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SICS Evening Education Updates : Dr Alison Smyth : Management of Advanced Heart Failure

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Summary

This edition of Education Evening updates with the Scottish Intensive Care Society will feature Doctor Allison Smith discussing advanced heart failure. You will hear about the Scottish National Advanced Heart Failure Service, how to get in touch with them, how to define advanced heart failure, cardiogenic shock, and proper intervention. Doctor Smith will also provide information about mechanical circulatory support and cardiac transplantation, and then will transition into two case based discussions. Don't miss this exciting opportunity to learn more and gain insight into advanced heart failure from one of the top experts in Scotland.
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Dr Alison Smyth, Specialist in Cardiology and Advanced Heart Failure management, will join us for a clinical update on the management of heart failure

Learning objectives

Learning objectives: 1. Objectively define advanced heart failure and its associated symptoms. 2. Explain the role of the Scottish National Advanced Heart Failure Service and how to contact them. 3. Describe the treatments available for advanced heart failure and when specialized interventions are necessary. 4. Discuss criteria for admitting a patient to the SNHF Service. 5. Review how mechanical circulatory support is used to bridge a patient to a transplantation or other treatment option.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hi, everybody. Welcome to our May edition of Education evening updates with the Scottish Intensive Care Society. Thanks everyone for being here. Uh We've got a really interesting talk for you tonight and so we've got Doctor Allison Smith who is a cardiologist at the Golden Jubilee to talk to us about advanced heart failure. So Allison's especially doctor specialty doctor working within the Scottish National Advanced Heart Failure Service in the Golden Jubilee National Hospital. She's been there for the past six years after completing the training in Northern Ireland, aside from her role in cardiac transplantation and mechanical circulatory support, she has an interest in echocardiography and training. So I'm just gonna load your slides for you, Alison. Hi guys. There we go. So um be ready when you are okay. So hopefully, yeah, that's brilliant. So, hi, everybody. Um welcome and, and thanks for asking me to speak. Um as I said, my name is Alison. I'm one of the specialty doctors. I am in the Snafus unit in the Golden Jubilee in Glasgow. I have been there since I came from my family of registry training and I stayed ever since. So I've been working on transplant for several years now. Um I just wanted to, I suppose I have to think about um what I would like to talk about or what you might like to hear about as, as intensive care doctors. And so a few objectives which might be fluid as we go um are to define probably advanced heart failure. I think I'm going to focus the large portion of this on advanced heart failure and which is maybe more, more more your sort of useful for the type of six of patient's, you might be getting across your doors, um defying cardiogenic shock. Um I think pragmatically, I'm quite a pragmatic person, I think so pragmatically, um working in Scotland, who are the Scottish national answer for your service, who are we, what do we do where we based, how you get in touch with us? Um What do we want to know about? Who do we want to know about? What can we do differently? What can we do above and beyond what can be done in, in peripheral centers? When do we think about cardiac transplantation? And there's a couple of case based discussion's at the end. So I may or may not get through all of this. Um We'll see, we'll see how we go. Um I think the cases are useful and they do highlight some of the points. So um I'll be quite keen to try to get at least talking through one or two of those. So um yeah, what is advanced heart failure who have staffed and how to, how to contact us? So, I am based in the Scottish National Vance Heart Failure Service in the jubilee. The ward is called the National Services Division. That's the name of the ward that it's called the NSD Ward. And we work very closely with our colleagues in intensive care to um I've put the number of the telephone number for the world up there if you want to write it down. Because usually if you have a referral that you think you might want to discuss, if you're filling the ward and ask for the, for the consultant on call. There is at 24 7 RODA including out of ours and that's quite new. Um I completed that Rhoda of the fifth person. So there's now a full time Rhoda and there should always be somebody on call to talk to talk about, about patient's with you if you, if you need to, um we've got five sort of cardiologists. We've got four full time transplant surgeons on quite a big transplant team for retrievals. We've got four full time transplant coordinators and several sort of patient's or several nurses who do the transplant coordination. And along with their, their usual job, we've got a mechanical circulatory support coordinator. We've got a full time clinical psychologists and a team that work with him. And we've got a whole team of cardiac intensive. This they're based intensive cartu. So that's kind of how you get in touch with us. The said there is a consultant mobile via either the word or switchboard or you can page 0092. So um my advice would be if you, if you have a referral and you want to talk about it, uh either go through switchboard and ask for the consultant on call or the nurses in the ward. Um We'll put you straight through or give you my number. Um If it's this weekend, it's me. Um so defining advanced heart failure. So this is the position statement from the heart failure Association of the E S C. Um From 2018, it talks about advanced heart failure as severe signs and symptoms of heart failure with very minimal exertion. So these are kind of your end stage patient's usually in these patient's with very advanced heart failure, will have refractory heart failure symptoms and really will be progressively less tolerant of their evidence based medical therapy. Um And that's important. So when you start to have to pull back their hearts for your medication, it's a bad, bad sign. If they're not tolerating, there is inhibiting beta blockers except, and you're having to reduce them, you're not really winning if I could say that. Um So they tend to have recurrent hospital admission's despite maximally tolerated um therapy. Um I'm gonna talk a little bit more about that later on. Usually again, reinforcing the point, conventional pharma pharmacological and device therapy um by device therapy, usually that sort of see aarti um sort of pace, pacemaker device um therapies, they no longer provide adequate quality of life. Quality of life is a big, big thing when we assess our patient's so adequate quality or duration of life. And at that stage, we feel that specialized interventions are necessary. So really as the as the Scottish advanced heart failure service, we encourage referrals for patients with advanced heart failure. Um So again, this is just, I'm just put up slightly, I suppose more scientific data that they've, they've given in their, in their guidance, so severe and persistent symptoms of heart failure. So you're, you're moving into the NYHA class three or four symptoms, um severe cardiac dysfunction defined by a reduced LVEF of less than 30%. Sometimes that can be, you know, in an isolated RV cardiomyopathy type problem. And, but to sort of keep it simple, usually these are patients with severe severe LV dysfunction. Um and, and they have rising N T PRO BMP. Um they've had episodes of pulmonaire, systemic congestion, requiring high dose intravenous diuretics. Again, as I said, several hospital emissions or admission's with low out pit states or malignant arrhythmias. So these are people who are sort of bouncing I/O of hospital and I suppose we kind of want to try to catch them before they bounce I/O too much and you know, I can think of lots of these patient's over the years who have come I/O and in the night and night being recurrently treated for heart failure. Um And that definitely have met that, that bill. Usually these patient's have severe impairment of exercise capacity and with really inability to, to exercise. And if they're fit enough, we, we put, we pretend to put them on the, on the cardiopulmonary exercise testing um uh bike and we categorize them with regards to the peak view too. And the guidance would say sort of 12 to 14 would be our cut off. So that's quite um arbitrary, sort of cut a sort of arbitrary statement. So we have to think sort of outside that as well. So, extracardiac organ dysfunction due to heart failure. So cardiac cachexia is a, is a really big thing and it's a really worrying thing. So if you're seeing somebody becoming cachexia, cachectic with heart failure, we worry that they're starting to miss the boat. Um Liver, kidney dysfunction, cardio renal dysfunction. So all of these things are, are, are signs that start to define the person as having advanced heart for you. Um Can you next slide that Helen, please? Okay, sorry. Bear with me guys. Okay. Um I feel like that like Chris waited here guys and I'm sorry if that's um this is gonna be distracting sort of thing. So where do we get our referrals? Um We either get outpatient referrals or acute and patient referrals, acute and patient transfers. So the outpatients tend to come from cardiologists, um or heart failure nurses, um who make very, very good referrals from I supposed places that maybe don't have such a good cardiology input. So regional cardiology services across the country and those are patient's that we generally tend to bring to outpatient clinics and see them and then decide whether or not we can follow them up as um as outpatients or whether we bring them in and do a little bit of elective in patient assessment. Um But I suppose a large burden of the work at the moment is is acute inpatient missions or acute transfers. So I see referrals either through ICU doctors or through cardiologists or through both and with patient's presenting with cardiogenic shock. Um Cath lab referrals um which can either be from, from the west of Scotland and there's 22 sort of primary PCI centers here or indeed referrals that may come from out with that from the north or from the east who may require stabilization and transfer. Um And then either acute transfers from other cardiology. It's around the country of patient's who perhaps are not in overt cardiogenic shock, but they're not doing well on their current therapies. Next one. Yeah, thank you. Um So what do we offer? So I think really simply we offer assessment and treatment of patient's with advanced heart failure who are I suppose um to caveat that patient's who are potentially transplantable and I'm going to talk a little bit about who that might be and who might, that might not be. Which I think is useful for you guys seeing these people coming through your units. Um We offer, yeah, assessment and treatment of these patient's acute, acute and chronic patient's including patient's with cardiogenic shock. Um We offer both short term mechanical circulatory support and um in very selected patient's longer term mechanical circulatory support. And um we do cardiac transplantation where the only transplant center in Scotland and one of six transplant centers across the UK. Um So we've had a really big year and we've been sort of escalating in numbers over the past few years since I first came to Glasgow. And last year we did 40 transplants in the transplant year, which was the most um the highest number in from, from any center in the UK with, with very good outcomes. So we are transplanting more people. Um And we're, we're enjoying the benefits of that, I suppose in terms of good patient outcomes and uh a big post transplant workload, which were um we're working through um next slide yet. So I think the way I would try to think about this, the way we, we use mechanical circulatory support. And when I say that, I mean, you know, patients who come and need supported with um either bloom pumps, ECMO, short term uh left ventricular, right ventricular assist devices, anything that you're you're needing to use to support the circulation. It really is on a bridge to something. So whether or not this is a bridge to transplantation. Um So supporting the patient stabilizing the patient to be able to bridge them to the ultimate um the ultimate goal or the ultimate treatment option of of transplantation. Um Sometimes that's not quite clear cut whenever we first intervene on these patient's. And I suppose, if you can imagine, you're quite, quite not suppose not infrequently called to patient's who are pretty sick and you don't know that much about them. So good example of that might be, you know, a cardiac arrest or peri rest in the cath lab patient come in with the stemi, you don't have all the information, you don't necessarily know everything about their core mobilities. Um But you know, they're, they're 55 on paper, they seem to be a candidate um for, for transplantation or for advanced therapies and you go ahead and as a bridge to decision. So sometimes that's bridging to allow you to get more information to make a decision. And sometimes things do come to light during that, that, that may tell you that that transplantation is not an option for this patient, but it allows you to bridge to, to make that decision. Um And for patient such as Maya Krajisnik patient's um patient's that you can bridge to recovery. So we have had some patient's who have, you know, had really catastrophic myocarditis, um which is a recoverable condition, I suppose peripartum cardiomyopathy might be another example of that. Um where there is potential for recovery and the idea to support the patient to recover and the support can be wind just a little time. Like I'm not going to talk about long term L VAD as part of this talk, it's much too much for, for, for an hour, 45 minutes to an hour. But we do have patients who are on long term durable, kind of mechanical circulators supported by that. I mean, long term L VADs, we don't have a lot in Scotland. Um The device we're using at the moment is a HeartMate three and you may come across these patient's in your practice. Hopefully not. Um And if you do, uh we, we, we want to know about it. Um And uh we have a, we actually have an L VAD phone um on, on the ward that, that the patient's get access to that basically only rings if it's, it's a patient with an L vag with a problem. So, um the patient should have the number for that. Um But it, if you, there isn't a lot of them in Scotland. And usually if, if a patient with the long term, as I continue your, you know, doc comes into your A and E or you're asked to see them anywhere. And we've been more than happy to hear about that and to talk you through um any of the details of that if, if the patient's not conscious enough to do so, should say. Um So that was just to kind of mention that quickly. I'm not going to dwell on that too much. Um So this is a paper from the journal of heart and lung transplantation back 2009. Um It's the inter max profiles of advanced heart failure. So this is kind of how we categorize how sick sort of levels of sickness, of sick, sort of levels of how sick the sick are. So there's um so they talk through 77 profiles of, of um of advanced heart failure starting off with the worst. So I put arrows between, I suppose the to these are kind of the two that are most likely to be kicking around. Um I suppose in hospital sick, perhaps in I C U S or C C U S are kind of getting worse. Um So the first one is really, you're, you're, you're very, very sickest that need intervention within a few yards. These are the ones that you're sort of, we're most likely to hear about, I suppose from icy units elsewhere or, or any so kind of crash and burn patient's. Um there are likely to be in critical cardiogenic shock, um quite possibly perry arrest situations or post cardiac arrest situations with critical organ hyperperfusion, life threatening hypertension acidosis and raise lactate. So that's your cardiogenic shock patient's um which are sometimes, I suppose it's a slightly more obvious aspect of it so that those are the sickest, the very, very, very sick, sick sick patients. Um The inter max two ones are sometimes a wee bit harder to spot, possibly. So they tend to be patient's who are progressively declining, declining despite support. Um So that can be associated with worse renal function. So like a cardio renal type picture, the inability to restore their volume balance despite good efforts with diuretics and inotropes, um and quite often they will be nutritionally deplete. Um And that is your kind of inter max to patient. So I've got a case later on that might illustrate this a bit. We kind of turn this is sliding on inotropes. So these are patients that we feel would need sort of more definitive intervention within a few days. So it's not um pressingly urgent but they're not doing well on their current support. And then it takes you through the different categories that we're doing. So, inter max three or sort of state of dependent but stable. So they're on iron tropes, they're stable and there may be another temporary support. Some have demonstrated failure to win from that support and those are patient's that we know that we're going to need to do something with, but I suppose is not as pressingly urgent and then these are, I suppose the more patients were more likely to see it, outpatient selling. So intra max for patient's who have resting symptoms that can be stabilized quite close to their usual volume status. And usually the symptoms are at rest or minimal activity. So they're pretty limited patient's and ohh has three patient's and they, a lot of management and surveillance and where those are patient's that we usually see at the outpatient selling and we may assess them for transplant and they may, they may need transplant. But um that can usually be done, you know, it's sort of in the in the close outpatient setting. Um Inter max five, then our patient's again, who are, who have heart failure, definitely advanced heart failure. But um it's more more stable situations. Winter max five, comfortable at rest but unable to do much with activity. Then Indra max six. Um that's a typo in that. Sorry Helen. That's I've copied that across. That's not come across, right. So endo max six um tend to be, again, it's slightly far ignore what's written on that slide that's wrong and slightly further on down the scale. So patients are able to do a little bit more, but I kind of more maximal activity gets them. And then it takes us right down to in dramatic seven who may or may not need um support. So uh those are patient's who are without really episodes of unstable, unstable through a balance and her living sort of relatively comfortably. So they do have heart failure but they are stable and they may be happy enough with the quality of life and and there may not be an indication to go down transplanted, rude, rude with them. So sorry about the type of there was copy and paste and bits and I actually missed a bit. So um when do we think about transplantation or L VAD with these patient's? So, um first question to ask, has the patient, this is supposed questions we ask when we see these people. Um as more our patient basis, has the patient received all the available therapies? Have they had all the heart failure, therapies, all the oral medications, all the device therapies that are possible. Um Is the patient ill enough to need a transplant? Um Will the patient survive the surgery? Um So it's for anesthetic colleagues come in and all of our patient's have sort of through assessments by, by the surgeons and by the anesthetic team before we would even think about listing them. Um Are the competing comorbidities going to influence the outcome? I'll talk about that a bit more in a minute. Um We also need to balance out the scarcity of donors um and the donor pool that we're working with um interesting change in laws over recent years. Um And possibly we'll definitely, I think have increased um donors uh donors coming through. Um We possibly are trending towards higher risk recipients, maybe, um depending, but we are certainly being asked to consider higher and higher risk recipients. Um And they're, you know, we have to balance that against higher risk donors and that's all a very complex process that's done. Um as, as part of an M D T. Um uh heart transplantation is, is an irreversible therapy. It's a palliative therapy really. Um The way we talk to patients about it is that you're sort of swapping one set of problems for another set of problems really. So it's certainly not. Uh you know, I get out of jail free card where you, you get your transplant and, and everything's rosy and there's a big morbidity burden, especially in the first year. Um risk of opportunistic infections, risk of rejection, uh A lot of medication, a lot of side effects. So, um we need to bear that in mind and the patient need to be committed to transplant at the next slide there, Helen. So this is a good pneumonic um which has come from again, a journal in uh in the Journal of heart non in 2019. And I've seen this presented in multiple different talks. And I think it's probably the, the best bit of information to try to impart to probably more people seeing, seeing, maybe patient's in cardiology and it's rather than necessarily I see you, I suppose, but it's all good learning. So, um markers of advanced heart failure, we have a monarch, I need help. So I for inotropes. So an ongoing requirement for an atropic support, whether that's the beauty mean Milrinone, um whatever is being used, we use a lot of Milrinone interviewed um in here. Um uh So then we think about the N Y Nyha class and the BMP end organ dysfunction is something that I think is really important to highlight and doesn't maybe always get picked up through worsening. Liver dysfunction is a really bad sign. Um We trend the Billy Ruben quite closely and sometimes you can see sort of, you know, you can actually mark out Billy Ruben is rising um quite subtly before, before the, before the actual LFTs go off themselves. Um worsening renal function in the setting of her for there's a bad sign and probably indicates a pretty poor cardiac index ejection fraction, um which is not hard and fast rule, but a very low ejection fraction, um defibrillator shocks. So recurrent appropriate fibrillator shocks worry us especially if the patient has been quite stable and then starts doing this. Um more than one hospital like more than one hospitalization with heart failure in the last 12 months. And I remember when I first saw that. So that's very interesting because that's not a lot really. If you think about it, you know, 22 hospitalizations in a year for, for a patient, heart failure maybe doesn't sound like that much. But if somebody's otherwise relatively young and, and doesn't have any other comorbidities, which I'm going to talk about, then we should certainly be thinking about it. Escalating diuretic requirements, persistently low BP. Um, and, and again, I've already said this in the previous slide, but the inability, very, the inability to up titrate their medications or indeed the need to decrease them is a really worrying, a really worrying thing. And I think when we try to import some of this to our, to our colleagues in general cardiology and it's etcetera, that's probably the best I would pull out of that is this sort of, you know, a more than one hospitalization in 12 months and be when you're having to start reducing the medications back. Um, so we need to balance out the referrals as either too late or too early. So it's too early, sounds obvious, but the patient takes unnecessary risk and it's exposed to the long term complications for much longer than they should. Um, which, you know, when you're talking about maybe these patient's being referred in their, in their early twenties, you know, that that needs to be thought about. Is this the right timing is, is the person sticking off and is the time right? But too late referring too late, then you, we run the risk of all the sort of irreversible problems and either make the patient on transplantable or make the operation incredibly risky. So, um, it's trying to strike that balance and I think if in doubt, we would encourage our colleagues to refer earlier and, you know, we can always push it back, you push it down the line. But um if you refer to later, there's not that much that can be done. This is a paper from Heart, which is a little bit older. Now, 2011, it was really written by members of all the kind of transplant centers across the UK. And I'm not obviously gonna, I'm not gonna go through it too much, but it's a good paper and I just pulled out a little, it's, it's sort of the more more recent UK guidelines for referral and assessment. So again, it's things that I've already spoken about just in a slightly different form. So the conventional criteria for heart transplant, I've already, I've already touched on and we assess them using these, these systems, but uncommon reasons that we might transplant somebody I thought was helpful to, to mention so persistent hemodynamically compromising ventricular arrhythmias. So, um if you, if we had somebody who, who was having um persistent um compromising arrhythmias in, you know, in a, in another hospital, um it would seem to be refractory to treatment, then we would want to know about that. Refractory Angina isn't something that we actually see very much. Um but it is there in the guidelines, refractory Angina, which is not amenable to treatment. And, and then the more I think the really interesting group of patient's are these restrictive patient's restrictive cardiomyopathies, hypertrophic hypertrophic cardiomyopathies with persisting, you know, class a class 34 symptoms. So patient's who maybe have normal LV function but have very clear evidence of restrictive filling patterns. Um and, and a really very, very symptomatic and sometimes that's maybe a little bit, little bit misunderstood because their, you know, their heart function looks normal on a scam. There LV function is 55% and an LV function of 50% in a patient with Hokum is, is very low and, and that, you know, the minute that they're, that they're systolic function starts to drop, then that person is, is entering that kind of burnt out phase. So we like to get referrals of hypertrophic patient's. And um we, we actually have transplanted quite a lot of them over the past few years since I've been in Glasgow. So that's interesting. Um contraindications to transplant. I wanted to talk a little bit about it because that might be what comes up as you're seeing this person in the bed and I see in front of you, is there somebody that we want to know about or not? So age officially, it's not a cut off, not a barrier in reality. Um As I'm sure you guys can all appreciate in your job roles. It's escalating ages, escalating risk. And in reality, we really rarely transport somebody over the age of 65. And we have done um biological age, those versus uh versus actual age. But it's again, if people have patient's who are maybe 67 who are absolutely the fittest person, marathon runner, etcetera, etcetera, then absolutely. We're, we know we're always, we're always keen to here to discuss, but in reality, uh in reality that we don't, we really don't do much over the age of 65 I would say, um, renal dysfunction is important, irreversible renal dysfunction. The egfr is less than 40 irreversible um is listed in the criteria as being a contra indication. However, it's important to think what, what's causing that renal dysfunction because quite often it's cardio renal and coming from a poor cardiac output state. And if we actually augment the cardiac output, we can normalize the kidneys. I've seen that time and time again. So it's just, is that intrinsic renal dysfunction or, or is it, is it all just cardio renal? And quite a lot of it is cardiorenal diabetes itself is not, are contra indication? Very poorly controlled diabetes is a problem. Um And any significant end organ dysfunction, bar nonproliferative retinopathy is a contra indication to transplant. So, quite often when we get these referrals were asking those questions about i screening and foot screening. And um you know, when the last time you saw the diabetic team was and, and we're going to, we're going to a lot of detail on that because uh realistically, they have to really have no complications to be eligible. Uh HBA one C, we like that to be controlled. Obviously, if it's very, pretty controlled, it's much higher risk, but a relative contraindications nonetheless. So not a complete active sex. This is a complete country indication. As you can imagine, we aggressively immune, suppressed these people. Um So, active sepsis is, it is an absolute no go chronic viral infection quite often get asked about chronic chronic hepatitis is and things like that and it's not a complete contra indication if it's, if it's properly treated. Um And we would engage the virology teams and I D teams and hepatology teams, etcetera. Um If, if we had a patient's like that recent p is a, is a problem because that runs the risk of pulmonary infarction and pulmonary abscesses, etcetera. So we usually, it's a bit of a nightmare in that situation because it makes things very risky. So we usually try to tie the patient through until they're a couple of months down the line which make that risk less. Um But again, it's, it's a discussion to be had vascular disease, sort of severe symptomatic, either cerebrovascular disease or proof of vascular disease is a counter indication to transplant. Um And some of these arterial paths, cardiac um uh sort of post stemi non stemi patient's can end up with very messy vascular disease elsewhere. So we usually go looking for that with CT scans um to see what we're dealing with active malignancy bar kind of very localized nonmelanoma skin malignancy. So, any other active malignancy is a contra indication to transplant. However, the question is posed quite a lot, somebody who's had breast cancer three years ago, or lymphoma 10 years ago or whatever. And that's a case by case discussion. Um And we would always have that in conjunction with the new, the patient's oncologist and um whoever they, they've seen in the past and we're sort of looking for um risk of relapse how curative the situation is and, and how, what, you know, what, what, what they're, what they see the long term outlook for that patient. And we make the decisions on case by case basis basis. So previous cancer is not a contraindications. Uh from, from our point of view, it wouldn't be a reason to completely rule the patient out, then we should talk about it. Um, frailty, obviously, it's pretty obvious one, but that's quite, I suppose, quite subjective. So we do try to employ some objective frailty measurements if we can. Um But that's where the cardiac cachexia starts to come in and those patients who become higher risk because they're, they, they have become increasingly friel things. We get asked a lot about substance abuse and psychosocial issues. Um So substance abuse, again, smoking, tobacco, alcohol misuse, um drug misuse of other, of other drugs. It's a problem and usually patients have to demonstrate at least six months of abstinence. Um Before that would be considered. Now in the, in the very urgent, urgent sort of cardiogenic shock, sick patient, she might have all that information and it's, it's trying to piece it all together and in an emergency in the emergency situation. But um, uh I suppose the problem, the problem behind that then is, is the non adherence to the medications, post transplant and how well that patient will do. So, it's quite often a bit of a case by case basis thing as well. We measure urinary cosigning for nicotine um outpatient clinics and things. Uh patient's who are, who, who have committed to, to stop smoking, etcetera. So, um it's it can be actually bit controversial sometimes. That's sometimes we have quite a lot of discussions about it. Um psycho socially, patient's need to have adequate social support, stable accommodation, um family support, etcetera, etcetera. So we as well as psychologists comes into play. Um and usually he assesses those patient's with regards to all those kind of issues and provide support. Um Previous codex surgery is not contraindications but becomes increases the risk obviously. And, and some of the congenital patient's, we don't do congenital transplant in Glasgow, obviously, the congenital side of patient's who've had several surgeries before. Um So it's not a contraindications but definite increases the risk and then skeletal myopathies. Um So obviously, some of the muscular dystrophies are so strongly associated with DCM. So we have come across this quite a bit usually if it's, if it's a mind, um my skeletal uh problem, like the, like the becker's um who have good functional capacity. Otherwise that, that's not a rule out either. So, I suppose what I'm trying to summarize from that flight is there's a lot of relative contraindications. There's not that many complete contraindications and sometimes you're better to pose the question and then we discuss it at our end and, you know, feed feedback. So um we can work around quite a lot of things. I suppose if, if we've got all the information, but that's why sometimes we ask all the information whenever people phone. Um sorry to the next slide. Hell yeah. So the tiers of listing, we have three tiers. Um We've got a super urgent list and they tend to be patient's in intensive care on either ECMO or by ventricular assist devices. I'm not going to dwell on this talk too much on the in depth details of those devices because I could be here for three hours and I won't be, but we can do that. Another time is people are interested. Uh But what you can see, we've got super urgent here. We've got an urgent ear, the urgent ear, our patients who are in hospital on either inotropes or a balloon pump, excuse me. And the routine patient's tend to be questions at home. So the super urgent list, which is the gray boxes, they can that only sort of started in 2016. So up until 2016, there was only the two tiers and then that tear was, was, was brought in. So as you can see, we do the vast bulk of our work across the UK in the urgent and the super urgent ear and the patient's on the routine list are are are not, I suppose um or less common common to be brought into hospital to get done. Um So the vast majority of the transplants over the over the certain over the past few years have been done off the more urgent and super urgent ears and these are patients who have come through in cardiogenic shock or have come through. We've been seeing outpatients and they get progressively more unwell with cardio renal dysfunction and they have to come in and be put on iron tropes and be listed urgently. So it was just the purpose of that size just to demonstrate, I suppose that um patterns have changed slightly and certainly we're doing substantial amounts of patient's from the super urgent list. So transplanting substantial amount of patient's from ECMO or or VADs in intensive care for the next one up. Thanks. So, um this is really kind of the outcomes for the super urgent registration. So those are the patient's, as I said, or her, her, the ICU patient's on either ECMO or mechanical support exam or, or bivalve ads, etcetera and realistically, yeah, I think the large proportions and who were listed on the super urgent transplants did get transplanted when you, when you see that um with a small, I suppose a small proportion of them who do die. And because there are significant complications from this, this these devices, so um these questions do intend to get transplanted quite quickly and they get the priority on on the on the super urgent ear as you would imagine. Um But obviously that that's balanced out with the additional risk of the devices and the risk of complications move on. Um So I just wanted to touch a little bit on cardiogenic shock. Um do a little small over here in 10 minutes, uh defining cardiogenic shock. So it's a severe impairment of myocardial performance and it results in a diminished cardiac output which then results in end organ hyperperfusion and quite often hypoxia as well. Um It usually presents as hypotension which is refractory to volume resuscitation and that's important when you're trying to make the diagnosis quite often. I would imagine it starts off with that very fact that the hypertension is not improving with your volume and actually your end organs are getting worse. Um different trials of defined in different ways, but to be pragmatic, usually a systolic BP, less than 90 for 30 minutes or more cold extremities, um altered mental status to the confused, progressively confused patient. Um they get a narrow pulse pressure, they get acidotic, raise lactate, elevated creatinine. So these are, these are all the kind of patient that we want to hear about. Um it requires either for sort of some sort of intervention in the, in the in the urgent, in an urgent way as as in that inter max one that I showed you earlier. So either pharmacological or mechanical intervention, um the primary insult is a reduction in contractility, um which results in lowered cardiac output hypertension. You then get systemic phase of constriction and then further cardiac ischemia which propagates the cycle, um peripheral vasal construction and then leads to your vital end organ damage from your inefficient stroke volume and your insufficient circuit circulatory compensations, which just this sort of vicious cycle that then gets created when you're, when you're dealing with cut with, with these patient's. Um I like the slide. This is a slide that comes from the European journal of heart failure. Um And it just defines the management of acute heart failure in sort of four categories. So if you're, if you're, I suppose the worst, the worst of these four categories are your cold wet patient's. So these are your patients' who are hypo perfused. So they're, you know, they're, as I've said before there confused. They've got their not making urine, they're cold, they're sweaty there, clapped out, but they're also congested um as well. So they've got their JVP up, they've got sides, they've got flu in their abdomen, they've got flu in the lungs. Um And they're pretty difficult to manage. Um, if they're, if they're cold and dry, sort of, that's more done. Your, your, your, your hypoperfused state, but the lungs are still relatively clear. So it's just, I think it helps to think about it like that to try to categorize where your patient is sitting and the best, the best case scenario, your patient is warm and dry and they probably don't need you. Um, but card, you know, acute heart failure doesn't always have to have the congestion side of it. You can have the patient who gets progressively more hypoperfused. Um I'm not a very, very, very good article that from 2016, if anybody wants to have a wee look at it, there's, there's quite a useful information on that. And so when referring cardiogenic shock, so early referral to a specialist center, um we would encourage early referrals, I suppose, um seems obvious but patient who are stable and I know Trump's but dependent on those inotropes and can't get any troops off patient's who are experiencing recurrence arrhythmias. I think I already sort of said quite a lot of this. So I'm just reinforcing it um in an index presentation of heart failure. If the cardiovascular support can't be wind, then we would like to get that referral early. And so as we can sort of see what to do about it. Um And if M C S is already implanted, so if, if you know if they've had ECMO already implanted as a, as a state as an urgent stabilization measure, then essentially before complications occur or before they get, you know, reversible or irreversible end organ problems. Um What can we add? Um again, I've probably already said most of this but sort of cardiac output monitoring. So when we take the patient's across, we tend to take them to uh to ICU to and put a P A catheter and, and float a swan to get some continuous monitoring. Um Careful addition of inotropic support as appropriate. And as I said, we do offer a bridge to transplant, but that's not the only things that bridge the decision of bridge to recovery is also important. And that can be very, very important for these really urgent emergency patient's that you really don't have that much information on, on my. Um sometimes it does come across eventually that they're not transplantable, but that's, that's a big call to make in, in two minutes of that. Uh you know, in it in an A and a resource where you're, you're trying to stabilize the patient urgently. We offer several forms of M C S including central support. So central ECMO and for the very selected patient's, we, we do, we do do biopsies, not that commonly. Um But for catastrophic myocarditis is especially if we're concerned about giant cell myocarditis, which we had a little slurry off a couple of years ago, we would biopsy, those patient's um can I take you back once via Khellin? Thanks. So, management, a cardiogenic shock, I suppose is, is a team approach. I'm not un intensive. It's so I'm not gonna pretend to know an awful lot about them to living these patient's and I'm not really going to pretend to know a huge amount about the visa pressure and the, and the, and the an atropic support above and beyond quite a basic level. But basically we, we manage them as a team. Um very careful fluid management, uh guided by your, by your cardiac output monitoring and by your, your P A catheter and which enables you to, to, to balance that. Um most of these patient's will require see, well, not most of them, but quite a lot of them will require filtering uh hemodynamic monitoring. As I said, we were doing nearly everybody that comes across through putting a pair Catherine allowing, allowing us to monitor the fluid states continues cardiac output monitoring, central venous or two monitoring and it helps to titrate what we're doing. So the next side there. Yep, thanks. So, um M C S devices that we use and again, I'm not gonna dwell too much on this because it's a whole separate talk. But there's most simple of these devices that we use and we use them a lot is the injury or a blue pump. It tends to or it does uh decreased myocardial oxy oxygen consumption. And decreases your after loot. Um It's a problem if you've got significant A are, um, and inflates during diastole and deflates during systole and modestly increases your cardiac output. So I would say modestly that sometimes that's all you need in these patient's and, and the jubilee we've got, we would bridge the transplant a lot with boom pumps and we mobilize the patient's with the broom pumps. So, some of these patients are in Broome pumps for several weeks to months and they mobilize with them in with supervision, which is pretty uh pretty interesting to see. Um impella is something that we're doing a little bit more of. Um we wouldn't, I suppose to be a senator with the huge amount of experience and impella. Um but we've had some very good results with patient's, we've bridged the transplant with impella. So, thus far, um it's a continuous pump and that's the difference. So a blue pump is, you know, act with your cardiac cycle. Uh impella is, is acting independently of your heart function. Um continuously pumping blood, sucking it out of the L V and progressively unloads the L V as a result. Um it decreases, again, decreases myocardial oxygen consumption. And um it's contraindicated in if you've got significant aortic valve disease because as you can see from the little picture, it goes right through the aortic valve. So if you've got a mechanical aortic valve, you'll not be able to get that in if you've got significant pacific aortic valve disease, you'll not be able to get that in. Um Obviously, you can either put that in through the femoral artery or it can depend in surgically and the surgical cut down at the axilla. Um So significant peripheral vast disease is a problem. You have to have reasonably sized vessels to allow that. And then obviously, the thing that maybe people maybe have a bit more experience with or not is the A ECMO, which we can either do peripherally um or centrally, I'm not going to dwell too much on ECMO because it is a whole talk about itself. But it's something that we use quite commonly. The short term mechanical assist device is that we use um can either be used as a, as a right ventricular assist device, a left ventricular assist device or a combination, which is what we're, what we're trying to buy VADs. So essentially, it's a, it's too big pumps that's at the end of the patient's bed with Cannulas that go in through a central sternotomy. Um We can put an oxygen ator with that. Um usually at the start and then the auctioneer comes out as the patient gets a bit better and we can either support the right side or the left side of the circulation or both patient's can mobilize with these and they can mobilize all around the hospital with these. Um And, and we very successfully British the number of patient's in recent years to transplant with these by ventricular assist devices. And those are the sickest, sickest patient's. Um And then for the very select patient's sort of long term durable Elvis and I just put a picture of chest X ray to see cause I think it's uh pretty cool. Um These are these little pumps that gets surgically implanted into the LV apex without paragraph that was into the aorta. Um The patient goes home with that, they have a drive line that comes out of the tummy area and they carry battery packs around there around their waist and they go about their business and that, that is in the UK, that is as a bridge to transplant. So we would usually use these devices for patients who have pulmonary pressures which are too high for transplant. So they've got type two pulmonary hypertension and we can't bring those pressures down with a blue pump or other means. Um And those patient's have a, have a nail that implanted to bring the pressure's down to make them transplantable. So they're not licensed in the UK for Destination Therapy as they are in some other countries. And again, probably a whole another talk if, if you, if you want to know much more about that. But um we do have about four or five of them at the moment around the country. Um And generally, if, as I said before, if you have a problem with your patient Manele that give us a shout. We're more than happy to take that call. Um So what do we want to know? So again, I've just sold stuff I've been through. So what'll through it quite quickly? So age weight B M I B M I is a big thing. BM I cut off of 35 is, is a, is a, is a strict cut off. So the B M I has to be has to be less than 35. So the patient be transplantable. Um Other things I already mentioned, social support, etcetera, etcetera. Very kind of mentioned a lot of this and cardiac history um more relevant. I suppose you guys working a nice to use. It will be the cardiovascular state, the lactate trends, any anti tropes, the patient's ready all in cardiac monitoring. If you have it to have access to do that, very helpful and end organ function is very important. Any ongoing infection, neurological state and echo echocardiographic data. And sometimes that is just uh the case of somebody has put an echo probe on and, and you know, has very rightly picked up a pretty, pretty significant finding. Um and patient and the family need to be willing to consider advanced heart failure therapies. And you know, um most people are, I think how we uh just stuck this in just for, for notes. So the referring team can be whoever wishes to refer, I suppose. Um quite often that is, I see units. I've taken quite a lot of phone calls from um, intensivist rounds place. Um, but whoever is referring, they make contact with the uncle cardiologist, either directly on the mobile or through the page. And really is we could have take the lead for the liaising with the on call intense list and the on call transplant surgeon. So you're dealing with one person ideally and that's hopefully how it should work for these referrals if you make them. And then we come up with a plan and, and an answer, I suppose as to what we think is feasible and then we feed that back to the referring team. And so that's technically how it should work. There is a referral form on the website. If you go onto Google and you put in snuffs, um referral, it comes up, I'll not lie. I don't really make people fill this out. I tend to take the details and fill it out myself. Um It's for us to keep a record of, of the referral. Um Well, it has all the helpful information. So it's helpful even just to know the kind of bits and it's all stuff that, that, that we, that we want to know. Um So that can be found on the website. So I'm gonna talk, I'm gonna be well through a couple of cases. If I've got time, please just stop me whoever is in charge if, if I don't just stop me when you need to stop me. Um, this is, uh, that'd be okay. So these, I think these are some, some of them have interesting points. So I'll certainly do the first, the first couple. So this is a 26 year old man who was referred from a district general from a cardiologist in the district general. He was 26 previously been well, policeman. Go to the gym has a twin brother know, past medical history. Pretty definitely a pretty, pretty well guy, but was admitted to the medical admission's unit with shortness of breath orthopnea and PND. But his appetite is very poor and he had very sort of very, a lot of abdominal bloating. He last felt well over three months ago and I've just been getting worse with his exercise talent during this time. Um, on admission, he had a sinus tacky, which is a really worrying sign for these patient's, um, with a clear chest stats were fine. BP was probably for a young guy. He said that's gonna be okay. Um, but it was a wee bit technic and it was cool and clammy. Um, blood wise, he had small crp rise, normal uni quite substantially deranged liver function, I think obviously that then tends to drive people down the wrong road sometimes. Um, but with a bilirubin of 40 and, and LFTs, as you can see, small troponin rise, um, a positive D dimer as they all do So we've had a lot of the referrals that come to us via A CT PA. So he had the CT PA to rule out A P and it showed um cardiomegaly and the pulmonary congestion as you might have guessed with the title of this talk. So I did have lovely echo images but given how big they are, I could not put them in so you can close your eyes and imagine that this gentleman has a seven centimeter ventricle with an ejection fraction of about 10%. It was pretty catastrophic. Um So that's a pity. They they don't play, but he was referred pretty early to us from his local hospital to see, see you or from CCU to to us quite early, which is good. Um Given his young age, persistent sinus tachycardia and the persistent sinus tachycardia is sometimes if I'm teaching some of the kind of cardiology juniors, it's one of the most worrying things. Um severe left triggers, just the style of dysfunctions. BP was about 9200 at best and his lactate was sort of sitting, I think maybe 234. So I was referred quite early. Um Thankfully, they hadn't really given him any heart failure medication yet, apart from IV diuretics, which was the right move. So we we just dried them out and dry them out and dry them out and didn't try to start anything. But he remained a great concern at the ward level. We did a right heart catheter that we like to do. Um, we love to do these and we just do them on our ward. We've got our own room at the bottom of the ward and we can just sort of do them as we want with. The nurses are trained to operate the X rays. So it's, it's pretty handy actually. So, um as you can see is feeling pressure, filling, pressures are up um with a wedge of 21 is mine or a with eight. Um uh but a very low cardiac output states as you can see. So cardiac output of two and Kartik index of one and the mixed venous oxygen saturations were 34%. So that's incredibly worrying. Um And this was a guy if you remember that kind of walked, walked in off the street. Um and you know, had a clear chest wasn't an overt heart, heart failure in the traditional sense, didn't have crept in his lungs or massive ankle edema. He was, he was, he was entering that kind of sliding cold clammy down that side of the pathway. Initially, we put a blue pump in him. So we did that pretty early. Uh And this probably summarizes what went on over the course of several weeks. But um the blue pump went in and initially felt a good bit better. But unfortunately, he continued to slide. So in that inter max two, sliding an eye on a trip. So his appetite was poor. He lost weight. We had two energy feed him his profusion just wasn't optimal. And in the end, he had a biventricular assist device implanted. Um He spent 60 days in intensive care on the super urgent list. He was a blood group. O so he waited a bit longer for a heart. Um Unfortunately, probably waited longer than we would have expected. But thankfully, he underwent successful cardiac transplantation that was about four years ago and he's absolutely great. Um And he comes to clinic and we see him every six months and he's living his life. So that was a great result. So in summary, he was a DCM, we referred him for genetics and he was a titan gene mutation. So I think ultimately, this was going to happen and this is not something that was ever going to be recoverable. He had borderline cardio cardiogenic shock and presentation and then actually progressive cardiogenic shock during his admission and he required advanced mechanical circulatory support to bridge him to transplant. Um I have this maybe a slightly quicker case. I don't know. Again, stop me from going on too long. Um Have a 56 year old man. He was referred by a local caf lab. Um He was previously fitting well. Um he was a butcher I think worked in locally in Glasgow, had a background history of hypertension. Um It was a non smoker and he presented through the and 80 with three hours of chest pain came to the Cath lab initially. Yes, troponin was very, it was only 40 which um I suppose would indicate to me it was quite early into the presentation, but he had an anterior anterior ST elevation transferred to the Cath Lab on arrival at the Cath lab. His BP was 50 systolic and his lactate was seven. So pretty promptly, the team, we have a sort of a, an ECMO kind of shocked team type thing situation. So I think they put out a call relatively early on into this man's arrival to, to say that he, you know, we, we may need help with him. He hadn't included left me and so his whole left name was completely occluded. Um and that was opened and stented, but unfortunately, he had a blue pump it in, but progressively was deteriorating in front of them. And actually this man had, we had a little MG T in the Cath Lab about him and he had peripheral V A ECMO and started completely conscious. Um He's a cool as a cucumber this guy. So he ended up on peripheral V A ECMO and then adopt intensive care. Um He didn't require it and to be intubated at any point during any of this, he did have multiple episodes of kind of monomorphic and polymorphic ct again, the echo if I could show you it was lovely. And so his LV was quite chunky and hypertrophied. And I think, and actually there was concern was this some kind of underlying infiltrative hypertrophic picture. But um either way his LV was catastrophically impaired with, with a large, large left main stem territory and fart, um, he had an L V O T V T I which is sort of served at Marcus stroke volume, which was, I think less than six. And actually with the Blue Pump Falls was pretty much nothing. I was, yeah, the blue pump was so he was in a bit of a holding pattern really. So he went on peripheral the HMO and some to be the main first Maori infusion. Um he had a kidney injury which recovered nicely on the support. His liver derangement recovered nicely in the support. And we thought after about four or five days, we would try to assess for potential for recovery because I suppose the ultimate aim is to try to get the ECMO out and get the man on the meds. But unfortunately, given how significant the LV infarct was, we weren't able to do that. And he ended up being listed on the super urgent list and underwent a transplant in 48 hours for this poor guy. So he got some pretty quickly. He was a blood group. A maybe it's discharge from hospital day 12. And interestingly, the pathology did demonstrate just substantial myocardial necrosis and there was no evidence of anything else going on. Um I might do one more because I think this is possibly quite relevant and then I'll leave the leave the last one. So that summary for that guy, as I said, extensive left main stem in forked was very shocked on arrival. Um He was stabilized quickly with M C S A period of time allowed for recovery. He wasn't winnable and for the parameters that we were able to measure and, and he was bridge to transplant. In the last case, if I've got time was an 18 year old female that was referred to us by one of the ICU consultants. I think in uh one of the local hospitals. Um she's an interesting one. I think she had no known past medical history. Um no recent travel abroad, she's clearly vaccinated. Um Fitting well girl was at college one week history of abdominal pain, generally unwell sore throat to leg pain and extremely pyrexic on arrival to A and E she deteriorated pretty rapidly in A and E I believe with a metabolic acidosis, high lactate oliguric, very septic. Um She had a CT done to look for the source which showed bilateral renal cortical crucis, but no obvious sepsis. And she was admitted into medical HD you where she had increasing escalating pressure requirements and she received over four liters of fluid with really very, very little response. I think initially in the day, I think if I'm right, she had had an echo done by one of the cardiology team that said her heart looked okay. But certainly the, the intensivist who saw her later on that evening, she was progressively declining. She pulmonary congestion. She had developed plural effusions and she had a fight scan done by one of the, the ICU team and it showed her LV was globally hypokinetic and she had an injection fraction about 20%. Her I D C was standing. It'd again, I had those echoes to show you. But you can imagine. I'm sure other concerns about her. She was quite your pathic. She's hyponatremic. She was some sort of Penick, etcetera and her lactate remained elevated. So given the mixed picture of sepsis and um kind of cardiogenic nature to this picture, she was discussed with us to see if it was somebody that we would want to know about or take and on discussion, we did bring her across to um to assess her, given, given her cardiac dysfunction um on arrival, she was very distressed. She was agitated. She was on a lot of um pressors, she was acidotic and had a high lactate on your acc um on a therapy of 260. Her echo looked quite thick, quite chunky and there was supposed a bit of suggestion with this amount critic process which troponin wasn't very high. So um it wasn't high up there in the, in the in the list of diagnosis. She actually did go on to have a biopsy the next day, which was okay. Um But a swan catheter was floated. Um And despite, I suppose, um uh the the in the set in the setting of severe sepsis, I suppose it's just trying to keep this in mind. So Kartik index was 3.5 which were relatively was reassured about. In the first instance, the STR was low in keeping with sepsis rescue to was low. Um And her filling pressures were elevated. Um So she was intubated pretty quickly. She was on Europe and she required filtering and fluid removal. Her blood, her, she had a biopsy which ultimately came back okay. But her blood cultures, she had a in the Syria, her cardiac index, the consequent day despite um adding in some dobutamine to this mix to try to wean down some of the pressers, her Kartik index remained 2.5 and in the setting of severe sepsis, we thought that probably wasn't um indicated that a low cardiac output state for this in this setting. So the decision was made to support her with a blue pump. Um She underwent a four day period of blue pump support. Her um echo demonstrated almost complete lb recovery. I'd probably say was complete. By the time she was discharged, her blue pump was wind and removed. Um She did remain on uric and unfiltered and initially, eventually she went over to the local renal unit where I believe she's been discharged. Eventually off dialysis. Um So again, a young patient, I suppose that accepted cardiomyopathy and with a very mixed picture of shock. So mechanical circulatory support in the setting of septic shock alone um is not ideal, but I think in this, in this setting, her, her sepsis, the cardiac and 62.5 was low for, for, for, for a very septic patient. Um and the blue pump provided that's like extra level of cardiac support. She didn't require escalation to more advanced M C S. Um And she demonstrated my accorded of recovery and I think I'll stop there. Can you flick through that next case? Helen? It just at the very, very end just looks like like thanks. So the take home messages. So refer early if I suppose it's better if we can avoid M C S. Um And but every day counts on, on this supports because of the complications that build up for the patient's. Um There is a role for specialist cardiac units for cardiogenic shock management of different modalities including central access, pay a catheter, monitoring and experiencing dealing complications. Um I think I stole this slide from one of my colleagues had given a similar talk. But I think if in any doubts call and you know, we can talk it through and we, whenever we take referrals, we discuss them as a team. We don't very rarely does one person make this decision. So usually we, we, we take it away and we think about it and we, you know, we, we can, we can feedback. But I think if you, if you have any doubts or questions or you need, you need to talk a case through, then please give us a shout on the, on the contact details that I had flashed up before. And that's me. That was, that was really interesting. Alison. Thanks. Thanks so much. Um There's some questions in the chat about. Get my own question. At first, I was lucky enough to be with you guys for six months about, I think three years ago and you were doing about uh 20 yard transplants year at that time. And I think you mentioned at the start, you were doing 40 something transplant this year and you were the biggest unit in the UK. So that's pretty impressive. Why do you think it's been such a, a change in your unit to be in to become one of the major sectors in the UK? And, and what does that mean for your outcomes? So I think we've obviously we've had this discussion amongst ourselves as a team quite a bit. I think there, there has been the change in the organ donation law, um which I think has had an uh the opt opt out law, which definitely has had an effect. Um We're getting more referrals. So I think you can't transplant patient if they're not there to transplant. So we are getting more referrals, I think as we get out there more, um we're getting more referrals and therefore them were with more patient's, you know, getting to us the right patient to the right bed. Um We have a pretty, you know, a growing team should have say. So, a growing team of surgeons um appointed a new surgeon in the last couple of years. He came up from Papworth who's brought with him a wealth of experience in D C D transplant, which again is a whole another talk. But um donation after circulatory death and he had sort of been paramount and setting up a service in, in Papworth. And he's brought that expertise to us and we offer both DBED transplantation and we have a D C D retrieval service as well. So, um I think that's probably had an input as well, but it probably a combination of, of more referrals, therefore, more potential recipients, people being more aware of, of us as a service. Um And, and the change in law, I think it would be my, my thoughts on that, but I'm sure other people might have other ideas. It's, it's um it's, our outcomes have been very, very good. Um Are 30 day survival is over 95% I believe. And the 90 day survival, 94% that's our kind of our, our personal figures. So, um I think we're selecting the right people. Um and, you know, and, and have very it's a very labor intensive process as I'm sure you witnessed when you were there. So, these patient's are followed up for life. It's, um, that's been quite hard to suppose to know everybody quite understand that. So we, we, we see them here for, they never get discharged. So, um, the transplant clinic is, uh we have, we started off with one clinic a week and we know I have had to do three a week. And even at that, we're sort of bursting at the seams. They get seen every week for the first eight weeks, maybe. And then they get seen every two weeks, then every four weeks. And so even at a year, they're still being seen maybe every couple of months and they get, I think something crazy like 16 or 20 echoes in the first year as a big lot of work for your echo department. Um We biopsy them usually six biopsies in the first six months. Um which is we do that on the word ourselves. So it's um it's uh you have the exposure to the responsibility to look after his patient's very well afterwards and that responsibility is also to the donor. And so you've got sort of got to people and you know, to think about it as well. So, um yeah, with reversing at the same spots. Good. That's great. And then um memory darn is asking how long the patient's easily weight on the super urgent list. So I actually, I'm in the process of auditing this. Um So it's pretty, I haven't actually finished it yet, but uh because I think what would be really nice to counsel the patient's whenever we're listing them is to be able to give them some indication of how long they might wait. Um So if, if I was a patient, I'd want to know that. So it's really difficult to say. So, the things that influence, I suppose I would answer your question slightly. Definitely by one of the factors that influence how long somebody waits for a transplant. Um So the bigger the patient, the harder it is to find them a heart. Um in simple terms. So uh it very much depends on your, on, on your, on your body size. So 100 and 15 kg male who's 6 ft is gonna wait a hell of a lot longer than 5 ft two female who weighs 50 kg. Um Adding into that is your blood group. So blood group O Zeus for um well, you wait a lot longer than blood group. A is um who can receive heart's from a Sandoz. And um it's a sort of a, it's a national pool lived of recipients. So at any one time, there might be between maybe zero and 10 patient's on the super urgent list across the country and they're all in the same pool. So we don't have, you know, priority over over Scotland if you know what I mean? So so that all the offers will then sort of go through how many patients from the super urgent list. So I would say on average in the current instead of play between a cup sometimes a couple of hours to to a couple of weeks to worst case scenario, a couple of months. But the guy, the young guy who waited 60 days was was was very long, I think on the super urgent list that would be longer than I would have expected. Um Other factors that come into play when you're talking about trying to find donors for patient's is their tissue antibody sensitization status. So, um if you have a lot of antibodies, um HLA antibodies preformed that makes it harder to find you a match and the transplant coordinators that we have here. Absolutely amazing. They do a huge lot of work when the an offer comes through, there's loads of things to think about logistics and order and flights and doing all sorts of stuff. But a lot of the initial part of the work comes and matching the heart's up and may get, they are on the phone in the middle of the night to the tissue type of lab and, and they get reports that then match cross match the potential donor to the to the recipient that we're thinking about and gives us an idea of what they're sensitization and the status would be. And then what the risk would be. Um And if the patient's are very healthy sensitized, which tends to happen if they've had previous cardiac surgeries or multi paris females, or the other ones, I've seen quite a lot of sensitization are definitely patient's who are congenital, patient's who've had, have, who've had a lot of surgeries before, can be very highly sensitized and sometimes can be so sensitized that that transplantation is not feasible. Um But then if that, if that answers your question, I would say in reality, you would like to hope on the super urgent list. You could, you could get them a heart within a couple of weeks, but, but we would never promise them that great. That's very, that's fine. That's excellent. Um There's no more questions in the group chat and if I don't have any more questions, that was really thorough talk. Thanks very much Allison. Um I'll just pass over to Helen to uh to sign off. Thank you Duncan and thanks Alison um for such a comprehensive talk. It's just good to have a insight into something that's super specialized. Um I just wanted to let everyone know, firstly, there's a feedback link in the chat and that's where you can get your certificate for people that have missed this. Um They can watch it back so you can let them know that. Um And our next talk is on 22nd of June and that's from Lucy Fleming from Aberdeen Royal infirmary, who's going to give us an update on ECMO. And so hopefully we can see you all then put that in your diary. Thanks everyone for coming in. Thanks again, Doctor Smith, by everyone.