by Thilaka Ravi on  September 27, 2014 at 3:49 PM Medindia Exclusive - Interviews and In depth Reports
 Heart Treatments in India - Heart Expert Discusses Challenges
Treatments for heart problems have vastly improved in India. Experienced heart specialist doctors, hospitals with state of the art facilities for treatment and recuperation, have turned India into a favorable hub for advanced heart treatments for patients in India and abroad.

Medindia heard Dr. Manokar Panchanatham, a prominent heart intervention specialist 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?

A. Donor 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 factors.

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 transplanted.

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?

Sometimes 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?

A. 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).

Q. From your experience what are some lessons learned in Patient Centric approach in Heart Failure in India?

A. 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.

Diuretic therapy (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.

Sudden death 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. Sensitivity 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. Sadly 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 immunosuppressant drugs.

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 remarkable.

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.

Organ donation and organ transplantation are 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?

A. One 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. 100-200 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.

So choose a heart-healthy diet always, exercise regularly and avoid smoking and excessive alcohol consumption to keep your heart safe and healthy.

Source: Medindia

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