Heart Transplant Scenario in India
Heart Transplantation celebrates its 50th anniversary in December 2017. Worldwide, thousands of these procedures have secured longer survival and better qualities of life for patients with end-stage heart failure. The natural history of these patients is repeated admissions to hospital. Worse still is the survival-less than 30 percent make it to two years. It must be remembered that the survival with end-stage heart failure is worse than AIDS, lung and pancreas cancer or leukemia.The therapy is relatively new in India and can be considered to be in its infancy. However, in the last 5 years there has been an increase amongst medical communities establishing heart transplant programs. 1/3 Indians have Hypertension and/or Hyper cholesterolemia. Up to 1/2 have Diabetes or prediabetes. These diseases are the ingredients for heart disease and failure. About 4-5 million Indians have advanced heart failure. Globally this is 20 million. Advanced heart failure is a terminal and degenerative disease. It manifests as shortness of breath on exertion, swelling of the legs, abdominal swelling and palpitations. The diagnosis is confirmed with specialized tests, Echocardiography being the mainstay. Patients who have very poor functioning heart pumps are first considered for conventional treatment. If this is not possible, the patient is worked up for a heart transplant.
Patients with stroke, bad lungs, advanced kidney or liver disease are considered with caution. There is also an assessment of the psychosocial status of the patient. It is important that the patients are in a position to take tablets lifelong to prevent rejection of the new heart. Also they must be amenable to regular follow-up. Once all the tests are complete and the patient is found to be bad enough to consider transplant, they are placed on a waiting list whilst awaiting a suitable donor. Matching is based
on blood group, size of the donor to recipient, gender, pulmonary vessel pressures. To ensure suitable and adequate donors, the communities need to be aware of organ donation. One donor can save several lives as other solid organs such as the kidneys, liver; lungs, pancreas and small bowel are also harvested. Donation is a special gift of life and should be considered as the ultimate spiritual sacrifice. The south of India has made major strides in donation. Hence, the waiting time for transplant has fallen.
The transplant procedure enlists the expertise of many specialties. Nurses, physiotherapists, social workers, psychologists, coordinators and family practitioners contribute majorly to the successful outcome. In the hospital surgeons, anesthetists, perfusionists, cardiologists, microbiologists, intensivists working together deliver a unique expertise that will give the heart transplant recipient the best chance of good outcomes. On the night of the transplant there is a meticulous set up and co-ordination whereby the heart is harvested from a donor and then transported to the recipient hospital. Care must be taken to preserve and protect this organ. The time from removal of the heart to the point of perfusing (feeding it with blood in the recipient) it must not exceed 6 hours. The best results are seen with short times less than three hours.
The recipient traditionally spends a few hours on the breathing machine.He/she is woken up and allowed to breath spontaneously within 8 hours. Intensive Care management is continued for 2-4 days if all is well. There after the patient is transferred to the ward for ongoing surveillance, physiotherapy,education regarding drugs and routine tests. Some patients are discharged as early as a week following the transplant. Ongoing surveillance largely by Echocardiography and biopsies ensure rejection is prevented and treated when necessary. Rejection is the Achilles heel of all transplants. However, with newer drugs the incidence of rejection requiring a visit to a hospital is now less than 12 percent. Many programs are now reducing the amount of immunosuppressive drugs early on. This is particularly the case in India where rejection is not as prevalent as the Western world where various genetic mixing predisposes to rejection.
Problems associated with immunosuppressant have to be monitored and treated accordingly.
Crucial to any major therapy is the success and long-term survival. For children undergoing heart transplant 40 percent survive to 20 years. For adults this is 25 percent making it to 20 years. This is a massive improvement on the 1-2 years that most of these patients would have seen. Currently the only competitor for heart transplant is mechanical hearts (VADs).However, this is very costly, has lower durability and is associated with bleeding and strokes.
Rejection is the Achilles heel of all transplants. However with newer drugs, the incidence of rejection requiring a visit to a hospital is now less than 12 percent
The transplant procedure enlists the expertise of many specialties. Nurses, physiotherapists, social workers, psychologists, coordinators and family practitioners contribute majorly to the successful outcome. In the hospital surgeons, anesthetists, perfusionists, cardiologists, microbiologists, intensivists working together deliver a unique expertise that will give the heart transplant recipient the best chance of good outcomes. On the night of the transplant there is a meticulous set up and co-ordination whereby the heart is harvested from a donor and then transported to the recipient hospital. Care must be taken to preserve and protect this organ. The time from removal of the heart to the point of perfusing (feeding it with blood in the recipient) it must not exceed 6 hours. The best results are seen with short times less than three hours.
The recipient traditionally spends a few hours on the breathing machine.He/she is woken up and allowed to breath spontaneously within 8 hours. Intensive Care management is continued for 2-4 days if all is well. There after the patient is transferred to the ward for ongoing surveillance, physiotherapy,education regarding drugs and routine tests. Some patients are discharged as early as a week following the transplant. Ongoing surveillance largely by Echocardiography and biopsies ensure rejection is prevented and treated when necessary. Rejection is the Achilles heel of all transplants. However, with newer drugs the incidence of rejection requiring a visit to a hospital is now less than 12 percent. Many programs are now reducing the amount of immunosuppressive drugs early on. This is particularly the case in India where rejection is not as prevalent as the Western world where various genetic mixing predisposes to rejection.
Problems associated with immunosuppressant have to be monitored and treated accordingly.
Crucial to any major therapy is the success and long-term survival. For children undergoing heart transplant 40 percent survive to 20 years. For adults this is 25 percent making it to 20 years. This is a massive improvement on the 1-2 years that most of these patients would have seen. Currently the only competitor for heart transplant is mechanical hearts (VADs).However, this is very costly, has lower durability and is associated with bleeding and strokes.
