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.