the heart to the lungs. Now, in order to stop blood flowing back into the atria, each of these ventricles have a valve. Valves are there to stop backflow of blood and to maintain unidirectional blood flow. Sometimes there are heart problems that mean the valves don't work properly. They either don't revert back to their original shape or they become loose and we can replace those valves either biologically or mechanically. If we look back at the surface of the heart with the coronary artery, a common defect that you might see here is coronary heart disease and that's when these arteries become blocked with layers of fatty deposits. Now, in order to treat that medical condition, you can have a stent put in which keeps that artery open and maintains blood supply to your heart. So, in order for your heart to pump the blood around the body, you need to maintain that heart rate and resting heart rate is maintained by a little bunch of cells in the right atria that signals when the heart needs to beat. Now, if you need to increase your heart rate, because your body needs more oxygen or more glucose, then adrenaline is released from your adrenal glands. It's what causes that fight or flight reaction and it will increase your heart rate to provide more oxygen glucose to your body if you'd like to know more about heart dissections, then see our website for lesson plans and risk assessments. Thank you for watching. And now that we've seen the heart all dissected out, we'll just look at it in the context of where it sits within the chest cavity. So it's explained on the video that the heart is about the size of a human fist. So it's not completely inaccurate. You can see in comparison to the lungs. It's about a third of the size of the chest cavity with the right and the left lung on either side, the heart and the lungs work in combination. So we need the lungs to be able to oxygenate the blood. And then we need the heart to be able to pump the blood and all the organs in the body. So without the heart working effectively, it affects every single other organ because its job is to pump, to ensure delivery of oxygen and glucose so that each tissue in the body is able to live and breathe normally. So we need that morgan old to function as one with the heart and the lungs together. Uh And you'll know that the heart muscle itself is made up of units. So it's made up of sarcomeres which internally and each sarcomeres made up of actin and uh myosin filaments that are able to contract and expand and that's what causes the pumping action. It's really important to understand that with the muscle for, in order for it to be able to beat, there's a conduction system in the heart to be able to pass electricity that stimulates the muscle to be able to contract. And what's really unique about the heart is that, that automatically happens. So it's an automatic pacemaker. So it can be influenced by outside factors. So you can have sympathetic parasympathetic stimulation which either increase the heart rate or decrease it. But actually the heart beats all by itself. It's amazing to think of an organ, big strong muscle that beats from the minute you're born until the minute you die. And it never takes a rest. When we think about the anatomy, we think about the physiology of how it works. And when we talk about heart failure, we're just talking about, well, why would that organ not work? And has it been designed role? So is it congenital? Is it something that's from birth? There's been a structural abnormality. So maybe it's been born with valves that are not quite in the right place or maybe one side of the ventricle is smaller than the other and weaker. Uh So you can have a thing called hypoplastic left heart where the main pumping chamber, which the left ventricle that we learned that takes all the blood to the body that ventricle isn't able to sustain that 5 L of blood per minute that we need to be able to grow properly. So it could be that, that's something you've had from birth could be something that you've had from birth. So it's an inherited heart disease such as cardiomyopathy. But actually you live for quite a period of time without any effects, you maybe don't even know that you have it, that actually is affecting the structure of the heart itself. And when the heart starts to feel what happens is it becomes dilated and bagging or it becomes sort of very thick and very stiff. Any abnormality, whether it's something you've had from birth or something that you have acquired can cause the heart to fail. And so heart failure is always defined by a structural abnormality that leads to a reduction in performance and can be tested through a blood test called BNP. So looking at the release of a natural peptide from the heart that tells us that the heart is failing itself, let's just talk about that from a patient pathway perspective. It's like one of the most common reasons for heart failure. And that's because the blood supply to the heart is diseased, that is known as coronary artery disease. So if we look at the top left of the picture, we look at the gentleman there that looks very much to me like he's having a heart attack. So I'm not sure if anyone in your family has ever had a heart attack or if you've witnessed somebody that has had one, it's very difficult to forget what they look like when you see it. So that clutching of the chest, the pain is so severe, it is very common. So the minute a muscle is affected by lack of blood supply, it sends out a signal to the body with a very severe pain. And that's what that gentleman is, is witnessed or is it sorry, is displaying in the? You can normally they go a very different color, go very gray and they get very sweaty. Uh And it's not long from that point until they can collapse. So the heart can actually stop beating completely uh because it's under so much distress if you take that scenario and met lots of patients in my time who think that maybe it's heartburn. So which is another very painful uh sensation that you have at the very center of the chest. Some of the acid from your stomach refluxes up into your mouth. It's very commonly mistaken uh that the two can be quite similar. Uh And if there's a delay in you recognizing that's a problem with your heart and getting to the doctor, that also means there's a delay in the blockage being repaired. And for all organs, they have a time period of which they can survive without oxygen. And for the heart, that time period is six hours. So from the minute the heart muscle has got a blockage which is stopping blood and oxygen from gassing to it. There's six hours for that blood flow to be restored. And if you look at the top right hand picture, you can see that that's a picture of PC or percutaneous coronary intervention. And that's where a small nice little stent is placed inside the vessel just to open up the blockage. So the catheter is passed alongside the blockage, a balloon with a stent is inflated and it restores the blood flow and the blockage is cleared. If you don't manage that within that six hour time period, then you can see on the bottom left hand picture that the heart muscle becomes damaged and you can see the word there irretrievably. So once the muscle is damaged, it doesn't have an ability to repair itself just because the blood flow is restored. So some of the decisions that we have to make in medicine are based upon how likely it is that we can restore blood flow and actually have an improvement in the function of of the heart. Uh and will always be the offer for the percutaneous coronary intervention, but you can still be left with damage that that happens afterwards. And in response to that scar tissue, the heart can respond in lots of different ways, but the scar tissue itself doesn't contract with the rest of the other tissue. And over time, what happens is that it dilates because it can contract, you actually just have blood that swirls inside the ventricle rather than actually being pumped out I've mentioned a few times about a thing called an ejection fraction. So the ejection fraction is just the percentage of blood sits in the ventricle and it gets pumped out at the end of systole or that infraction period. And so in a normal healthy heart that would sit anywhere above 50 or 60% all blood that comes in from the lungs in the left ventricle would be pumped out again. So when that ventricle dilates and you have scar tissue that isn't working properly, that percentage drops. And that's one of the criteria for diagnosing. The heart failure is the reduction in the ejection fraction. Here, it is just a little bit more uh blown up and looked in and you can see the scar tissue, which is denoted in the color gray. And when you look at it uh in real life and you have anyone with heart failure, the tissue just looks discolored, just looks abnormal. Uh normal muscly heart would be very red, uh bright in color. And you can see the difference just in the diagram. There is stability for some uh development of new blood vessels. So if you see in the top right hand picture or the top right hand side of the picture, you can see a thing called neoangiogenesis. So once the blockage has occurred, and if it even if it is corrected, if there is a chronic filling delay, the heart has the ability to regenerate some of the blood supply, but it doesn't have the ability to make a new muscle. So once it's damaged, it is permanently damaged. What can we do about it? And there's lots that we can do about it. And it's extremely important to recognize that it's a process from the top of the screen down to the bottom. So if you just look at the top tablet, the medical therapy for heart failure has been extremely transformative for people that are living with it. Very good for controlling their symptoms and actually good for improving the ejection fraction that I spoke about previously, just four different treatment strategies. And if we just think about that big baggy heart or that ventricle, it's not pumping very well. What impact does that have on the rest of the body? And that tells us a little bit about the symptoms that people feel. So if the pump isn't working effectively, you get a lot of backlog because where the system worked perfectly before and you have 5 L of blood that's constantly flowing through the heart, being oxygen in the lungs, coming back into the heart and then going to the rest of the body that no longer effectively works. And so what you find is that people get fluid overload. So a lot of the excess fluid can no longer be pumped, it's pushed out into the tissues and they get swelling in their ankles, they get fluid that resides in their lungs. Because it cannot be cleared effectively. And that makes them feel breathless. They'll also describe to you that it's very difficult to lie flat in bed at night. And overall their actual ability to be able to exercise will be reduced. Because of course, when you exercise the muscles in your arms and your legs, they call for extra oxygen or for the heart to beat that little bit faster. It's very difficult for a heart that is failing, be able to offer that. So the treatment is around reducing the fluid that is there so that it can help the heart to pump more effectively and also to increase the contraction of the heart. So that the heart can be more effectively. When it goes, there are four different treatment strategies and they've all been shown in trials. So in drug trials where they have randomized large numbers of people to having the tablet or not having the tablet actually be effective at reducing hospitalization. So even more than like a very good endpoint for describing that people are feeling better, they're not coming to hospital as much uh and also to improving their quality of life. So the first treatment strategy is tablets secondary to that obviously extremely important that if you've identified a problem with the heart, a structural problem, you treat it. So when we look back at the coronary artery disease pathway that I spoke about with the last gentleman, if you can prevent somebody from having further heart attacks, then you will prevent damage and you prevent the heart failure getting worse. Because once you start with heart failure, it's actually a chronic life limiting illness. So you're not able to completely reverse it. You don't want to do is to allow it to be worsened by not controlling secondary prevention. So secondary prevention, lifestyle changes. So that will be reducing the amount of salt that is in your diet, reducing the amount of liquids that you take in. It will be increasing exercise, be reducing uh smoking or s stopping smoking and affect doing as much as the patient can to be able to prevent that from happening again. And with all these treatments, we know that your chance of surviving out to five years. Once any form of heart failure is diagnosed, it's 50% that's one in two will still be alive at five years. So, although these treatments are excellent and they offer symptomatic relief, we know that patients are on a pathway will eventually end in an early death. So since the 19 seventies, we've been looking at ways in which we can do that. Heart transplantation was developed first, you know that it was a surgeon called Shwe that did the first heart transplant. There's also been a mechanical look to see. Can we design something that can sit inside the heart or even replace the heart and do the work of the heart so that the heart is no longer failing. And that's called a left ventricular assist device. And where that sits now, in terms of treatment for heart transplantation is, it's used as a bridge in the UK because we don't have enough donor hearts for the demand of the people that are on waiting list to get one. So if your heart is continuing to fail, we can give you a little bit more time to allow you to wait for one by using a left ventricular assist device, take a wee breath. And just in summary of what we've chatted through, we've looked at some of the anatomy and some of the physiology to help us understand some of the causes of heart failure. And then we've then had a look at some of the treatment options and where heart transplantation sits in that treatment option pathway. Just in summary, we know that heart failure affects around 1 million people in the UK. It's not as common as what cancer is, but it is the second biggest killer of people within the UK. And we know that once you have heart failure, your survival at five years is one and two. And we know that transplantation sits at the end of that treatment pathway for a small number of people. So less than 1% of those 1 million people will be offered the opportunity to receive a transplant and that it is a very effective treatment. I'll explain to you now, in the next part of the presentation. Why that is, we talked about buying time. We talked about waiting times on the transplant list. And we know that if you are listed for a heart transplant in the UK, you will wait on average 18 to 24 months, up to two years. So the difficulty for doctors that work in transplantation is getting the timing right. So picking up the patients, we know I've got heart failure, monitoring them, making sure that if they're suitable to have a heart transplant, that we get them listed in times, they have enough time to wait. Sometimes it's not possible to get that completely right. And so we can use another piece of technology that keeps the heart going for longer. This is L VA therapy or left ventricular assist device therapy. Let's just have a little bit more of a look at it in detail to see what it is. So you can see the mechanics of it in the picture. You can see that it is basically bypassing the heart. So blood is being drawn out from the left ventricle. You can see that it's entering into a mechanical device like a pump that is placed that sits in, in with an outlet pipe which sits inside the left ventricle, which then goes into a pipe which goes from there into a mechanical device that's attached to an electrical cable and then the blood is pumped out into the aorta. So in effect, it's going past the ventricle and into the aorta and being pumped by the mechanics of the device. You remember from the picture in the slide before that the patient was wearing a pack and on that pack basically were batteries. They must always carry two batteries at any one time. And then the cable allows for that to be connected to the batteries and the batteries can be plugged in when patients are at home to charge it. That's a very, very effective way to treat heart heart failure because you can set that to flow at the 5 L per minute that we talked about. So you can take over the workload of the heart, actually allow the heart to completely rest and you do the work of the heart itself. I'm sure you're thinking well, that just sounds like it's perfect. And why would you need to have anything else? And the problem with this is that once you pass the blood through the pump, then you need to thin the blood out. So it doesn't clot and block the device off and it's that complication needing to have a tablet called Warfarin that makes it not as effective in the very, very long term. So this is looking at surviving once you have a left particulars this device uh without having a heart transplant. And if you just have a look, this is basically time and night since implant, that's along the x axis and then along the y axis, you can see that once we get out about two years, your chance of surviving is actually 50%. So remember we said that when you have heart failure, your chance of surviving is 50% for five years. And although this bridges you some time, it doesn't bridge you a very good sur it doesn't offer you a long term survival option. Just at the minute, we haven't quite managed to figure out how we can do this without needing to take the Warfarin therapy and the tablets can cause some of the complications. Heart transplantation is and still remains to be despite left ventricular devices being invented the gold standard. And so this is a short video that was made a few years ago out of the Freeman Hospital. And it's an excellent program. It was made by the BBC and it's called heart Transplant Chance To Live. So it shows some of the surgeons and some of the impact of hearts on patients. So I'll now let you go and watch the video and then you can rejoin me in the presentation once you've seen it. So what's the current on your flow? Now, temperature is good. Saturation is good. C is good. It's fine. E everything looks good. This heart is beating all on its own just like it was a few hours ago in the donor's body. So they can assess it en route. We can see the function of the heart, we can see the heart beating and we can uh assess the other other parameters which can suggest whether the heart is struggling or whether the heart is beating very nicely. So we regularly check the blood specimen and um, Paul is checking the oxygen and the lactate. So that is not only reassuring, but it is very amazing as well. Everyone can see the heart beating and not many people in their lifetime get to see that even if somebody who operates in hearts every day, day in day out still took me by surprise the first time I thought it. But um up by the time the old heart is ready to be removed, his new one has been outside the body for almost six hours. So let's have a little bit of a look now that we've seen what it's like to have the heart transplant. Let's have a little bit of a look at the transplant program in the UK. So you can see along the X AX as you can see the year. So 2011 to 2012, right up until the early two thousands. And then you can see the numbers of patients that are sitting on a transplant list. That's the black dots at the top that are joined by a line. So roughly at any one time in any year, the amount of people that are waiting on a transplant can be as high as 340 people. So of that 1 million people that we talked about that have heart failure. There's about 300 of them that would be listed and found to be suitable that a transplant would be a good option for them because their heart is not uh they're going to die despite being on optimal medical therapy. Uh We don't offer them a transplant. You can then see in the bar charts below, you can see the number of donors and the number of transplants. So you can see that there's a gap between the people that are on the list and the people that actually receive the transplant. And it's this gap, the LVAD therapy sits in to try and buy some more time because we don't quite have enough donors to be able to do enough transplants that we need to do. And if you just look geographically across the UK, you can see that there are six centers that offer transplants in the UK. And you can see that most units offer the same amount so that light blue or the heart transplants and the dark blue or the lung transplant population. So roughly every center is doing between 25 and 40 transplants every year. So that means that in any given month, we're doing one or two transplants. So they are still quite a unique event. Uh And they're not, not something that happens on a daily basis. If you just look at what actually happens once you're registered onto the transplant list, you, we actually record information to see who gets transplanted, who gets removed off the list because they're too sick. He dies based on the list. It's very important to see and remember just because people are listed doesn't mean that they're going to have the actual chance to have the transplant. And in the bar charts in the gray portion, those are the patients that have died on the waiting list, waiting for a transplant. The blue at the very bottom are those that are consent and then the lighter blue are those that are still waiting the middle grade just before the red bar or those who become urgent. So those are people who have been at home and being managed on the list having all of their medical therapy, but then their heart decompensates isn't able to cope so well and they end up in hospital and potentially in intensive care was on the transplant. We talked about survival if you have heart failure and talk about survival, if we plan to keep the LVAD in permanently. But what is survival like if you have the transplant? It's just highlighted in green there. You can see the five year survival once you have a transplant is 80%. And we know from studying internationally transplant of many, many years that it's been around that. It also depends on why you needed the transplant and the age at which you receive the transplant. So actually having a new heart offers you the chance of survival up to 80% at five years. So it's an absolutely fantastic treatment. Uh if you have the chance to, to get one and it absolutely transforms your life. If you think about when you have your heart failure, medic, when you have heart failure and you have your medications and your therapy, there's an awful lot of tablets, an awful lot of lifestyle changes that you have to make. When you have an LVAD in, we talk spoke about the batteries and we spoke about having to be able to always be near a par. So to be able to plug in, to make sure you need to ensure that that LVAD always has enough energy to be able to work, has a huge impact on your lifestyle. Alongside, you will still require treatment for heart failure with all the tablets. Cause if you remember the pump goes into the left ventricle, it doesn't go into the two ventricles. So you still got to treat the heart as a whole. So you're still on all your treatments for right heart failure. And you have the left ventricular cyst device which is about 5 kg in weight or so to be able to carry by the time you have the battery packs. Um, the lifetime modifications that you've got to make a heart transplant. Once that's implanted, that heart is perfect. It's not failing, doesn't require any treatment. What you need with a heart transplant is you need your body not to reject it. So you need to take tablets for immunosuppression. And once you're immunosuppressed, you need to make sure that you keep a check on your skin. Uh because your, your immune system has weakened. So your chances of cancer is higher, the immunosuppression can affect your kidneys. So we have to keep an eye on your kidney function like for many years. But other than that, you're taking some tablets and having some routine appointment, you're able to exercise fully, be able to go on holiday. So many things about quality of life for people are just transformed when you have a transplant, I'm not the best person to be able to tell you that because I haven't experienced it. I know from patients, I've got to know over time the difference that it's made and being able to return to work, having a full and active life and having hope again, it's very miserable living with heart failure. Uh And so heart transplant is a fantastic treatment if you can access it. Well, what we talked about tonight, we've talked about what heart failure is and the fact that it affects 1 million people in the UK, we know that it's a chronic life limiting illness. About 50% of people surviving 8 to 5 years. And we know that heart transplantation is the gold standard therapy. It's an excellent option and it's available to less than 1% of all those that have it. Sadly, because we don't have access to enough organs. So hopefully, as we've gone through the talk, you'll have seen the benefits of what transplantation can offer. I'm going to hand over an eye to Chris Bay, uh back to Kirsty and also to the patients that are with you this evening. So you can take the discussion further up on the screen. You can see I've given you a link into my email address and also you want to be able to contact me on social media. I'm very happy to, uh, to take any questions and I hope for any of you that are gonna go out and do some work experience surgery. I hope you have a fantastic time and please remember you can do whatever you want to be. Don't let anyone ever stop your have a fantastic evening. It was lovely to be able to chat with you today. Ok. So I hope you all enjoyed the video from MS Booth. Um, I see, um, so much lovely engagement in the chat. I've picked a few questions um, to mark in the Q and A. So we'll start from there. But, um, as we go along, feel free to add any additional questions that you have and um, yeah, hopefully we can have a chat so I'll pass it over to uh, Mister Bayless. Yeah, hi, everyone. So, uh, nice questions I think we'll uh there's a two, a couple of questions on sort of how, um the, what we call the heart in the box, the O CS machine where you saw the heart beating um before it's transplanted works. Um And then also how LVAD S work. So I think for the heart in the box question. So, um there are two ways we um basically preserve the heart from the time between it out of the donor. Uh And going into the recipient, you have to do something. Um If you, if you were to just take a heart out, leave it as it is and bring it back to the donor, by the time it got there, the heart muscle would have would have died and it wouldn't work. So there's two ways of doing that, the, the most common way and the, the way that we still most frequently is to um stop the heart with a solution that contains potassium. Uh And basically, so that rests the heart, we then take the heart out of the donor, um flush it with some more of this preservative solution. And then we um put it in a bag uh of basically salty water and then put it in an ice box. Um And that's pretty good. It works. That'll buy you about four hours um to do the transplant. The other option is the heart in the box, which is also called the organ care system. Um and that's a very interesting bit of kit, essentially. What you do is you, you take the heart out in the same way. Um, but you also take some blood from the donor. Um, and the machine is very clever. It's got a little pump in there, um, and oxygenates the blood and basically you can, um, deliver warm oxygenated blood to the aorta of that heart. It'll give the heart a blood supply and the heart will then beat by itself. Um, the box is clever and it's got a little to a couple of little electric pads so you can actually pace the heart to make it beat as fast as you like. Um, and then you can collect the blood from that. Um, and it can give you an idea as to how that heart is using up uh, glucose. Um, and give you an idea of how functioning. It's not put in the, although the heart beats because the heart's not beating around any resistance. It's not perfect for telling you how well the heart works, but, um, it probably does give us a bit more time. Um, so at the moment, there are two reasons for using that. One is if you've got, um, a, a lot of distance to cover or you're gonna be putting it into a recipient that's gonna be quite complicated so that, you know, the operation is gonna take a long time. Um, the other reason for using it, um, depends on the type of donor we use in the UK. There are two broad categories. So we either have someone that's um uh a brain dead donor. So in that case, they, they've died because their brain function has stopped. But we can keep um the rest of their organs going by using, you know, uh breathing machines and things. So the heart is actually beating. So in those patients, we, we know that the heart is good. Um So typically with those patients, we would put the um or like I say, if it's, if it's a long distance or a long operation, we'd use the organ care uh system, the other options for patients whose when we take the heart after their heart has stopped. Um So in those reasons, um we don't know how well the heart's gonna work. So we need some way of assessing it after we've taken it out of the donor. Um So that's the, the sort of primary reason that that heart in the box came to life. Um And that's a fairly new, fairly new um thing for, for several years now. Um But that's the other reason we use it. So it's a, it's a very clever bit of kit. It's a very expensive bit of kit, which is one of the reasons we don't use it for everybody. Um But it's, it's hopefully gonna expand the horizon of, of transplant as time goes on. Um So yeah, that's the the heart in the box in terms of uh how left ventricular assist devices work. So they've, they've been around since the sixties in various forms. Um but the current models are a little bit like jet ski. So in a jet ski, you have uh an impella. So what happens is the, the impeller sucks in a large volume of water um from the ocean and then it fires out the jet out the back and the LVAD works in very much the same way. So you, you basically attach it to the left ventricle of the heart and it sucks blood out of the left ventricle and then it fires it back around and we attach a graft to the aorta. So it fires that black blood blood background uh into the heart. It's a bit more sophisticated than the jet ski. It uses electromagnets so that the impeller inside is actually floating in air. So it doesn't touch any sides. So, uh it's sort of a frictionless system. Um But that's how it works. The, the sort of interesting quirk of people with LVAD in is because that blood flow is just LAMINA, it's not got a pulse, the patients won't have a pulse. Um So it can be quite an interesting little quirk for, for patients with an LVAD. But um, like Miss Booth said, it's not a perfect technology. You have to take blood thinners for it. Um You have to be sort of it, it comes with a battery pack. So you've got to know, you know, when you're gonna charge your batteries and, and things like that. So, um I think there was a question about whether or not sort of uh artificial heart might be a, a solution. Um So that it's possible in the future the technology, you know, is always improving. They're, they're moving towards trying to have uh left ventricular assist devices that don't have an external battery pack that you need to plug in and charge. They might have, they're working on um you know, charging like you have uh on your phone things where you could essentially um have a battery inside you and then on a night time have some sort of um you know, contactless device that attaches to you and, and charges it wirelessly. Um But there's still the problems with having to take blood thinners and the complications of that. Um uh the, the device does chew up your red blood cells a bit. Um So that can lead to some issues. Um So yeah, at the moment, it's quite a long way off. The other thing that the, the ventricular assist devices don't do is they don't support the right side of the heart. Um So in the long term, um patients can run into trouble if the right side of the heart starts failing um on the LVAD. So, um a at the moment, they really are a sort of bridge to a bridge to transplant. Um Occasionally with people with things like a a viral cardiomyopathy. Um Occasionally people do recover enough to have the LVAD sort of turned off on their own heart function take over. Um But yeah, primarily at the moment we, we put them in for patients to, to get them to a transplant. Um Probably what's the survival rate? Five years. So I think we had a graph or so five years is about 70 70% after a heart transplant, uh patients will still be alive. Um How the heart removed from the donor. So, yeah, like we said, um it's a good question. I think we've, we've probably touched on it, but essentially we in the same way that we do our open heart operations sort of day in day out. We if you deliver high potassium solution to the heart, it um sort of nullifies the electrical pathways uh and allows the heart to, to have a rest. Um And if the heart's not beating, it doesn't need much of a blood supply. Um And then if you cool it down, it needs even less. So that was the, the way that we can take our heart out safely. Um uh Is anyone else in your 12 month supply? Right? So this is quite complicated stuff. So I'm not surprised that this is, would have gone over my head in year 12 as well. So, um I think, you know, one of the things to take away from, from these kind of uh sessions I think is, is a flavor of it. See how enthusiastic uh people could be about it, see how life changing these interventions can become and, and see if it sparks a, a bit of interest that you can then pursue further. Um Should we take one more question and then uh we'll have like a another Q and A at the end of the session. Uh Yeah, if you found a question you want, there was one that I thought looked interesting about kind of how do you find a suitable donor for the um for the recipient? So for example, could you transplant uh an adult heart into a, into a child? Which I think, I guess the principles of finding a suitable donor? Yeah. So um so primarily you see you need to make sure that they match on a blood group. Um We also there are some other um parts of the cross match. Well, that what I mean is everybody has a will have a blood type. So when people say things like a bo um positives, negatives, that's your blood type. So you, you have to have a recipient who or a donor who matches or has a, a blood type that will suit you. Otherwise your immune system will reject the heart um regardless of how much immunosuppression you take. Um So that's the sort of primary first thing we look at and then we look at the, the height and weight of the recipient and we look at the height and weight of the donor. So, um, generally we try and match them like for like, um, if you're, but there are some exceptions. So if you're putting a, a male heart into a female recipient and you can, um, uh, than the size match, you can put a slightly smaller heart in. Um, If you're putting a female heart into a male recipient, you need a slightly bigger heart. Um just because of the, the size of the actual muscle mass that's there. Um in terms of transplanting into Children, um its size is the, is the key. So you could put a small adult heart into a, into a child. Um But uh if it's a very small child, then they will need a small heart. So, um so they'll need a AAA heart from a, a child donor. Um which is why when you see things like burning hearts and a long term mechanical support that's used more often in the, in the pediatric population than in, in adults. I mean, that was a fascinating session. I think even I loved some things and I wish Miss Booth had been there to teach me my cardiac physiology back in first year.