Heart Transplant: Hope for the weak hearted

While Asian Heart Institute and Max Healthcare are foraying into heart transplantation, scurrying for donor hearts, whopping cost of transplant surgery and recurring cost of immunosuppressant drugs continue to thwart heart transplant programme in hospitals, reports Rita Dutta

Rama Rao got a new lease of life after he underwent a heart transplant at Hyderabad-based Care hospital

Life for 23-year-old Rama Rao was an agonizing tale of hospital visits, battling breathlessness in ICU and popping medicines- all in an attempt to keep his heart pumping. Hailing from east Godavari district of Andhra Pradesh, Rao had developed viral myocarditis (inflammation of the heart muscle) which aggravated and led to heart failure. Just when medication was failing to show any improvement, just when hope was beginning to wane, a despondent Rao was told that what he just needed was a heart transplant.

Around the same time, a 12-year-old boy admitted to the hospital with severe head injury, and after initial treatment was pronounced brain dead. After the usual rounds of counseling and consent of his parents, the heart of the brain-dead boy was transplanted to Rao. A year after the transplant, with the aid of little medication, Rao has bounced back to a normal life.

The hospital which gave a fresh lease of life to Rao, bore the entire cost of his treatment amounting to a whopping Rs 18 lakh was Care Hospital, Hyderabad. Beams Dr Gopi Chand Mannam head, cardio thoracic surgery, Care Hospital, the man who gave Rao a second chance at a heart, “Rao’s outlook towards life has transformed after the surgery.”

While Rao’s story reflects the advancement of cardiac care in India, with Mumbai-based Asian Heart Institute and New Delhi-based Max Healthcare planning to foray into heart transplantation, India’s position to be a Mecca for medical tourism stands strengthened.

However, the journey of heart transplant programme in India, which was pioneered at the All India Institute of Medical Sciences (AIIMS), New Delhi way back on 3rd August 1994, has been riddled with lack of donor hearts, expensive surgery, recurrent cost of immunosuppressant drugs and poor awareness about brain death.

While annually around 4000 to 5000 Indian patients would require a heart transplant, a beacon of hope for patients with end stage heart failure (an intractable state of heart failure) due to dilated cardiomyopathy or recurrent myocardial infarction, it eludes the reach of many a needy patients.

According to Padmashri Dr K M Cherian, CEO and chairman, Frontier Lifeline, Chennai and the pioneer of heart transplant in the private sector, “So far, only 43 heart transplants have been conducted across the country.” The figures are scanty, when pitted against 2,057 heart transplants performed in the US in year 2003, says Dr Cherian, who has 11 heart transplants under his belt.

Worldwide, approximately a little over 3000 heart transplants are conducted, annually. Cumulatively, over 66,000 heart transplants were conducted in over 200 centers till the middle of 2003, as per the International Registry for Heart and Lung Transplantation.

According to Dr Gopala Krishna Gokhale, head, cardio thoracic surgery, Global Hospital, Hyderabad, “Worldwide, heart transplant is plunging due to shrinking pool of donors, attributed to improved emergency care, and road safety rules in the west. However, this is not applicable to India, which does not have improved Emergency Medical Service (EMS) care yet.” Dr Gokhale has conducted heart transplant on 32-year-old Ramesh in February 2004, who had dilated cardiomyopathy, a condition in which heart dilates and cannot pump blood.

Hospitals, which have started their heart transplant programme with much gusto, have been discouraged by the difficult and arduous task of scurrying for donor hearts, with relatives of brain death patients refusing to donate due to superstitious humbug. Explains Dr Asok Seth, head, Cardiology, Max Healthcare, New Delhi, “A growing notion exists in the minds of the people that soul exists in the heart and hence should not be given for transplant. Then, there is psycho-social bent of mind of Indians which hold that donating organs would lead to the trauma of the body.”

Getting the correct match is another challenge. “The donor heart should be healthy, less than 45 years and free from Coronary Artery Disease (CAD). This excludes many potential donors, because cardiac arrest sustained patient are not eligible for cardiac transplantation,” says Dr Cherian, past president of the Indian Association of Thoracic and Cardio vascular Surgeons.

Lack of awareness about brain stem dead and it associated formalities among medicos, coupled with the ignorance of the potential of heart transplant among cardiologists have dealt a blow to the heart donation programme, resulting in poor referral to centres offering heart transplant.

Laments Dr L Shridhar, cardio thoracic surgeon, Apollo Hospital, Chennai, “We have conducted our last heart transplant in 1999. Where are the donor hearts? Affording patients tired of waiting for four to five months for donor hearts go shopping in other hospitals, hoping to get better medication that may cure them.”

The desperate hunt for donor hearts has spurred the trend of using “marginal donors” at some hospitals. The transplant of Rao is a case in point. While the usual practice is to match the recipient and donor body weight, in Rao’s case, he weighed 40 per cent heavier than the donor. “The surgery was still conducted as there is enough evidence to justify the effectiveness of undersized heart in heart transplant. To our knowledge, this was the first of its kind in India heart transplant by marginal donor,” says Dr Gopi Chand, who has conducted over 20 heart transplants while working at the Royal Brompton Hospital, London.

So far, only 43 heart transplants have been conducted across the country Dr K M Cherian CEO, Frontier Lifeline, Chennai	Worldwide, heart transplant is plunging due to shrinking pool of donors Dr Gopala Gokhale Global Hospital, Hyderabad	Heart transplant figures are not ballooning, as logistics and expenses do not favour it Dr Ramakant Panda CEO, Asian Heart Institute, Mumbai

According to Dr Ramakant Panda, CEO, Asian Heart Institute, who has conducted 30 transplants while working in Cleveland Clinic and Harefield as cardio thoracic surgeon, heart transplant figures are not ballooning, as logistics and expenses do not favour it.

The cost of the heart transplant surgery is anywhere between Rs 8 lakh to Rs 10 lakh and the monthly cost of immunosuppressant drugs is Rs 15,000 to Rs 20,000. With 10-year survival rate for heart transplant patients being around 45 to 50 per cent, the expense is surely unaffordable to most patients.

“Though technically, heart transplant is easier than bypass surgery, it is not an economically viable solution. Such surgeries are still sponsored by the community or the hospital,” says Dr Panda.

Kolkata-based Birla Heart Institute has discouraging tales to narrate, after taking pains to get approval from the government to conduct heart transplant. Says Dr A Kaul, head, cardio thoracic surgery, Birla Heart Institute, having experience of conducting heart transplant in Germany, “Even as two patients qualified for heart transplants in our institute, we could not conduct the transplants. In one case, the patient backed out when informed about the recurring cost of immunosuppressant drugs and in another, we could not find a donor heart.” BHI’s endeavour continues, with the authorities applying for renewal of permission for conducting transplant.

Orchestrating a team of two surgical units, infectious disease specialist, immunologist, transplant coordinator, psychiatrist, dedicated cardiologist for management of congestive cardiac failure, intensivist, transplant nurses, anesthetist and histopathologist is a massive task, which the profit-driven private hospitals shy away from. Quick co-ordination assumes significance as the period between retrieving the heart and transplanting it should not be exceed three hours, says Dr Panda.

“There is lack of co-ordinated infrastructure to be able to harvest these organs from distant centres and a cardiac surgical team to fly in to harvest the heart and then fly out to do the operation. Since only the major cities have such facilities, that is why transplant programmes have not developed in other cities of this country,” says Dr Seth. Co-ordinating recipient services, admission, travel readiness are other hassles, he adds.

But if hospitals have initiated kidney and liver transplant programme, why only a few of them evince interest in heart transplant? Logistics. Post surgery, heart transplant patients have to make regular visits to the hospital for endomyacardial biopsy for checking the patient’s heart. “This invasive procedure requires a day of hospitalisation, in comparison with the non-invasive Blot test for liver and kidney transplant,” explains Dr Panda. The stakes are also higher for heart transplant. If a kidney transplant is rejected, then the patient can be put on dialysis, but when a heart transplant fails, then the pateint dies on the spot.

But while private hospitals are working out the logistics of starting a transplant programe by sponsoring the treatment or waiving off the fees of the surgery, why public hospitals have not been forthcoming? The proverbial lack of resources. Explains Dr Anil Patwardhan, head, cardio thoracic surgery, King Edward Memorial Hospital, Mumbai, “The post-operative care for heart transplant surgery is demanding. The patient needs to be kept on ventilators for a few days, in the isolation ward and requires hospitalisation for at least two weeks. Rather than extending the facilities to save the life of one, one can save the lives of many more by using the same resources.” He feels that other public hospitals cannot be compared with AIIMS, as the latter does not face resource crunch.

With rampant kidney rackets casting shadow on organ donation, what could be the ethical issues in heart transplants? None, says Dr Arun Bal of Indian Journal of Medical Ethics. “Heart transplant is cadaveric donation and cannot be compared to renal transplant which is a live transplant. No ethical issue can arise in heart transplant as the Transplantation of Human Organs Act, 1994 clearly defines brain stem death,” says Dr Bal.

Faced with paucity of donor hearts, experts are exploring various non-transplant possibilities. Medication is what most cardiologists fall back on. However, as Dr Ashwin Mehta, director, cardiology, Jaslok Hospital, Mumbai points out, “A patient put on medication cannot survive beyond six months. And even if it is affordable for a patient to be sent abroad, the waiting time is not less than six months to a year, which sometimes is too late.”

The other option is an assist device which help the patient to stay alive until the donor heart is available. Assist device biventricular pacing, designed to promote resynchronisation and improve hemodynamic performance in patients with heart failure, works very similar to a pacemaker. There are leads implanted through a vein into the right ventricle and into the coronary sinus vein to pace or regulate the left ventricle. “But it’s useful to only to a select group of people,” says Dr Gokhale.

Then, there is ventricular assist device. Explains Dr Ravi Kasliwal, director, cardiology, Escorts Heart Institute and Research Centre, New Delh, “The device is more like a bridge to transplant, keeping the patient alive for a few months before the donor heart is found.” While Escorts Heart Institute and Research Centre, New Delhi will soon be offering ventricular assist device AbioCor from by ABIOMED Inc, Dr Kasliwal doubts the affordability of the procedure, which he states is “horrendously expensive” with the costs ranging between Rs 10 to Rs 15 lakh.

Long term alternatives to the heart transplant, “stem cell therapy” and “artificial heart,” have captured the imagination of researchers. The artificial heart, now being used on a trial basis in the US, includes two artificial ventricles with valves and a motor-driven hydraulic pumping system, and costs about 70,000 USD.

With the belief that heart did not have regenerative quality being shattered, stem cell therapy appears to be the next best bet, with some institutions in India already on this trail. AIIMS, has also notched another first by being the first global centre to offer stem cell injections. According to Dr Arti Vij, in charge, Organ Retrieval Banking Organisation (ORBO) of AIIMS, “When a patient fails to get a donor heart, we suggest stem cell injections. The patient, of course, is chosen based on certain protocols.” The stem cell injections, co-ordination by ORBO and the heart transplant clinic which renders special care to heart transplant patients, both pre and post operatively make AIIMS a unique heart transplant centre in the country, adds Dr Vij.

Some do believe that more intensive research is needed on stem cell therapy, and if at all it is effective, it may be more expensive than heart transplant. That brings us back to heart transplant, the best and most effective procedure, according to most cardio thoracic surgeons.

Realising the potential demand, AHI is preparing to start heart transplant programme within six months, offering the treatment at a subsidised cost, where the doctor will waive off his fees, said Dr Panda. Close on heels of AHI, Max Healthcare will start their heart and lung transplantation programme within a year. “We are also looking at developing a dedicated transplant team for an effective management of the patients with end stage heart disease,” says Dr Seth.

To plug in the lacunae in the existing programme, awareness about brain death and organ donation need to be strengthened, along with addressing various psycho-social issues of people through various educational programmes. How can the treatment be made more affordable? “The government needs to play a major role in reducing the tax of immunosuppressant drugs and strengthening resources of public hospitals so as to enable them to cater to the needs of heart transplant patients,” suggests Dr Bal. To which Dr A K Bardhan, cardiologist, Woodland Hospital, Kolkata, adds, “Insurance should include heart transplant in its ambit, as practised in the West.”

On an optimistic note, Dr Gopi Chand observes the transplant programme in the west took decades to evolve after the first successful human heart transplant by Dr Christian Barnard in South Africa in 1967. “India’s heart transplant programme would go through a gestation period, before it picks up.”

There will be thus be a day, whilst a mourning family would be proud that they followed a noble thought, there will also be many Rama Raos with smiling faces, bright with the hope of a better future, as they continue to lead perfectly normal lives, thankful that someone had decided to work for their cause.

rita_dutta@rediffmail.com