In early January last year, Alex Moroianu had her last normal day.
Life was pretty good. She was working her first full-time job as a management consultant in Perth, while finishing off a research paper based on her masters in astrophysics, studying black holes and neutron stars.
She went out that night with her boyfriend and some friends, dancing until 3am. But the next day she could barely walk, wracked with pain and nausea. It wasn't just a hangover.
"From that day, it just never really stopped. It got worse and worse, and we couldn't figure out why."
Alex was in severe heart failure — a shock for someone who'd been pretty much healthy until that point.
In hospital, her doctors told her the left side of her heart was functioning at a fraction of what it should, and the right side wasn't doing much better.
They sent her home with medications and a life vest — a device she had to wear day and night that would shock her heart if it started beating erratically.
She never had to go through the shock of the defibrillator vest because she was only out of hospital for three weeks before she went back in to stay.
"The first day I was in there, the doctor came to me and he said, 'We think you need a heart transplant and we want you to get listed urgently as soon as possible,'" Alex says.
"It was very scary. I remember crying a lot.
"But by the end of the week ... I realised that a heart transplant was my best chance at a good life."
Alex deteriorated quickly. But while she was a good candidate for transplantation — young and otherwise healthy — the weeks just kept ticking by without a heart becoming available.
"I started getting really scared," she says.
"Things were just getting worse and worse for me and the heart just wasn't coming."
The tyranny of distance
This is the thing about living on the west coast of a big, sparsely populated country like Australia.
A transplanted heart starts to deteriorate as soon as it's removed from a donor's body, transported on ice in the same kind of esky as you can buy at your local hardware store.
Most of the population — and by extension, most organs that can be donated — are on the east coast.
And Perth, where Alex lives, is usually just too far away for an east coast donor heart to last until it can be transplanted.
The current gold standard of heart transplantation, where the heart is transported on ice in an esky, gives you about five hours to get the organ out of the donor and into the recipient, says John Fraser, an intensive care physician based at the Prince Charles and St Andrews hospitals in Brisbane.
"Four-and-a-half, five hours, you think, oh, that's pretty far," Professor Fraser says.
"But you've got to remember the size of this vast brown land.
"So there's many many places in Australia we can't retrieve hearts from or we can't transplant because it's too long [to travel]."
But the tide is turning thanks to a study, co-led by Professor Fraser, called the Living Heart Project.
Keeping a heart beating en route
The Living Heart Project uses a new technology keeping hearts viable for longer.
It's called hypothermic ex vivo perfusion (HEVP) and involves putting the donor heart on a rig that keeps the organ at 8 degrees Celsius — like putting an ice pack on an injured muscle to stop swelling — while pumping blood and a nutrient solution through it.
So instead of being static and on ice, it receives oxygen and nutrients and has waste products removed, just as it would be if it was still beating inside the body.
The first phase of a clinical trial into HEVP has just finished.
In contrast to the four- to five-hour window of a normal transplant, Professor Fraser and his team showed they could sustain a heart for as long as 8 hours and 47 minutes. Not by choice, but because COVID restrictions slowed a transfer between states.
"There was a big kerfuffle getting out of one hospital and across a border," he remembers.
"In the past, if it wasn't for that rig, that donor heart would have not been usable and would have had to be disposed of, which would be a crying shame for the family of the donor, but even more so for the recipient who's prepped."
Working with Professor Fraser on the Living Heart Project is David McGiffin, who began his career as a cardiothoracic surgeon in the 1980s.
"It was night and day. When I started heart transplants, doing a fellowship in the US, it was miserable," he says.
"The one-year survival was 50 per cent. You knew one in two was going to die."
These days, survival rates are 90 to 95 per cent. But Professor McGiffin sees the Living Heart Project as the next big step in heart transplantation.
"We're not going to be having to turn hearts down because of the logistics," he says.
"There's nowhere that a donor heart could be in Australia or New Zealand that could not be transplanted in Australia or New Zealand."
A heart for Alex
Alex was one of 36 people in the first phase of the HEVP clinical trial.
Her transplanted heart came from the east coast — something that wouldn't have been possible otherwise.
Many stories of heart transplants mention long, drawn-out recovery, but Alex says she felt the difference "almost instantaneously".
"I felt what blood flow felt like again, as strange as that sounds," she says.
"I felt my blood pulsing in my head, pulsing through my body.
"My hands were warm and I didn't realise I was lacking that until I woke up and I was like, 'Wow, this feels so different'.
"I could breathe easily. I could walk without feeling like my heart was about to explode."
Phase two set to begin
This first phase of the research looked at hearts from donors who were brain dead but still had a beating heart.
The next phase is set to look at whether it's possible to use donor hearts that have stopped beating. Professor Fraser says this will be a win not just for people needing transplants, but donor families too.
"That's an even bigger number of potential transplant hearts that we could resuscitate and reboot," he says.
"There are many places across Australia that now can give their organs for transplantation and that's a huge solace for people who've lost someone from their family. But at least, thank God, someone has benefited from their sorrow."
As for Alex, it wasn't until after her old heart was replaced that her doctors were able to see what might have caused her sudden heart failure in the first place.
Her team found a build-up of white blood cells in her old heart, indicating her immune system may have reacted badly to a previous infection and attacked her heart tissue instead.
Her doctors guessed genetics may have also played a role in her quick decline, but there's no arguing with the speed of her recovery.
"I'm back at the local gym now. I'm able to do cardio for half an hour, one hour. I feel very fit and healthy again," Alex says.
"Now every major event like my birthday or Christmas, even going somewhere with my friends and having a great day, has this different sense of gratitude that comes with it.
"Every time something wonderful happens, I'm extra appreciative of it."
