ACTACC Project Grant

What are we looking at?
Cardiogenic shock (CS) is a term used to describe deterioration of the pump mechanism of the heart such that it cannot provide sufficient blood flow to the rest of the body. Historically, drugs were used to help the heart pump until it showed signs of recovery. In the last 5 years, temporary mechanical pumps, which substitute the function of the heart while it recovers, have been used with promising results. Research studies suggest that the faster CS is recognised and the heart supported (by drugs or pumps) the better the patient outcomes.

Why are we looking into this?
In 2015, 7% of patient safety incidents in the NHS were related to a failure to recognise a deteriorating patient or act clinically. Many hospitals have developed systems to improve the recognition and response to deterioration in severe infections but there does not exist a similar infrastructure for CS. Moreover, the complexity of both patients and therapies, including temporary mechanical pumps that support the heart, continues to increase.

The decision to support a patient with a pump is complex, not least because there are numerous devices available. Although mechanical pumps can be life-saving, they are costly, incur complications and do not work in everyone with CS. By contrast, some patients who present with CS have irreversible chronic heart failure and may be best served by avoiding invasive, life sustaining therapies and technologies. Such multifaceted decision-making requires clinicians from different specialties to have a discussion at very short notice, often in the middle of the night and within minutes of being alerted of a deteriorating patient with CS.

Current response systems to CS in the NHS are logistically challenging and highly inefficient, requiring multiple, time consuming phone calls. Whilst systems like CS teams exist internationally, there is little research to confirm the best structure of the CS team and the discussion process and minimal data suggesting that they benefit patients.

How do we plan to do this?
We plan to identify a team of specialists who are available 24/7 to discuss CS patients at Barts Heart Centre. In parallel we will install a telecoms service that overcomes current inefficiencies to allow this team of specialists to be alerted and discuss optimal patient management via an immediate multi-disciplinary conference call. We will then collect data to identify the best structure of the team and conference call as well as whether this system benefits patients with CS.

How will the project help?
The data generated from this project will hopefully support idea that the combined interventions of establishing a designated multidisciplinary team to manage patients in severe CS as well as the introduction of a telecoms service that allows immediate multi-specialty conference calling in emergent situations will improve care in CS. The study will collect data to identify the key elements of the team, the multidisciplinary discussion process as well as the efficiency of decision-making and implementation of best care.

Introduction
Lung cancer is the second most common cancer in the UK and is the leading cause of cancer related death. Where appropriate, surgery to remove the tumour and the surrounding lung (lung resection) provides the best chance of cure. Frequently patients are either current or ex-smokers with related lung or heart problems which increase the risks associated with surgery. Following surgery patients may suffer long term shortness of breath, greatly limiting their day-to-day function and lowering quality of life. This shortness of breath is not solely caused by the removal of part of the lung but also from a decrease in the performance of the heart. Although the surgery does not directly involve the heart it is thought that the damage is caused indirectly by the surgery and by the removal of part of the lung.

Function of the heart following lung resection
In a previous study our research group showed that the function of the right side of the heart (the right heart) is decreased following lung resection. The decrease in right heart (the part that supplies blood to the lungs) function was associated with a prolonged stay in the high dependency unit and blood markers indicating damage to the heart. The process by which the damage occurs is poorly understood, but it is thought that an increase in the forces preventing the right heart pumping blood (resistance) is to blame. The decrease in function in the right heart may be caused during surgery by the diminished blood supply to the cancerous lung and, post operatively, as lung resection can cause a long term increase in resistance.

Diseases that cause an increase in resistance to the right heart have been shown to cause damage to different parts of the right heart. An acute increase in resistance can cause inflammation, thinning and scarring whilst a long term increase in resistance causes the right heart to thicken. We believe that the potential damage during the operation will cause permanent damage to the right heart and contribute to shortness of breath and functional limitation.

To investigate the potential inflammation/scarring and the function of the heart we will image the heart with specialised MRI scans. We have used this technique in our previous study with over 80% of patients "easily tolerating the scan" and 84% happy to participate in future research.

Aims
The aim of the research is to determine whether damage occurs in the right heart during and following lung resection and, if so, does it result in scarring. We will compare the function of the right heart before, during and after surgery to determine if the inflammation causes the decrease in right heart function following lung resection. We anticipate that the study will increase our understanding of how the right heart may be damaged by lung resection. We believe this will guide further studies aiming to prevent such damage, ultimately limiting the disabling breathlessness and decrease in heart function that so greatly affects patients' lives.