Heart Transplant in India for Foreign Nationals: A Guide

A heart transplant in India for foreign nationals is possible, but on different terms from Indian citizens. A foreign patient is listed with the national organ network and offered a donor heart only after every Indian hospital has declined it. The median wait is about a year, the transplant costs a little under $50,000, and a left ventricular assist device (LVAD) can keep the patient alive and well while waiting.

Dr. Biswarup Purkayastha, Consultant – Heart & Lung Transplant and Vascular Surgery, Artemis Hospitals, Gurugram, India, is one of the consultant surgeons in the KIMS and Artemis heart and lung transplant unit. The team behind the unit operates across six centres in the north, south and west of the country, and offers heart transplants, lung transplants, combined heart and lung transplants, ventricular assist devices and extracorporeal membrane oxygenation (ECMO), a machine that pumps and oxygenates blood outside the body, including ECMO transfers across India. His session for doctors in Africa set out what a foreign patient's heart transplant actually involves: the rules, the wait, the money, the devices that bridge the gap, and the single factor that decides most outcomes before the patient ever boards a plane, which is when the referral is made.

Who needs a heart transplant?

A heart transplant is the definitive treatment for end-stage heart failure, the point at which the heart can no longer pump enough blood despite full medical therapy. It sits at the top of a treatment ladder. Medicines come first, and in Dr. Purkayastha's practice they remain the mainstay until the ejection fraction (the share of blood the left ventricle pumps out with each beat, normally above 50%) falls below about 20%. Below that threshold he starts to consider devices: first an implantable cardioverter defibrillator, then mechanical support of the circulation as the patient becomes breathless at rest. Current ESC guidelines recommend a primary-prevention defibrillator for most patients whose ejection fraction stays at 35% or below despite at least three months of optimal medical therapy.

For a foreign national, heart transplantation has one structural advantage over lung transplantation. In Dr. Purkayastha's words, heart transplant is "a little forgiving", because an LVAD can bridge a patient with end-stage heart failure to a heart, a bridge that has no equivalent for lungs. That matters because the defining feature of a foreign patient's transplant is uncertainty over when a heart will become available.

Why Indian patients get the first offer of a donor heart

Indian citizens have priority for every donor organ, so a foreign national is considered for a heart only after them. Organ allocation runs through a three-tier system. At the top is NOTTO, the National Organ and Tissue Transplant Organisation. Below it are five Regional Organ and Tissue Transplant Organisations (ROTTOs), one each for the north, south, east, west and north-east. Below those sit state-level organisations.

A foreign national is listed with NOTTO, the national body, but becomes eligible for a heart only once every other hospital in the country has refused it, whether for size, shape or blood group. Working through every check in the system takes, by Dr. Purkayastha's estimate, six to seven hours at the least, against a usable window of four to six hours for thoracic organs. By the time a heart reaches the foreign national's turn, its reliability is a real concern.

There is one important exception. When the foreign patient is already an in-patient at the hospital where the donor is, and the state organisation declines the organ, the in-hospital patient moves to the top of the priority. The full mechanics, and why the exception favours transplant centres with active in-house donation, are covered in donor heart allocation, waiting times and costs for foreign nationals.

Heart transplant waiting time for foreign nationals

The median wait for a heart for a foreign national is about a year. The longest Dr. Purkayastha has seen is 12 to 14 months. How quickly a particular patient is matched depends mainly on three factors:

• Blood group. A recipient with a blood group that can accept a wide range of donors waits less.
• Body size. A donor heart must be sized to the recipient. International guidance accepts a donor weighing at least 70% of the recipient's weight in most cases, and teams increasingly match on predicted heart mass; Dr. Purkayastha's team prefers a donor body surface area within about 10% of the recipient's, or a height within about 10 cm. Many foreign patients have a different build from the typical Indian donor, so a heart offered to them is often a large size mismatch.
• The team's reach. A team present in several regions sees offers from several regional organisations. Dr. Purkayastha's team also uses hypothermic oxygenated perfusion, a technique that keeps the donor organ cool and supplied with oxygen during transport, and which in his account extends the usable life of the organ from about four hours of static cold storage to 8 to 10 hours.

Heart transplant outcomes for foreign patients

The results are better than the uncertainty suggests. Of the 20 to 25 foreign heart transplant patients Dr. Purkayastha's team has handled over five or six years, he could recall only two who did not receive a heart: one was converted to a ventricular assist device, and one could not find a heart and went home. Most received a heart towards the end of their window rather than early in it. One patient was kept on a temporary short-term circulatory support device for about six weeks before a heart arrived, by which point the team had exhausted its other options.

The waiting period is the dangerous phase. If the patient deteriorates, the options are temporary veno-arterial ECMO and reassessment for an LVAD. Dr. Purkayastha described a patient on an LVAD who wanted a transplant and never received one as "almost unreal", because the device allows a patient to wait for years.

How an LVAD bridges the wait for a heart

An LVAD is a small pump implanted in the chest that takes over the work of the failing left ventricle. It is driven by an external controller and two battery packs that the patient wears through the day and recharges while resting. The only lifestyle restriction Dr. Purkayastha cites is swimming and other underwater activities; people with LVADs have returned to gyms and run half marathons.

An LVAD serves three purposes:

1. Bridge to transplant, for a patient already accepted for transplant who cannot get a heart in time, a common position for a foreign patient waiting in India.
2. Bridge to candidacy, for a patient too sick to be listed, whose organs recover on mechanical support until he or she becomes a suitable recipient.
3. Destination therapy, a permanent solution for patients who are not candidates for, or do not want, a transplant.

Durability has changed the calculation. Earlier devices lasted three to five years; current destination therapy devices are lasting 10 to 12 years and some longer. In Dr. Purkayastha's phrase, an LVAD was a five-year solution five years ago and is a decade-long solution today. Device generations, prices, candidacy criteria and the workup are set out in LVAD as a bridge to transplant: candidacy, devices and referral.

Heart transplant cost in India for foreign nationals

Dr. Purkayastha put the cost of a heart transplant for a foreign national, including the additional legal requirements, at a little under $50,000. He cited the Artemis package as $45,000 for the transplant and $5,500 for the workup. On top of that comes the cost of waiting. A foreign patient with heart failure living in India while listed typically visits the hospital once a fortnight, and he estimated hospital and medication costs over a 12 to 14 month wait at about $20,000.

The costs that do not appear on a hospital bill are just as real. The patient and family have to live for months in another country, with very different food: much of northern and western India is vegetarian. Dr. Purkayastha noted that conditions for families today are probably a lot better than they were five or six years ago.

When to refer for a heart transplant

The single largest determinant of a foreign patient's outcome is the stage at which the referral is made. Of every 25 referrals Dr. Purkayastha receives, he sees about two that are properly worked up, at a stage where an LVAD or a transplant can be discussed. Most arrive with an ejection fraction of 5 to 10%, and, as he points out, nobody reaches an ejection fraction of 5% over a fortnight unless the cause is viral myocarditis. By then even an LVAD can be out of reach.

His message to referring doctors is to start the conversation at the beginning of the heart failure journey, not near its end. Modern drugs can delay heart failure by a decade, but the decision about the long-term path has to be made at the first moment, not after years of outdated therapy have left the heart a dilated, failing chamber. He described a young man in his twenties whose left ventricle had dilated beyond 90 mm: the only option left for him was a transplant. Coming to India early, even only for a workup, is in his view the right way forward.

The investigation he asks for most is a right heart catheterisation, which measures pressures in the right side of the heart and the lungs and tells the team whether an LVAD will work. A patient whose right heart has already failed and whose ejection fraction has fallen to 10% gains little from it. The criteria, and what to send with a referral, are detailed in the LVAD article linked above.

Related reading

The questions doctors put to Dr. Purkayastha during the session, on organ availability, waiting periods, costs and LVAD candidacy, are answered in the Live Discussion. His separate masterclasses cover pulmonary hypertension, coronary artery disease and heart failure and coronary artery disease, and more surgical topics are collected under cardiac surgery.