Interviewed by Katarina Zorcic and Christopher De Luca
Can you tell us what you do as an epidemiologist?
Dr. Alba: I do research mostly on prognosis and outcomes, specifically related to heart failure and mechanical circulatory support. For example, I look at ways to predict a prognosis using accurate models, what factors are associated with certain clinical outcomes, and whether a patient’s characteristics are associated with good or bad transplant outcomes. I also conduct some research specifically on educating physicians on how to read papers on these topics, how to report findings using specific methodologies, and how to improve the quality of certain tests.
What inspired you to specialize in studying heart organ transplants and heart failure?
Dr. Alba: I find heart failure a great topic to study because it has a wide variety of patients – sometimes you treat patients who got sick very rapidly and other times you treat patients who have been gradually getting sicker for many years. You help them [the patients] make decisions throughout their journey. You can see the impact of your care very rapidly in patients with an acute disease. Patients with chronic diseases are very interesting as well, especially for conducting research. The only disadvantage is that evaluating the impact takes a little bit longer. But I think the combination of acute and chronic care makes it a very fun specialty.
How do you work with other medical professionals, such as transplant surgeons and cardiologists, to ensure the best possible outcomes for patients undergoing heart transplantation?
Dr. Alba: In general, I think that in an academic environment, you work with a lot of different specialties. When you specialize a lot, you know a lot about a specific problem, so we aim to work as a multidisciplinary team for two reasons: (1) to care for the patient in the best possible way, using all of our resources and (2) to get advice from other physicians on topics we don’t know much about. We are very lucky; we have a great team. Our small heart failure team has good communication with ICU surgeons.
Can you tell us a little more about the differences and pros and cons of patients undergoing heart transplantation or mechanical circulatory support?
Dr. Alba: These two interventions are very high risk – they involve a high-risk, open heart surgery where your body is connected to a bypass machine. In general, the average population will live longer after undergoing a heart transplant. So that’s why we do it. Unfortunately, it’s not a cure and some patients are not candidates because of the strict selection criteria. For example, patients who have high blood pressures cannot have a heart transplant because the heart will fail. But we know that if they have a mechanical heart for some bit of time, those pulmonary pressures will go down in 99.9% of cases, and then they can undergo a transplant. Also, heart transplants have the disadvantage of requiring immunosuppressive medication, which can make patient outcomes worse with other underlying comorbidities, such as cancer. However, patients on a mechanical heart don’t require immunosuppressive medication. Overall, we always try to prioritize heart transplants as the long-term outcomes are much better for heart transplants than for patients with mechanical hearts. So if a patient is a candidate and doesn’t have any absolute contraindications, we will proceed with a transplant. Another drawback to transplants is the waitlist. Sometimes patients don’t have the luxury of time. In that case, we put the mechanical heart to make sure that the body is very well perfused and then we proceed with transplants. So we choose mechanical hearts over transplants when the patient is not going to survive to transplant, has a contraindication, or is not a transplant candidate.
How do you think advancements in organ transplantation have impacted the field of heart failure management?
Dr. Alba: There have been a lot of advancements in heart transplants, and care is changing a lot. We still have a lot to learn. One of the important problems in heart transplants is rejection. Patients are kept on immunosuppressive medications to prevent rejection, but the higher the doses of immunosuppressive medication, the higher the risk of complications, toxicity, and side effects. So there is a lot of research to try to minimize immunosuppressant use in vulnerable patients. The other problem we see is that the arteries of the heart are a very vulnerable target. One of the main causes of death in the general population is heart disease – at least 50% of which are related to the arteries of the heart. There is a lot of research to try to treat proteins in the arteries of transplanted hearts to prevent cardiac allograft vasculopathy.
How important is it to encourage organ donation?
Dr. Alba: I think that it’s super important, especially since there is a huge shortage of organ donors. I have specifically talked to groups in community settings about problems in the field. There is probably a lot of misunderstanding about providing your organs for research and that they are going to be misused. I think educating the population about the impact of donation and the advances that are being made by doing research on donated organs is very important. I don’t know if many people know that one person can save eight lives at the time of their death. I also think that it’s very important to intensify or to spread that message to the younger population, especially those in high school and university, while also hearing their concerns and misunderstandings to try to break some myths.
Looking to the future, what advancements in heart transplantation or heart failure management do you see on the horizon?
Dr. Alba: Currently, we perform organ donations after we declare brain death. But once a patient dies and is not brain dead, how we can still use those organs? That’s a huge body of research, and in Australia and England, they are doing these types of transplants where the heart is taken out of the body after circulatory death. Additionally, there is a lot of research trying to understand a new concept: tolerance. There are many mechanisms that trigger and increase tolerance in our immune system to prevent a rejection response. There is a lot of research in this area to try to reduce the use of immunosuppressants. There is also a lot of research concerning mechanical hearts – trying to increase the longevity of these hearts and the life of the batteries. Finally, there is a lot of research on trying to make patients with heart failure live longer so they don’t require a transplant until later on in life or if it’s absolutely necessary.
Organ Advocacy Initiative 