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Heart transplants: less invasive for a new lease on life
In the interviews published in International Hospital, we focus on a particular field of expertise to find out about current developments. We spoke to Susan Vosloo, specialised in Cardiothoracic Surgery, working in private practice at the Christiaan Barnard Memorial and Vincent Palotti hospitals in Cape Town, South Africa. She talks about the developments and future trends in cardiology since the first heart transplant in South Africa in 1967.
Q. How has technology in cardiology improved over the last 40 years?
Without a doubt, technology has become more accurate, and yet less invasive. In the past, cardiologists often had to do an angiogram to accurately define complex defects, but now adequate information can be obtained with echocardiography to detect congenital and acquired cardiac defects. We can identify problems much more accurately without an insult to the patient which is critical, particularly, for small babies.
Surgical techniques are designed for most cardiac abnormalities, and, consequently, the results obtained are much improved. This means that mortality rates have fallen over the years. There had been a shift from measuring success not only as survival, but in terms of quality of life, which has led to a better quality of survival for the patient.
When we speak about evolution, it has to be mentioned that the progress in the field of trans-catheter valve insertions, in some cases, means that patients do not require surgery. A severely ill patient can avoid a major operation thanks to this.
Q. What type of research has been done over the last decades?
All over the world, many programmes have ongoing research projects on various aspects of congenital and acquired cardiac diseases, as well as transplantation and alternatives to transplantation, like mechanical circulatory support.
Q. Has there been an evolution in the science of heart transplants?
Much progress has been made in the field of immuno-suppression. It is paramount to prevent rejection of the organ at the lowest risk infection. Finding this balance is the biggest challenge. Fortunately, newer drugs assist us to find this balance, and also have reduced the risk of other organ dysfunction. Today, cardiac transplantation with a positive outcome is much more likely than in the past.
In South Africa, we have a small community and therefore we also perform small numbers of transplant operations annually. Unfortunately, there has been little technological progress since Dr Christiaan Barnard transplanted a heart in the 1967. The indications for heterotopic heart transplantation (in other words, piggy-back procedure), with less favourable results, are scarce as other options are available to these patients.
Especially in Germany, the UK and the USA, with their larger populations, research in xeno transplants are much more common. This is where organs are transplanted from a different species, like pigs and baboons. Pigs are being genetically manipulated and bred to alleviate the shortage of organ donors.
Q. Is there an alternative?
There is another option too for patients who deteriorate due to the worldwide shortage of organ donors, namely mechanical support. If a programme does not have enough donors, an alternative may be mechanical support.
I am thinking of the Berlin Heart which was was the most used device for a long time. This entails extra-corporeal pumping chambers of significant size. The disadvantage is that the patient remains confined to hospital. Nowadays, there are other newer devices include the Heart Mate (developed by Jarvik Labs) or Heart Ware devices, which use smaller, implanted impeller pumps to maintain adequate circulation. Due to smaller driving cables being inserted into the body, the infection rate is consequently also much lower.
Mechanical support was always seen as a bridge to transplantation, but that is no longer the case. Smaller devices are now seen as destination therapy. This potentially will lower mortality rates on cardiac transplant waiting lists.
Q. What are the trends you have seen in cardiology?
A sub-speciality is emerging in paediatric cardiology called GUCH (grown-ups with congenital heart disease). Worldwide the number of older and younger adults over the age of 18 years with congenital heart disease has now exceeded the number of children younger than 18 years.
This is quite understandable as children with congenital heart disease in the current era have survived corrective surgery and grown up. This means that they will need specific care later in life. However, there is a gap between paediatric and adult cardiology, and, for this reason, this new discipline will have to be filled in specialists from both disciplines.
Q. What is the current state of cardiothoracic surgery in South Africa now?
South Africa hovers between the first and the third world. In the first world (such as the USA, UK and Europe) children with congenital heart disease get immediate and appropriate care. In the third world (such as Africa and parts of Asia), there is no or very little support to have these heart defects corrected. In South Africa, we have the added problem of logistics. There may be a hospital where help can be provided, but the patient may live in a rural area with little or no transport to the hospital and cannot get to the hospital on time or at all. This is still a big problem in South Africa today.
Having said that, there is so much potential in the first world to reach out to the third world in this respect. For instance, organisations like Chain of Hope, Heart Link and Heart to Heart do wonderful work in this regard.
Q. Tell us about your involvement with the World Congress: Paediatric Cardiology and Cardiac Surgery.
As the chairwoman of the organising committee of WCPCCS, I am very much involved in different aspects of this congress which will be held in Cape Town in February 2013. The World Society for Pediatric and Congenital Heart Surgery (WCPCHS) is the first global surgical organisation of its kind; it was established a few years ago. It is an international society that brings all congenital heart surgeons all over the world together. On the following websites, one can find the progamme and also register. Go to www.wspchs.org or www.wcpccs2013.co.za
Q. What can a participant attending this congress expect to gain and learn?
We are offering an outstanding faculty which makes this a great scientific event that can also be attended by health workers caring for less privileged patients all over the African continent.
Q. What do you still hope to achieve in your career?
At this stage of my career, I wish to continue enjoying providing my services to society, always striving to improve patient outcomes, and continuing to train those who will do this for the next generation.
Q. A final word?
We as humans have a limited time on earth, but it is important, I believe, that we leave a contribution to the universe, in the way one works, brings up your children, everything really. My motto is to do everything possible to leave the world a better place, however small my contribution may be.
European Respiratory Society 2012: Every breath counts
The annual congress of the European Respiratory Society (ERS) took place in Vienna, Austria, 1-5 September 2012. Some highlights of the scientific programme are presented below.
Multidimensional approach to non-cystic fibrosis bronchiectasis
One of the leading experts in the field of respiratory infections, Miguel Angel Mart
Quo Vadis, ICU?
International Hospital asked experts from Belgium, the United States of America and Switzerland on the subject of finding the most optimal solutions for intensive care in a climate of austerity where the cost of healthcare is constantly rising and budgets are shrinking. They share their views on the question: Given the cost of healthcare, shrinking budgets and other challenges, what is the the most optimal way forward for intensive care?
CRITICAL CARE SUFFERING THE MOST
Shambhu Aryal, M.D. and Enrique Diaz-Guzman, M.D., Division of Pulmonary, Critical Care & Sleep Medicine, University of Kentucky, USA
We live in an era where healthcare is very exciting, but, at the same time, faces challenges it has rarely seen before. There are new discoveries and inventions every day, evidence-based medicine is at its best, patients are sicker than ever before and healthcare costs are the highest ever; yet we are faced with one of the worst economic situations, shrinking budgets, shortage of human resources and increased expectations from both the community and the government. The cost of healthcare has steadily increased over the last few decades. In the United States for example, the total per capita healthcare expenditures have increased 560% since 1980 [1]. Healthcare costs now comprise over 15% and 10% of the Gross Domestic Production of the United States and most European countries respectively [2]. Intensive care medicine, being a resource intense specialty, consumes a significant proportion of these healthcare expenditures [3]. This cost can be expected to continue to rise for several reasons: (i) an aging population; (ii) a rise in uninsured and underinsured population; (iii) use of newer and more expensive drugs and technology; and (iv) specialisation of care.
There are several other challenges to healthcare. Despite rising healthcare costs, the budget for healthcare is shrinking in most countries. There is also a concern that amid the economic recession, healthcare research funding is suffering a dramatic cut. Moreover, due to the painstaking and expensive nature of healthcare training, fewer and fewer people are opting for healthcare as a career choice; in many situations, the number of people entering the workforce is smaller than the number retiring [4].
Critical care medicine is, unfortunately, suffering the most. Despite its significant role in providing high quality healthcare and reducing healthcare costs for over half a century, Intensive Care Medicine still struggles to get the needed attention. The proportion of federally funded research dollars spent on critical care is significantly lower than the percentage of dollars spent delivering that care compared to other specialties in the USA [5]. Moreover, it is expected that there will be a huge shortage of critical care providers in the near future, but little has been done to address this issue [6].
There are several ways we could work towards addressing these challenges in healthcare in general and intensive care, in particular. One important approach is to diminish the unnecessary variation in care that exists across regions, hospitals, and providers [7]. There are several ways this could be done: better standardisation of care practice through protocols and care pathways; standardisation of the ways ICUs are organised and managed; use of evidence-based practices; avoidance of laboratory and radiological tests that have little utility in patient management; use of generic versus name brand drugs, and use of conservative transfusion practices [8]. Mechanical ventilation is associated with not only chances of increased complications, but also significant higher daily cost. Consequently, interventions that result in its reduced duration could lead to substantial reductions in total inpatient cost [9]. Similarly, since end-of-life care consumes a large proportion of ICU costs, a better focus needs to be put on judiciously reducing this cost without compromising the quality of end-of-life care through identifying terminally ill patients and instituting palliative rather than restorative care [10]. This would also mean better communication with patients and families to enable them to make more informed decisions. At the same time, measures to close the ever increasing gap of the need versus availability of ICU staff including physicians, nurses, respiratory therapists and pharmacists through a more attractive training and job environment should be sought and implemented. And finally, the importance of arranging better funding for research in the field of Critical Care cannot be over-emphasised.
References
1. Smith C, Cowan C, Heffler S, Catlin A. Health Aff (Millwood) 2006; 25: 186
POC testing in resource-poor settings: using diagnostics outside of traditional setting
Point-of-care testing has long been promoted as the next major advance in diagnostics in high income countries. Their potential has not yet been realised in these market, but their impact on resource poor settings could transform the lives of millions of the world
Three-dimensional echocardiography in clinical practice
Echocardiography has become an integral part of modern cardiology. Being non-invasive, it is useful in assessing ventricular size and function, diagnosing and evaluating valvular disease, and investigating chest pain, possible cardiac emboli and congenital heart disease. Recent advances in non-invasive imaging of the heart with three-dimensional echocardiography (3DE) have simplified our understanding and management of heart diseases. Transthoracic 3DE provides an easier, accurate and reproducible interpretation of the complex cardiac anatomy. It provides unprecedented views of cardiac structures from any perspective in the beating heart helping in clinical assessment of cardiac pathology. One major advantage of the third dimension is the improvement in the accuracy and reproducibility of chamber volume measurement by eliminating geometric assumptions and errors caused by foreshortened views. Another benefit of 3DE is the realistic en face views of heart valves, enabling a better appreciation of the severity and mechanisms of valve diseases in a non-invasive manner.
by Dr Shantanu P. Sengupta
Real time three-dimensional echocardiography (RT3DE) has been a major advancement in the field of cardiac imaging. Advances in the acquisition, storage and analysis of RT3DE images have made its use increasingly common in echocardiography laboratories, not only for research purposes, but also in daily clinical practice. The technique provides a good spatial and temporal resolution of images of the heart. Also, adding the fourth (time) and the fifth dimension (functional assessment of the cardiac structures) is now possible due to recent advances in this field of cardiac ultrasound.
Usefulness of 3D echocardiography
The first 3DE images of the heart were obtained by Dekker et al in 1974 [1]. Since then, various 3D systems have been developed based on a reconstruction of acquired two-dimensional images (2DE) synchronised to the electrocardiogram and respiratory motion. This tool has contributed valuable information on cardiac anatomy and function. However, due to the lengthy image-processing time required, its earlier use was clinically limited to a few echocardiography laboratories and the research arena.
The recent development of matrix transducers with more than 3000 crystals along with new processors has led to the acquisition of real-time images without the need for off-line reconstruction. These new advances have allowed the application of 3DE to daily clinical practice [Figure 1, 2].
Three types of images can be acquired with 3DE: near real time, full volume images; real time (