From Medication to Transplant: The Heart Failure Treatment Ladder

A heart failure patient waiting here typically needs a hospital visit about once a fortnight, and hospital and medication expenses run close to $1,500 a month. Across a typical 12 to 14 month wait, that adds up to roughly $20,000 in pre-transplant costs, before the transplant itself.

Just under $50,000 in total. Our package for a foreign national is $45,000 for the transplant plus $5,500 for the pre-transplant workup.

The single most important test is a right heart catheterisation. I want pulmonary vascular resistance under five Wood units, or at least reactive to pulmonary vasodilators, along with the transpulmonary gradient, the pulmonary arterial pressure index against body surface area, and the oxygen step up. Patients with intractable arrhythmias, or more than moderate tricuspid regurgitation with right heart failure symptoms like congestive hepatopathy, are not good candidates. But if the right heart is intact and the failure is confined to the left side from ischaemic disease, that patient is still a strong candidate for an LVAD.

The law is unambiguous that an available organ goes to an Indian citizen first. But there's a specific exception for in-house patients: if an organ becomes available at the same hospital where a foreign national is already admitted, and the regional transplant organisation refuses it or nobody from that region can retrieve it in time, that in-house patient, even if foreign, moves to the top of the list. The hospital only has to inform NOTTO directly, rather than waiting on a no-objection certificate from every regional organisation in the country, a process that can otherwise cost the hours that make an organ unusable.

Temporary VA-ECMO, or reassessing the patient for an LVAD, buys the time we need. The durability of these devices has changed the calculation: an LVAD that used to be a five-year solution five years ago is now good for a decade or more.

Medical management continues until ejection fraction falls below roughly 20%. At that point the team starts considering an AICD, an implantable cardioverter defibrillator, and as the patient's heart enlarges and breathlessness worsens toward NYHA class 4, the next decision is between temporary VA-ECMO support or a ventricular assist device.

The only firm restriction is swimming or other underwater activity. Beyond that, patients on LVADs have gone to the gym and run half marathons.

The first generation were the Thoratec devices and the original HeartMate. The second generation brought the HeartMate 2 and the HeartWare. The third generation moved to larger magnetically levitated pumps, and the current generation, led by the HeartMate 3, has shrunk that same design down to close to the size of a palm, weighing under 150 grams all in, with a markedly lower risk of clot formation.

Lithium-ion battery packs are rated for about 24 hours, though patients have gone camping and stayed off the grid for as long as 36 hours with the device continuing to run without issue.