Innovation

Specialists at Royal Brompton and Harefield hospitals are using 3D imaging and printing to create exact replicas of patients’ hearts to help them plan and carry out surgery.  

The technique requires specialist cardiovascular magnetic resonance (CMR) imaging, which uses powerful magnets and radio waves to take detailed pictures of the heart.

Every CMR scan produces hundreds of images that are stored and displayed using advanced computer software, to create an exact three-dimensional digital replica of the human heart. This means experts can view the heart’s structure, including the muscles, chambers and valves, in a particularly lifelike way, to assess how well the heart is pumping and quickly diagnose a variety of problems, including:

• congenital heart disease
• wear and tear of heart valves 
• any other damage to the heart.

Now experts at Royal Brompton and Harefield hospitals are going one step further and using 3D printing to turn the digital replica into an actual exact model of a patient’s heart. 

How is 3D imaging and printing used?

Dr Sonya Babu-Narayan, honorary consultant cardiologist and British Heart Foundation Imperial College clinical senior lecturer, is interested in the role of CMR in preventing and treating heart rhythm disturbances in patients born with congenital heart disease, as well as using 3D imaging during invasive heart procedures.

She says: “The availability of 3D modelling when preparing for and performing heart surgery or other cardiac procedures allows two really important things to happen. 

“Firstly, surgeons and other clinical team members are able to better grasp how a patient’s heart is affected by their condition. This leads to better care and allows us to diagnose and repair conditions with less need for invasive diagnostic procedures. 

“Secondly, a 3D model can be a huge help with the communication between the clinical team and the patient. A 3D visual representation of the heart is so much clearer than anything we could put in to words. 

“We can even go one step further and get the model 3D printed. Seeing and handling an actual model of their heart can be so much more informative than two dimensional drawings or other images.

Another advantage of printing a 3D model of the human heart is the opportunity to improve training. Heart disease comes in many different forms and the more cardiologists can learn about the structure of hearts with these problems, the better they will be able to treat them.

Ground-breaking innovation: scarring of the heart

The 3D programme at Royal Brompton and Harefield hospitals, supported by biomedical engineers Materialise, has also done something that no other hospital in the world has done, which is to print hearts that also show regions of scarring. 

Scarring, often caused by heart disease or surgery, is one of the reasons that patients may have life -threatening arrhythmia, a condition where the heart is beating too fast, slow or irregularly. 

At Royal Brompton Hospital, using 3D modelling, consultants and surgeons can gain a better understanding of what kind of scarring causes different types of arrhythmia. 

This research is invaluable for improving treatments for patients with arrhythmias in the future. The aim is to prevent patients from requiring a defibrillator as a precaution and to only implant the lifesaving device when it is certain they need one.

Experts at Royal Brompton and Harefield hospitals were the first to pilot a revolutionary microchip that measures how well a patient’s heart is functioning

Designed for patients with chronic heart failure, the sensor, known as the CardioMEMS™ HF System, is implanted during a minimally invasive procedure using a cardiac catheter, a thin tube that is passed up to the heart through a vein in the leg. The miniature wireless sensor is inserted into the pulmonary artery (the main blood vessel carrying blood from the heart to the lungs). 

Once in place, the device – which has no battery or replaceable parts – enables clinicians to remotely monitor changes in blood pressure in the pulmonary artery, which is a good indicator of worsening heart failure.

Monitoring from home

Each day patients lie on a specially adapted pillow for a few minutes. The pillow receives data wirelessly from the implanted sensor and is connected to a monitor that sends the readings directly to the patient’s doctors. The hospital heart failure team then analyse the readings and determine if they need to adjust treatment. This is likely to be before the patient experiences any symptoms and can prevent a potentially life-threatening deterioration.

With around 900,000 people living with heart failure in the UK, cardiologists hope the device has the potential to improve management and treatment for many patients. 

Significant impact on patient care

Results from a randomised controlled trial in the United States, which were published in The Lancet, showed the sensor reduced hospital admissions by an average of 30 per cent after six months, compared with a control group. 

Professor Martin Cowie, consultant cardiologist at Royal Brompton and Harefield hospitals, says:

“With this device, patients can send regular information back to their heart failure team easily and from the comfort of their own home. This will help us detect any worsening in cardiac function early and take steps to prevent it, before patients experience a decline in their health.

“It will also provide a better way of deciding whether patients are having the best treatment, allowing us to take a more tailored approach for each individual patient.”

The hybrid theatre at Royal Brompton Hospital, which was built with £4.2 million funding from the Royal Brompton & Harefield Hospitals Charity, combines the environment of an operating theatre with the imaging capabilities of a catheter laboratory.

The facility is the largest of its kind in Europe and incorporates the most modern theatre equipment found anywhere in the UK. The advanced imaging technology, operating table and integrated computer software work together, which means operations can be planned in advance in unprecedented detail.

The operating theatre enables doctors to carry out different procedures for a patient in the same session, rather than interventions being staged over a period of time and several hospital visits. 

Patients spend less time in hospital, benefit from shorter recovery times and experience less pain and scarring.

Combined cardiac procedures that involve both a surgical and transcatheter approach (a thin flexible tube inserted into an artery via a small incision in the groin, chest or shoulder) are available to a greater number of patients. 

The facility means the Royal Brompton and Harefield hospitals' expert surgeons and interventional cardiologists can offer more minimally-invasive procedures, for example, coronary artery bypass graft (commonly known as heart bypass) with coronary angioplasty, which involves inserting a stent via a catheter to treat a blockage in the artery.

Dr Richard Grocott-Mason, medical director at Royal Brompton and Harefield hospitals, explains:

“The hybrid operating theatre provides our specialist teams with the latest cutting-edge technology and means current and future patients will benefit from pioneering treatments. It supports our ongoing commitment to deliver a multidisciplinary approach to patient care and offer world-class specialist treatments that are not widely available elsewhere.

“As our experts continue to push boundaries and carry out increasingly complex procedures, patients will be provided with greater choice and have access to more minimally-invasive treatment options.”

A 39-year-old mother, who was losing her battle with heart failure, was able to spend Christmas 2017 at home with her family after receiving a total artificial heart at Harefield Hospital, one of the few people in the country who has been able to leave hospital with the ground-breaking equipment.

A total artificial heart is a pump that is surgically installed to provide circulation and replace heart ventricles that are diseased or damaged while a patient waits for a heart transplant. Harefield Hospital is only centre in the UK that uses the device as a treatment for patients with heart failure.

The patient

Selwa Hussain was urgently referred to Harefield Hospital with end stage heart failure, and her heart function was deteriorating so rapidly that doctors had to put her on ECMO (extracorporeal membrane oxygenation), a life-saving device which delivers oxygen from outside the body and maintains circulation. Selwa, who has familial dilated cardiomyopathy, had been free of any symptoms until 2016.

Ms Diana Garcia Saez, specialty doctor in cardiothoracic transplantation who implanted the total artificial says: “Despite us increasing her medication, Selwa’s condition was getting worse very, very quickly. 

“Often, a ‘left ventricular assist device’ can be used to maintain circulation in patients with failing hearts, but this wasn’t an option because it would not have supported the failing right hand side of her heart. The only option to save her life was to implant a total artificial heart.

Selwa said: “All I remember from before the operation was crying to my sisters, and giving my final wishes to my family. I remember when I woke up, being told my heart had been taken out, and I was so disorientated I thought ‘what does this mean, have I died?’”

A successful operation

The operation was led by Mr Andre Simon, director of heart and lung transplantation and ventricular assist devices. Mr Simon said: “The operation went very well and Selwa’s recovery has been excellent. For us as a medical team, being able to use the total artificial heart gives us an option when all the others have been exhausted. Without it, Selwa would not have survived.

Selwa says: “I can’t thank the staff at Harefield enough: they have been absolutely amazing: everyone, the doctors and the nurses, but the physiotherapists are such experts, and the caterers, the cleaners, the healthcare assistants – they are all so positive for you, even when life felt very bleak. It is an incredible place.

Nurses from Royal Brompton and Harefield designed an innovative, award-winning bra that helps women’s wounds heal after heart surgery.

A team led by Melissa Rochon, clinical nurse specialist in surveillance, worked with medical manufacturer CUI to design and manufacture a bra for female patients who have trouble with wound healing after cardiac surgery.

Research shows that women are more likely to have surgical site infections (SSIs) than men, because if their chest area is not properly supported, pressure can be put on the chest incision, causing the wound to gape.

Existing post-surgery bras with removable straps were only available up to a D cup, but fluid weight gain is common after heart surgery and around half of all women need this size or bigger after their operation.

Responding to patients’ needs

The bra that the team designed (the BHIS™ Bra) has side support to reduce tension on the wound and adjustable fastenings to allow for fluid gain and different sized wound dressings.

During a trial period at Royal Brompton and Harefield hospitals, the proportion of women suffering SSIs reduced significantly.

The new bras are now being used at Royal Brompton and Harefield hospitals, and teams from other hospitals are interested in using them. Heather Lynch, who has used the BHIS bra, said: “The bra proved to be a great help upon my return home. It is both comfortable and supportive and alleviated any concern I had about my chest wound.”

In July 2017, the innovation won a National Patient Safety Award for the ‘Best Product or Innovation for Patient Safety – Public Sector’ and was praised by the judges for being “grounded in evidence”.

Patients living with complex cardiac abnormalities and irregular heart rhythms receive ground-breaking treatment in the state-of-the-art catheter lab at Harefield Hospital. The advanced equipment, including a remote-controlled robot, means greater numbers of patients are being treated at Harefield for some of the most common and debilitating heart conditions.

Patients seen in the cath lab benefit from one of the most advanced facilities of its kind in Europe. Experts are able to treat patients with complex cardiac arrhythmias (heart beating too fast or irregularly). This includes atrial fibrillation, the most common arrhythmia, which affects one to two per cent of the population and more than five per cent of over 65s, and can cause disabling symptoms and increased risk of stroke. The facility also provides state-of-the-art treatment for patients with life-threatening arrhythmias such as ventricular tachycardia.

Dr Vias Markides, consultant cardiologist at Royal Brompton and Harefield hospitals, said: "We wanted to create a state-of-the-art facility that would increase our capacity to treat those patients who we know are currently living with heart problems. I am delighted that we can support even more people with this impressive new facility at Harefield Hospital.

"The cath lab will also provide staff with unique learning, giving them access to some of the most advance equipment available for treating common and complex heart conditions. I would like to take this opportunity to thank St Jude Medical, our partner in this initiative, for their support."         

An increase in precision

The Hansen robot in the lab at Harefield Hospital means that Royal Brompton and Harefield hospitals is the only one in the country to benefit from two types of advanced remote catheter navigation, each having unique strengths. Both allow precise catheter manipulation and reduction of exposure to X-rays for both patients and staff.

The robot means that specially trained cardiologists can treat patients with increased precision by the use of remote control and high-tech 3D mapping technology and is ideal for treating patients with atrial fibrillation and other complex arrhythmias.

Specialists at Royal Brompton and Harefield hospitals have joined forces with RM Partners, the west London cancer alliance hosted by leading cancer centre The Royal Marsden, to diagnose patients with lung cancer earlier.

The NHS England-funded initiative, which includes patients having access to a mobile CT scanner, is the first of its kind in London and means people in Hillingdon and in Hammersmith & Fulham who have been identified as being at increased risk of lung cancer will be invited for a lung health check. If appropriate, they will then be offered a CT scan in a convenient place on the same day.

Lung cancer is by far the most common cause of deaths from cancer in the UK because the majority of people are diagnosed in its late stages when treatment has a more limited impact.

Twenty GP surgeries across the two London boroughs are taking part in the pilot and over 7,000 current or ex-smokers between 60 and 75, are being invited for a lung health check. Hammersmith & Fulham has the highest lung cancer incidence and mortality across west London, and Hillingdon has the lowest one-year lung cancer survival rate.

People in Hammersmith & Fulham will be invited to a lung health check at Royal Brompton Hospital, while those in Hillingdon will be invited to a mobile CT scanning unit in Tesco or Sainsbury’s car parks. The mobile CT unit uses a novel wireless technology developed in the UK which, for the first time, allows scans to be transmitted for remote diagnosis within minutes, rather than being couriered on CDs.

Dr Anand Devaraj, consultant thoracic radiologist at Royal Brompton, is leading the work. He said: “Early detection of lung cancer saves lives, but often people are diagnosed at a late stage of the disease, having been unaware of any signs or symptoms in the earlier stages. The earlier someone is diagnosed, the more effective the treatment they can be offered.

“This pilot is a real opportunity to help improve people’s lung health. Those who smoke will be offered help to stop and, where we find people who do not have lung cancer but a different condition, we can make sure they are referred for the appropriate treatment.”

Nicola Hunt, Managing Director at RM Partners, said: “This is a fantastic project that we know can have an immediate and significant impact on the early diagnosis of lung cancer. We are extremely excited to be the first Cancer Alliance in London to offer a mobile service, which gives patients easy access to health checks and CT scans within their local community.

The initial pilot will run for one year, with the study into the outcomes and results for patients ongoing for a further year.

Find out more about the project on the Evening Standard website.

Experts at Royal Brompton Hospital are helping some of Great Britain’s elite athletes achieve their potential in time for the 2020 Summer Olympics in Tokyo.

In the first collaboration of its kind, the hospital’s experts have joined forces with the English Institute of Sport (EIS), the Institute of Sport Exercise & Health (ISEH), and Imperial College London in a project to boost respiratory health in elite athletes.

The project aims to reduce the impact of breathing problems on the athletes’ availability for training and competition as, despite having high levels of fitness, a number who compete at the highest level are still susceptible to respiratory illnesses. According to EIS data, respiratory illness is the largest health problem among UK athletes.

Problems experienced both in training and competition include respiratory infection (with symptoms such as headache, persistent coughs, sore throats and nasal discharge) and asthma, which can have a significant impact on both training and competition performance.

Dr James Hull, consultant respiratory physician at Royal Brompton Hospital and an expert in athlete respiratory health, said: “Respiratory illness is the most prevalent health issue in athletes. This project offers a great opportunity for us to really understand this area properly, to help athletes remain fully available for training and competition.”

A battery of tests

The project will evaluate and support improved care in the prevention, detection and diagnosis of respiratory illness, in over a hundred athletes identified as being particularly susceptible, from a cross-section of Olympic and Paralympic sports.

The athletes will undergo a battery of tests, including lung function, immune and allergy status, respiratory tract bacterial profile, medication use and illness history at EIS sites across England.

In the two-year period to 20 July 2017, there were 630 respiratory illnesses recorded in 402 athletes, with an average of nine days of restricted training per occurrence, totalling around 5,800 days or nearly 16 years of training days impacted.

Over 30 per cent of the affected athletes had repeated occurrences in the two-year period, with the diagnosis of upper respiratory tract infection - sinusitis, laryngitis and the common cold - accounting for 85 per cent of them followed by asthma with 11 per cent.

‘Brand new, cutting-edge’

Dr Rod Jaques, director of medical services at the EIS, said: “Royal Brompton Hospital is one of the top institutions for understanding upper and lower respiratory tract problems in the UK, the data we collect will be vital in progressing our understanding of athlete respiratory illness and health.”

Dr Mike Loosemore, lead consultant at the Institute of Sport, added: “This is absolutely brand new, cutting-edge stuff. This is going to be world-leading, beyond any question. It’s a really big advance,” adding that the research could be of wider public benefit if more accurate diagnoses lead to a reduction in the use of antibiotics.

Royal Brompton has been at the forefront in the development of a new drug-free procedure to help patients who suffer from severe asthma.

‘Bronchial thermoplasty’ involves a tiny probe being inserted into the lungs and has reduced emergency hospital admissions for life-threatening asthma attacks by 55 per cent, with researchers finding that patients benefit for up to ten years after treatment.

In September 2018, the National Institute for Health and Care Excellence (NICE) recommended that bronchial thermoplasty should be rolled out nationally as an NHS treatment.

Professor Pallav Shah, consultant physician in respiratory medicine at Royal Brompton, pioneered the procedure. He said: “Some of our patients had difficulty walking upstairs, and are now doing intensely physical things like rock-climbing.”

How does bronchial thermoplasty work?

The smooth muscle in the airways of asthma sufferers is usually thicker than those without the condition. When it contracts, it significantly restricts the airway, causing breathing problems.

Using a special catheter, via bronchoscope, a tiny probe is used to transmit radiofrequency energy to the smooth muscle in the airways of the lungs. Heat of 65 degrees centigrade is applied to remove the smooth muscle in the airway wall.

As a result, this enables patients’ airways stay open during an asthma attack.

The procedure usually takes place under general anaesthetic and is carried out in three separate 45-minute sessions.

Doctors treat the lower part of the right lung first, and the lower left part three weeks later. A few weeks later a third 45-minute operation treats the upper sections of both lungs.

Research has shown that bronchial thermoplasty can almost halve the number of severe asthma attacks and cut the average number of emergency hospitalisations patients need by over 80 per cent. Since 2010, 2,500 patients worldwide have undergone bronchial thermoplasty to deal with their asthma.

The patient

Nicola Kerr, 43, was able to complete a 170-mile hike in the French mountains within two months of having the procedure earlier this year.

Nicola has suffered from severe asthma since her 20s and has been hospitalised because of the attacks.

She told the Mail on Sunday: “Instead of reaching for the inhalers every morning and coughing all day, I now wake up fine. It’s simply changed my life.

“My lungs were so big that I actually needed four treatments. After the final treatment, I began to feel the difference. Two weeks later, the difference was amazing.

“In July, I hiked down Mont Blanc and I’ve just come back from a trip to the Pyrenees. I’m down to a quarter of the medication I was on and still use inhalers, but I haven’t needed to go back to A&E since – it’s wonderful.”

Find out more about bronchial thermoplasty 

A new endobronchial valve treatment called Zephyr has been pioneered at Royal Brompton Hospital for the treatment of emphysema, a form of chronic obstructive pulmonary disease (COPD).

COPD occurs when the lungs and airways become progressively damaged preventing the absorption of oxygen. Portions of the lung become unable to function, causing extreme breathlessness.

In September 2018, The National Institute for Health and Care Excellence (NICE) revised its recommendations to say that severe emphysema patients can be routinely referred for Zephyr valves on the NHS, after trials found the valves improve the quality of life, exercise capacity and lung function of those with emphysema.

How does the Zephyr valve work?

The Zephyr valve works by stopping airflow into the diseased region of a lung, and providing an escape route for harmful fluids and gas.

Emphysema occurs when lungs become progressively damaged and the air sacs, which absorb oxygen, stop functioning properly.

The lungs become less efficient, rendering the patient unable to get rid of stale air, or breathe in enough fresh air.

The new Zephyr valves are between four and seven millimetres long and are shaped a little like a shuttlecock. They comprise a nickel and titanium alloy wire exterior and soft silicone inner tube. A tiny opening allows stale are to escape.

It works on a similar principle to lung reduction surgery, where part of the lung is surgically removed, but has the benefit of being less invasive with the valves gently inserted into the lungs via a bronchoscope.

Professor Pallav Shah, consultant physician in respiratory medicine at Royal Brompton and principal investigator, said: “The new trial validates what several smaller studies have previously shown – that Zephyr valves help patients become significantly less breathless and more active, improving the overall quality of their life.”

The patient

Colin Gregg, 74, developed emphysema 12 years ago.

He told the Mail on Sunday: “I’d climb a flight of stairs and be fighting for breath. And I couldn’t manage hills on the golf course – I’d have to use buggies. The condition is like taking a deep breath and not being able to breathe out again, so it’s impossible to get more fresh air into your lungs. It is horrible.”

In July 2016, Colin had four valves implanted into one lung during a 45-minute procedure.

He added: “It has given me a much better quality of life – and since it’s a degenerative condition, I’m now thinking of having the other lung done. I’m delighted to hear this procedure will now be offered to so many more patients like me.”

Find out more about COPD.