who is consultant cardiologist at KHM hospital, and teaches
at Sri Ramachandra University and is visiting faculty at The Ohio State
University, Columbus USA and had him speak on some of the challenges
faced by heart specialists in India who treat heart complications.
Q. What is
special about heart transplant as compared to other transplants?
compatibility is a crucial factor in organ transplants. Liver and kidney for instance, are driven by
a complex HLA compatibility based on complex array of
In heart transplant the biggest challenge is the
time factor known as cold ischemia time which is the time we can keep the heart alive once we
remove it from the brain dead person for transplant. The heart allows only 4-6
hours to be transplanted into another body. Liver gives you 12-16 hours, Lungs
allow 10-18 hours and the kidney can be kept for nearly 24 hours before it is
Another difference in heart transplant is, it is
not driven by complex HLA
compatibility. The only requirements for heart donation are same blood group
and size of the patient. The donor and the recipient should have the same blood
type and meet the size match. The difference in height of the donor and the
receiver should not exceed 1 feet and the weight not more than 10 kg. This
gives heart transplant surgeons a lot of leverage in picking and choosing a
heart for transplant.
Q. Despite this leverage that a heart
transplant surgeon has—simple donor compatibility, what are some challenges
that you've seen in heart transplantation in your experience in India?
the cardiac surgeon is told that the heart donor is say, 18 years old. But the
person could be small sized, probably undernourished and may not meet the size
match. For instance, we were told that an 18-year-old's heart was available for
transplant. We noticed that though the records said she was 18 years old with a
matching weight, the girl looked undernourished and smaller—more like a 14
year-old. The under-sized heart was a mismatch for the 70 kg man. The patient
with the transplanted heart didn't survive.
Another drawback is the alert for organ donation
comes when it is too late to retrieve the heart. It is usual for family and
friends here to keep waiting by a person's bedside till the heart stops and
then they call. A 29 year-old woman had a severe head injury and the family
kept waiting and on the 9th
day they decided on organ donation. By then
the heart function had gone down and had to be discarded and only the kidneys
and liver could be harvested.
Q. Do you
think LVADs (Left Ventricular Assist Device) have a future in India?
LVADs are a great option,
provided the cost factor meets your budget. LVADSs have picked up immensely in
the US because the number of heart transplants is not going beyond 2000 heart
transplants a year. Death due to heart attack has dramatically gone down from 30% in the 1960's
to 3% currently, which is a big achievement for intervention specialists. But
heart failure mortality remains at 50%, which means the demand for hearts for
transplant is more than the supply. LVAD is on demand system and can be readily
used, provided you can afford it.
In Chennai city there is only one person alive who has LVAD and the cost
is approximately Rs. 1 crore (USD $163,300).
From your experience what are some lessons learned in Patient Centric approach
in Heart Failure in India?
I believe Patient-centric
approach is good for the patients when treating heart ailments. Sometimes a
patient says, "If I go to this place of worship I will recover," I don't argue or question a patient's beliefs until they
interfere with my treatment modalities. I do not wish to anger
rationalists and scientists but I sincerely believe that Faith and Beliefs play
an important role in the neuromodulatory signals that control our body and
mind. Hence in Heart
Failure, the autonomic nervous system which affects the pathology behind
Sudden Deaths in Heart failure always plays a key role. So, to belittle one's
beliefs and faith does not augur well for my practice.
(prescribing load reducing agent) is not a life saving therapy in heart failure
but using diuretics or "water pills" is a routine intervention
in heart disease treatment
. When I
prescribe diuretics I tell my patients to monitor their fluid intake and
output. Sometimes when a patient says there is more urine output if I take the
pill at 8 o'clock and not at 9o'clock, I agree with his theory and ensure his
compliance saying, "Fine take it at 8 0'clock." This is better than telling the
patient his theory is stupid and upsetting him and provoking noncompliance.
Going by the regimen which suits the patient
helps the patient best.
But patient response is
not the same in all sections of the Indian society. It varies according to the
social and educational background of the patient.
is a much preferred modality of death by most Indians—in fact it is considered
a gift from God. Especially after people cross their fifties many patients are
reluctant to prolong life with medical treatment. For both the patient and
family an unexpected and sudden passing away at night is much preferred to a
prolonged heart condition followed by prolonged treatment.
Q. Compared to other organs like kidneys and
liver the utilization of heart for transplants in India is low (heart-less than
20%, (liver 85%, kidney - over 90%) Why are we wasting so many hearts? A.
to heart transplant is less because not all heart specialists are involved in
heart transplants and few among them believe that heart transplantation is a
modality of treatment for heart failure. It is unfortunate that even senior cardiologists believe
that successful heart transplants can happen only in the West. This is
particularly relevant when you compare with kidney, where every nephrologist
worth his salt promotes transplant.
Let me explain with a bad
experience of mine.
A 26 year-old man needed
a heart transplant
. I spoke to him
and convinced the patient and his parents that a heart transplant was necessary
to save his life and he agreed to have his name on the transplant list. The
patient went to another leading cardiologist for a second opinion. The
cardiologist did a repeat echo and said, "Your heart is functioning perfectly
well. Enjoy life but don't get married. You don't need a heart transplant. It is
all humbug." When the heart arrived for transplant the patient refused the
offer saying, "Transplant means sure death." When I asked the cardiologist why
he misdirected the patient, he replied, "Yes I know he is dying. He will die in
a month's time without treatment. So let him enjoy life and die in peace rather
than fighting it out in a hospital room." It's a serious stumbling block that
cardiologists fail to acknowledge that we
can save lives with heart transplants in India
one week the family informed me that he had passed away in sleep. The worst
part was that I felt it was a preventable
death while the family thought that it was destiny.
From the patient's side,
the biggest challenge to heart transplant is finance. Heart transplant costs
about Rs. 5 lakhs (USD $8165) and then comes the lifelong expense of
I must mention here that
the initiative taken by the Govt of Tamil Nadu in supporting organ transplant
and paying for the patient's expenditure for immunosuppressant drugs is
Half of Kidney
transplants are live donor transplant and each cadaver generates two kidneys,
so the number of kidney
transplants is bound to be high. New, advanced immunosuppressant drugs
have brought rejection rates down in India. The higher number of successful
kidney transplants is not because transplant technology has advanced, but
because effective anti-rejection drugs are available now. It is possible to
blast a person's entire immunity to prevent the body from rejecting the kidney.
Advanced drugs ensure that the body accepts the transplanted organ and the
patient is able to lead a good quality life after transplant.
and organ transplantation
picking up quite a bit in India thanks to some committed co-ordination between
health professionals, government, media, public services like traffic police
and the general public. But we still have a long way to go in India in terms of
changing mindset as far as heart transplants are concerned.
Q. Do social and cultural factors influence
heart treatments? From your experience of working in many countries can you
give us a brief perspective?
example will explain this.In the
field of heart intervention involving angioplasty etc, the most advanced place
in the world is Seoul in South Korea. Second is Japan. It is based on a single
cultural factor that people there believe the soul rests in the breast bone. If
you have to cut the breast bone or the sternum for a heart
surgery, they think the soul is gone. Heart intervention advancement is
a necessity driven by social need there—to do everything it takes to keep the patient's soul intact
while the person is still living. That's the reason why bioabsorbable
stent was first available in Japan in 2007; it came to India it 2009 and is expected to hit the US market only in 2015.
Sociocultural factors influence treatments for heart disease to a great extent.
Q. What in your estimate is
the requirement of hearts for transplants in India? A.
heart transplants can happen per year in Chennai (in South India) if we
consider those patients who can afford the procedure. Let's suppose we tell the
patient that it would cost Rs.5 lakhs for a heart transplant and if the patient
can afford it, then in such a situation 100-200 heart transplants are possible
in Chennai. Taking the disease burden into consideration and if we are more
aggressive in supporting patients financially, the number could be like 400-500
per year in Chennai.
World Heart Day 2014 is just around the corner with its theme of
creating heart-healthy environments adding global momentum to ensure that areas
where we live, work and play do not aggravate our risk of cardiovascular disease
(CVD), the world's number one killer disease.
choose a heart-healthy
diet always, exercise regularly and avoid smoking and excessive alcohol consumption to keep your heart safe