|Year : 2021 | Volume
| Issue : 3 | Page : 257-259
How to set a heart transplantation unit in India - A narrative review
TK Jayakumar, Joseph Thomas, Dhaval Bhimani
Department of Cardiothoracic and Vascular Surgery, Government Medical College, Kottayam, Kerala, India
|Date of Submission||06-Dec-2020|
|Date of Decision||18-May-2021|
|Date of Acceptance||03-Jun-2021|
|Date of Web Publication||30-Sep-2021|
Dr. Dhaval Bhimani
1F, Aspire Home, Chamanampadi, Medical College Road, Gandhinagar, Kottayam - 686 008, Kerala
Source of Support: None, Conflict of Interest: None
Cardiovascular diseases (CVDs) have become the leading cause of mortality in India. This epidemiological transition is largely because of the increase in the prevalence of CVDs and CVD risk factors in India. In 2016, the estimated prevalence of CVDs in India was estimated to be 54.5 million. Heart failure (HF) is a major health problem in India with a postadmission mortality of 20%–30%. Heart transplant is the final treatment for HF if intractable to medical management. Number of heart transplantations done in India is still very less compared to the disease burden and may be attributed to less awareness for organ donation in India. As the number of heart transplantation is increased drastically in the past decade, we need to have proper information about heart transplantation program in India. This is our attempt to simplify information regarding heart transplantation for cardiothoracic units planning to start such a program.
Keywords: Heart failure, heart transplantation, start-up of heart transplant unit in India, surgical management of heart failure
|How to cite this article:|
Jayakumar T K, Thomas J, Bhimani D. How to set a heart transplantation unit in India - A narrative review. Indian J Transplant 2021;15:257-9
| Introduction|| |
Today, heart transplantation is the definitive treatment for end-stage heart failure, intractable to maximum medical management. Heart transplantation is increasing in our country in the past decade, especially in the past few years attributable to increase in awareness among common public regarding organ donation and its benefit, and better improvement in immunosuppression. P. K. Sen et al. performed India's first, and the world's fourth, heart transplant way back in 1968. This was accomplished on the back of a 100 canine heart transplant experiments, a feat which is unthinkable today. First successful heart transplant from brain dead donor was done in India at the All India Institute of Medical Sciences by professor Venugopal in 1994. Government of India (GOI) has taken initiative for organ transplant in India to prevent organ trafficking and to provide unique system for organ harvesting and organ recipient criteria. GOI has passed new act named THOA (Transplantation of Human organ and tissues) rules 2014 and formed National Organ and Tissue Transplant Organization (NOTTO). This organization is formed under Directorate General of Health Services (DGHS) to regulate the organ and tissue transplant and prevent organ trafficking. Till date, NOTTO is not being implemented in many states and they are following their own guidelines and regulations.
| Methods|| |
Here is a simple algorithm for starting a heart transplant in India.
[Figure 1] explains the steps required in setting up heart transplantation unit.
Step-1 (Team effort and spirit)
It is very important that full team should be formed and well motivated in this regard. Normally, team should consist of main and assisting surgeon, cardiac anesthetist, perfusionist, assistant, nursing staff – preferably senior and coordinator, physiotherapist, nutritionist, and last but not the least – cardiologist, well trained in posttransplant echocardiography. Surgeon is the team leader and may require assistant surgeon for two things when donor harvesting is far from recipient area then assistant surgeon needs to be ready with the procedure when team is arriving with heart to prevent the gap in procedure and save crucial golden period. Anesthetist should be well versed in proper guidelines for anesthesia in harvesting and in transplanting patient physiology for anesthesia and requirements. Well-experienced perfusionist is a must to avoid unwanted complication. Nursing support is always important in preoperative workup and during postoperative care. Coordinator is also an important person who will be in constant touch with patient and relatives in preoperative, postoperative, and follow-up period. Cardiologist is also a very important person in the team as, graft acceptance and rejection is followed up primarily on echocardiography and then if needed, with endomyocardial biopsy. Physiotherapist and nutritionist also play a small but very important part in postoperative management. Above all, team spirit is what matters because one man in team can never get to win matches, as it requires team effort. At our center, we have a fully functional team.
Step-2 (Legal perspective)
Hence, many centers and doctors are not preferring to start transplant unit because of legal issues. However, nowadays, it is easy to start and process a transplant center due to availability of information and support from government. Main part of this lies in getting license for transplant and getting registered. First step is to find requirement for transplant and harvesting center including set up, instruments, and environment, which is available on NOTTO website. How to register and how to get requirements needed for the same is also available on NOTTO website.,,
Once Step-1 and Step-2 is completed, intradepartmental meeting to be conducted by head of team regarding following things.
- To assign role to each member of team
- Each member should know about their role
- Whole process of transplantation should be explained in detail to each of team member.
Step-3 (Guidelines for harvesting and performing heart transplantation and its postoperative management)
Proper guidelines in department must be formed in terms of following.
- Preoperative workup
Proper guideline must be formed in department regarding, how the patient will be worked up preoperatively (including all investigation, and specialty consultation from other department), how to be categorized in list (urgency for transplantation), and plan for operation.
- Scouting team
- Scouting team includes surgeon, cardiologist, anesthetist, technician, perfusionist, and nursing staff
- They should be ready with all instruments needed for harvesting, intensive care unit (ICU) monitor, arterial and central venous lines, echo machine, solution needed for heart preservation, ABO, and HLA compatibility testing kit (all harvesting centers may not have all facility).
- Intraoperative guidelines – guidelines for harvesting and transplanting technique along with needed medication, especially immunosuppressant drugs, should be formed. Steps, we follow in our department, are shown in [Figure 2] and [Figure 3].
- Postoperative management – this is the area which is most vulnerable between success and failure. Guidelines to be formed in for the same in following context.
|Figure 2: Harvesting technique. SVC: Superior vena cava, IVC: Inferior vena cava|
Click here to view
|Figure 3: Transplant technique. ECG: Electrocardiogram, PAP: Pulmonary artery pressure, TEE: Transesophageal echocardiography, ETCO2: Endotracheal tube CO2, CPB: Cardiopulmonary bypass, LA: Left atrium, PA: Pulmonary artery, IVC: Inferior vena cava, SVC: Superior vena cava, ICU: Intensive care unit|
Click here to view
- Routine postoperative cardiac surgery management
- All aseptic precautions including restricting entry, as minimum as possible
- Echo and need for endomyocardial biopsy
- To start other needed oral immunosuppressor agent as per available blood result
- What if rejection occurs, what to do and how to proceed.
Step-4: Guideline for follow-up in postoperative period
- Once patient is fit for discharge, bystander is explained regarding the next line of monitoring at home, treatment, do's, and don'ts and when to follow-up or seek immediate help.
| Discussion|| |
In our department, we have achieved successful outcome after heart transplant in following ways:
We started our journey by getting all the information needed for heart transplantation and arrange workshop for the same from international faculty in our hospital, following which we have made our own criteria for the same. After fulfilling criteria needed for heart transplantation as per government norms, we applied for the license to government of Kerala, DGHS. They did inspection in our department and advised for changes to be made and after correcting all changes, we got license for heart transplantation. Once we got license for the same, we did mock drill for heart transplant alert and made everybody in team aware of the same. Rough idea was given to everybody regarding their role and work to be done by them. We followed our protocol for workup of the patient. Patient who had completed their workup has been instructed to stay nearby and be ready any time for alert. Kerala government has its own website for organ sharing (KNOS.ORG.IN) which maintains transparency in organ transplant. Once we completed our workup, we must upload all details on the same website (KNOS.ORG.IN), and we were put in waiting list for the same. Once we have a donor, we send a scouting team to evaluate in detail all aspects of donor patient, and once donor heart was confirmed good for harvesting, we notify our hospital regarding timing of actual procedure and arrival at hospital. Meantime, the second team was ready with preparation of recipient patient and transfer to operation theater and waited for the team to arrive. After arrival of first team, heart transplant was followed according to protocol and once over, we shift the patient to a separate ICU (well fumigated and restricted entry inside the ICU). We followed strict aseptic protocol including wearing autoclaved OT dress and no exit from ICU once we were inside until duty was over. Once patient is ready for discharge, then coordinator will make arrangements for fumigation of patient's home. Patient and bystander were made aware with all conditions regarding postoperative management and adverse event if at all happen and whom to seek help if any occurs.
Overall, heart transplant is team approach and once done, felt like a worth whole effort. All the very best to all of you for beautiful journey of heart transplantation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jones DS, Sivaramakrishnan K. Transplant Buccaneers: P.K. Sen and India's First Heart Transplant, February 1968. J Hist Med Allied Sci 2018;73:303-32.
Sen PK, Parulkar GB, Panday SR, Kinare SG. Homologous canine heart transplantation: A preliminary report of 100 experiments. Indian J Med Res 1965;53:674-84.
Venugopal P. The first successful heart transplant in India. Natl Med J India 1994;7:213-5.
[Figure 1], [Figure 2], [Figure 3]