Tracking the Transplant Trip
Less than a week ago, when a heart was harvested from a 27-year-old nurse’s son and driven across town and transplanted into a 21-year-old girl from Mumbai, everybody wanted a piece of it. The story caught so much of attention that every facet of all the people involved — from the ambulance driver to the cops who signed the donor’s death certificate had their 15 seconds of fame. And yet, two days later when another brain-dead patient’s organs were harvested from Sri Ramachandra University in Porur and rushed across town in exactly the same fashion, the flashbulbs weren’t following. It was business as usual.
Welcome to the world of heart transplants in Chennai. “There are so many people who seem to want to talk about this case, but the first question on my mind was ‘what’s the big deal with this surgery?’ We’ve been doing almost two transplants a month for the past couple of years so we’re a little surprised by the attention,” Dr K R Balakrishnan, Fortis Malar’s Director of Cardiac Sciences told Express before he did that attention-grabbing transplant.
All of this is a far cry from when transplants became entwined with the city, almost 20 years ago to the day. Though most people credit him with it, the legendary Dr K M Cherian only managed the second heart transplant in the country, as AIIMS’ Dr P Venugopal beat him to it in August 1994 — after the Organ Transplant Bill was tabled in Parliament that year. Writing to Express from Dhaka, Dr Cherian says about that landmark surgery that set the transplant ball rolling in South India, “The first heart transplant was done at Vijaya Hospital. The patient was Maimoon Devi and the donor was Hema Soundar Rajan,” he said before revealing, “No preparation was done. Since both the recipient and donor were ready, immediate arrangements were done for the surgery.”
The donor was found in the Railway Hospital here, where Cherian had performed quite a few landmark operations earlier, and the recipient was identified at Vijaya Hospital in Vadapalani. Even though things weren’t as easy as they are now, the flamboyant heart surgeon says that he wasn’t hit by any trepidation before the first heart transplant. “If it was not working, we would haven’t attempted it,” he says somberly. “It seemed like it would work and hence myself and my team took it forward.” Enough said.
In the two decades that have followed, it has been unmistakably proven that the city has become a hub for organ transplant and by a long shot, the numero uno heart transplant destination in the country (and most of the Asian continent). But mere expertise and a continuing stream of patients weren’t the only key to getting it there. As a cardiac surgeon puts it, “For some reason, and perhaps it’s ethnic, we’ve found that people in Tamil Nadu and generally in South India are a lot more receptive to donating organs of their loved ones. A similar trend has been seen in Gujarat. And this has been one of the driving points of our transplant programme honestly, because without donors, we have nothing.” In fact, Chennai’s organ donation rate of 14 per million population in 2013 is comparable with countries like Australia and Germany.
Back to the turn of the century. Things would then meander over the next decade till the health department, doctors and several partners got together to look at the possibility of an unified organ sharing programme — along the lines of America’s UNOS. “When we sat down to design the transplant committee (around the same time that a few organ rackets rocked the state) and set the rules for how things worked, we realized that it was a painstaking process, but the dedication of people like P W C Davidar and Dr Amalorpavanathan really helped,” recalls Dr Paul Ramesh, Senior Consultant Cardiothoracic and Transplant Surgeons at Apollo Hospitals.
And things were far from easy, till the Tamil Nadu Cadaver Transplant Programme was initiated in 2008 and instituted at the Rajiv Gandhi Government General Hospital, with Vascular Surgeon Dr J Amalorpavanathan at the helm as Convenor. “Back then, we would just not get allotted operation theatres,” says Dr Paul with a wry smile. “The coronary bypass surgeries were deemed more important and day-to-day than for our transplants!”
And at a time when there were no dedicated transplant teams, nurses, co-ordinators, grief counsellors or anaesthesists — doctors had to throw their scrubs into the ring and do it all. “There have been so many occasions when we’ve convinced the donor’s family to give the organs and they’d refuse as we are about to harvest them. But now, with professional counsellors and co-ordinators, things have really changed,” he adds.
And so the transplant juggernaut began rolling on as more and more hospitals signed on to do heart transplants. From just a few hospitals six years ago to seven centres that are actively handling transplants today, it is little wonder that 75 hearts have been successfully harvested and transplanted into patients in Chennai. “The system has constantly evolved. It has kept abreast with using technology, very little red tape and excellent coordination between the hospitals and the committee. This is why the transplant programme in Tamil Nadu has worked wonders when compared to other states in India,” says a top health department official.
And with surgeries being done with a flourish of familiarity, the only target in sight is improving the success rate of the transplant and improving the survival rate at the five and 10-year mark, post surgery.
While it has been said that success rate with heart transplants is less than 50 per cent, the confidence exuded by heart transplant surgeons is infectious. And as long as it keeps working, there can be very little to complain about — especially if you’ve got end-stage heart disease.
Maintain transparency and increase awareness on the importance of donor management
Emphasise the importance of outcome data to ensure that organs are being used appropriately
Develop India-specific immunosuppressive, infectious disease protocols to address our local conditions
Heart transplants are not cheap. Even in India where healthcare is relatively more affordable when compared to the USA, transplants are on top of the food chain
Heart transplants in India can cost anywhere between `20-32 lakh (approx)
Cost of transplants in the USA $6,25,000 (approx)
Cost of transplants in Britain - €500,000 (approx)
This includes the actual surgery, donor care, pre-op and post-op recuperation, ICU time and every other unforeseeable medical expenses
After heart transplants, survival rates for the patients varies vastly. While the one-year survival rate is around 87%, the number drops to 71% at the 5-year mark and the average is about 15 years. The longest survivor with a heart transplant was a man who lived 31 years after the surgery
How is a donor’s heart approved for transplant? Dr Paul Ramesh gives a low-down of the protocol that Apollo Hospitals’ team follows:
Hormonal resuscitation — redressing the imbalance in hormones caused by brain death
Exhaustive analysis of both a transthoracic and transoesophageal echo of donor’s heart
A wide panel of blood tests to detect latent bacterial and viral infections — both for short as well as long term outcomes
A coronary angiogram (for in-house donors) if they have a risk profile for coronary disease — increasingly common even in young donors in our country
A direct cross-match between donor and recipient at the time of transplant to reduce chances of rejection
Bronchoscopy for lung donors
Heart transplants are done for patients whose hearts cannot continue to keep them alive
The heart of a brain-dead donor is checked and then harvested before it is transplanted to the recipient, who has a chance at survival
Dr Christiaan Barnard performed the first heart transplant in the world on Louis Washkansky in 1967 at a hospital in Cape Town
Every year about 3,700 hearts are harvested and transplanted with US and UK being the major transplant centres in the world
Transplants involve great speed, precision and skill and extensive post-operative care