Three Ways an LVAD Buys Time: Bridge to Transplant, Bridge to Candidacy, and Destination Therapy

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.

There's no absolute guarantee, but our programme gives a referred patient the best realistic odds in the country. My team has presence across the north through Artemis in Delhi, the south through Kims and Aster hospitals in Bangalore, and the west through KD Hospital in Ahmedabad and a Mumbai centre, which puts us in direct reach of three of India's five active regional transplant organisations. We're also the only team doing hypothermic oxygenated perfusion, which extends a donor heart's viable cold storage time from about four hours to eight to ten hours and widens the geography we can pull an organ from. Matching still depends heavily on the patient: blood group, a height in the 160 to 180 cm range, and a weight in the 70 to 90 kg range, because we can only accept a heart within about 10% of body surface area or 10 cm of height. The longest wait I've seen a foreign heart transplant patient go through is 12 to 14 months. Of the 20 to 25 foreign patients we've transplanted over the last five to six years, all but two eventually received a heart.

It describes a patient already accepted and worked up as a transplant candidate who has not yet found a suitable organ. A foreign patient in India who cannot get a matching heart quickly is a textbook example, and the device buys the time the allocation system needs.

It applies to patients so critically ill it is unclear whether they will survive the next 24 hours, let alone qualify for a transplant. The device, often started as VA-ECMO, is used to restore circulation to the kidneys, liver and other end organs. Around four to five weeks on a VAD is often enough to bring end-organ function back to a genuinely good transplant candidate.

Patients around 50 to 55 or older, with a reasonable expectation of quality of life but who are not good candidates for an outright heart transplant, increasingly receive a third-generation LVAD as a permanent solution, now lasting 10 to 12 years rather than the three to five years typical five years ago.

Yes. A longer run on the device tends to sensitise a patient to a wider range of antigens, which the transplant team then has to account for when a matching heart becomes available.