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Joey Wahler (Host): They can save lives. So, we're discussing heart transplants. Our guest is Dr. Benjamin Mackie. He's Co-Chief of the Heart and Vascular Institute and Medical Director of the Heart Transplant Program at Tampa General Hospital. This is Community Connect: presented by TGH. Thanks for joining us. I'm Joey Wahler. Hi, Dr. Mackie. Welcome.

Dr. Benjamin Mackie: Hey Joey, how are you doing? Really appreciate you inviting me on the show today.

Host: Excellent. So first, can you explain for us, Doc, in a nutshell, what the specialty of yours of advanced heart failure and transplantation is? What's it all about?

Dr. Benjamin Mackie: You know, within medicine there's multiple different specialties and then subspecialties. And advanced heart failure and transplant is a subspecialty within cardiology. And our clinical focus is to take care of patients who have heart weakness or a condition that limits their heart's ability to perform the level of work needed for people to get through their day-to-day lives.

And, you know, heart failure is a very, very common problem in America. It's one of the most common cardiac diagnoses that people carry and associated with a lot of hospitalizations and people not feeling well and things of that nature. There's a spectrum of disease within heart failure. And the focus of my specialty is really on those patients that have advanced end-stage heart failure, and really trying to help usher them through the different therapies that we have to prolong their life and improve their quality of life.

Host: Absolutely. So speaking of which, what in a nutshell is heart failure? What's usually going on there specifically for those that are unfamiliar? And what are some of the common causes?

Dr. Benjamin Mackie: So, heart failure, I think people most commonly associate the term heart failure with people who have heart weakness, meaning that, you know, your heart is a muscle and that muscle can weaken because of many different circumstances or conditions, which we can discuss in a little bit more detail here in a second. But if the heart weakens as a pump, then it's not able to pump enough blood to the body in certain cases. And when that happens, people are quite sick and we need to do something to intervene and help the heart or, in extreme cases, replace the heart with heart transplantation. There are many other conditions that can also lead to heart stiffness. That's about half of the cases of heart failure. So, we would call that heart failure with preserved ejection fraction where heart weakness is heart failure with reduced ejection fraction. The most common cause of heart failure with reduced ejection fraction is coronary artery disease or when people have blockages in their arteries, plumbing problem with blood flow to the heart, they have heart attacks, they end up with muscular damage to the heart. And then, the heart is weakened in that respect.

For heart failure with preserved ejection fraction, those are usually patients that have longstanding high blood pressure, diabetes, things of that nature, that over time contribute to stiffening of the heart muscle.

Host: And so, what are the usual symptoms of heart failure?

Dr. Benjamin Mackie: Most commonly, shortness of breath and, in many cases, some fluid retention. So, swelling in the legs, swelling in the abdomen, overall fatigue. But usually, the hallmark symptom would be shortness of breath, particularly with exertion. So when people are performing physical activity of any sort, they notice some limitations beyond what they would expect if they had normal cardiovascular health.

Host: And how about some healthy habits that can decrease the chances of developing significant heart disease?

Dr. Benjamin Mackie: So, that's a great question. And I will also add that I don't think that we spend enough time focusing and discussing prevention. We spend a lot of time talking about treatment. But at the end of the day, I think the successful path forward for our patients and our population in general is to try to prevent these things from happening in the first place.

So, heart failure is consequence usually of other heart diseases. So if we take blockages, which I mentioned here recently, how do we prevent somebody from having a heart attack in the first place, which can lead to heart failure. So, that's going to be some lifestyle habits such as exercising regularly, eating well. We usually recommend the Mediterranean diet, not smoking, not consuming large amounts of alcohol, seeing your primary care doctor; getting your blood pressure checked, making sure that is well-controlled; having your cholesterol level checked, and making sure that those are within range, as per the guidelines that we have with American Heart Association. And if you do those things and you do those things from an early age, you know, the chances that someone goes on to develop clinically significant heart disease gets decreased substantially.

Host: So, let's talk transplants. You mentioned at the top of the conversation that, unfortunately, heart failure is very common. How common are heart transplants in the United States, and what's the usual expected survival rate for those that have one?

Dr. Benjamin Mackie: Yeah. So if you look at all heart failure patients, somewhere around 5% to maybe 7% of those patients would meet criteria to be labeled as truly advanced heart failure patients. And within that patient population, transplant is a therapy that we rely upon heavily. I would tell you it's a therapy of last resort. We want to make sure we've exhausted our ability to try to recover heart, strengthen those patients to the best of our ability. And despite all of our best efforts, patients have progression of their disease and they reach true end-stage heart failure and have failed all other options. And those are patients in whom we consider heart transplantation.

 Survival post heart transplant is quite favorable. So, on average 14 to 15 years and many times longer, sometimes shorter, kind of depending on if the course was complicated or not. And some other factors, primarily immunologic factors and how adherent we're able to be to the medical regimen post-transplant, which is relatively complex and extensive. From a standpoint of how common are heart transplants, so in America, every year there's 4,000 to 5,000 heart transplants done. So, we do operate in somewhat of a donor-constrained environment, which we're working through as a heart failure community, trying to find ways to have more hearts available, to help the patients who end up needing a heart transplant.

Host: And so, having said that, Doctor, what's the biggest challenge in caring for a patient that's on the waiting list? They're obviously in a vulnerable situation health-wise. What's the key to getting them through that, both physically and emotionally as well?

Dr. Benjamin Mackie: I think, first and foremost, the earlier that patients get to us, so if someone is labeled as having advanced heart failure by their primary cardiologist, the earlier we're involved in their care, the more likely, we are to be able to successfully usher them through their journey with heart failure.

And in those cases, where patients do end up requiring a heart transplant and do end up on the wait list, the care becomes pretty intense and is very, very hands-on at that point. About 75% of our patients that successfully get transplanted at some point end up in the intensive care unit here at TGH, where we're doing day-to-day management of those patients to ensure that they're clinically stable, and ready to go for a heart transplant surgery at any time.

I think the second part of your comments around what do we do to emotionally support the patients is really important. It's really a tough journey for these patients. They're in a life or death situation. Not a lot of creature comforts here in the hospital and in the intensive care unit setting. So as you can imagine, there's a lot of just day-to-day conversations. You know, we treat these patients like family. We grow very close to them and I think they grow very close to us. We have teams of people that provide emotional support. We have an integrative medicine team that comes and helps patients with finding some things to do to pass the time while they're waiting here in the intensive care unit. So, it's definitely something that we focus a lot on from an emotional standpoint

Host: Couple of other things. Any way to tell, generally speaking, roughly how long the average recipient might have to wait?

Dr. Benjamin Mackie: Absolutely. So, this is a very data-driven space as you can Imagine. Both from a standpoint of how long do we think someone's going to have to wait for a heart to how well are they going to do afterwards? And tracking and trending multiple different data points to inform those conversations and decisions.

It's really dependent upon a number of different factors. So, when we do a heart transplant, there's a few things that have to happen for that to work. Few big things. One, they have to be ABO compatible. So from a blood typing standpoint, you have to have compatibility, the donor and recipient have to be immunologically compatible. There's multiple different antibodies that we all have. Some people have higher levels than others, And we have to match those as well. And then, we have to match size. So, we can't take a heart from a really, really small person and put it in a very, very large person. It won't be able to do the amount of work required in that larger body.

So based upon all of those things, we're able to calculate on average how long someone's going to wait for a heart at any given clinical status on the transplant list. And that can range from weeks to months to days to weeks, depending on how those factors are coming together in each case.

Host: And in summary here, Doctor, what benefits can patients typically expect post-transplant? And what's the recovery like?

Dr. Benjamin Mackie: The benefits are profound. It's a transformational therapy when it goes well, which is the vast majority of the time. And these are patients that are literally on desk doorstep oftentimes, leading up to their transplant. And they go and have their transplant done. And when all goes well, they're usually up and walking around within 24 hours and generally out of the hospital in around two weeks. And they feel like new people. They can breathe again. They have energy again. They can walk around without limitation. Obviously, they're recovering from complex surgery, but they're back up on their feet. And then, usually within six weeks, they're driving again, doing most of what normal people do. And at three months, for the most part, we consider them to be fully healed. And then, other than surveillance for rejection and infections and having to take their medications every day, they go on to live very normal lives.

There's something called the Transplant Olympics that's done every year. It's an international type of thing. Many of these patients go on and compete in events that require high levels of cardiovascular fitness and do great and feel great, and it's a really wonderful thing to see happen.

Host: Wow. So, walking within a day and going home within a couple of weeks. I guess last question for you, Doc. On one level, what you and yours do along these lines is, fortunately, somewhat routine nowadays, but on another, even after all these years of it being done, if you take a step back, I would imagine even for a professional like yourself, it's really pretty amazing, isn't it?

Dr. Benjamin Mackie: Absolutely. I think the historical journey of, heart transplant is really an amazing one to read about. I think it's really a testament to not just physicians, but scientists and many, many other people always striving to push the boundaries of what's possible. At one point, people thought this couldn't be done right? And we got it figured out in the early '80s and it's just improved, you know, dramatically even since then. But I think solid organ transplantation in general is just a very, very impressive feat, I think, of the medical profession.

Host: Yeah. I mean, it's really got to still be one of the medical marvels that exists. So certainly, always interesting to hear someone like yourself that's involved in it on a daily basis. Well, folks, we trust you're now more familiar with the remarkable world, really, of heart transplants. Dr. Mackie, keep up all your great literally lifesaving work, and thanks so much again.

Dr. Benjamin Mackie: Thank you, Joey. I appreciate the time.

Host: Absolutely. Same here. And for more information, please do visit tgh.org. And if you enjoyed this episode, please do share it on your social media, and be sure to like, subscribe, and follow Community Connect: presented by TGH on your favorite podcast platform. I'm Joey Wahler, and thanks again for being part of Community Connect: presented by TGH.