Question 1

How can we be confident that a patient we refer will actually get a matching organ once they reach India?

Dr. Biswarup Purkayastha · Accepted Answer

There is no definite yes or no answer. We are one of the largest transplant teams in the country, with presence in the north, the south and the west, which exposes us directly to three regional transplant organisations, the active ones in the country; the eastern and north-eastern ones are not the most active. The team operates out of Kims hospitals in Hyderabad, Artemis in Delhi, KD Hospital in Ahmedabad, Sir H. N. Reliance in Mumbai, and Aster and Kims hospitals in Bangalore. We are also the only team in the country doing hypothermic oxygenated perfusion, which extends the life of the organ from a four-hour static cold window to eight to ten hours. On our list, a patient's chance of getting an organ is probably the highest and quickest in the country today. How quickly depends on patient factors: blood group, height and build, because we can only accept a heart within about 10% of the recipient's body surface area, or 10 cm in height. Many foreign patients have a very different body habitus, and when an organ does come to them it is often a large size mismatch. The longest wait I have seen for a foreign heart transplant patient is 12 to 14 months. Of the 20 to 25 foreign patients we have handled over the last five or six years, I can recall only two who did not receive a heart: one converted to a VAD, and one could not find a heart and went back. Most received a heart towards the end of their window; one was kept on a temporary short-term central ECMO for about six weeks before a heart came. The primary challenge is that patients are often referred in a very poor state, when even a VAD has become far-fetched. Of 25 referrals, I see only about two properly worked up, at a stage where a VAD or transplant can be discussed; most arrive with an ejection fraction of 5 to 10%, and nobody reaches 5% over a fortnight unless it is viral myocarditis. Timely referral, and coming to India early even if only for a workup, is the right way forward.

Question 2

What is the median waiting period for a foreign patient?

Dr. Biswarup Purkayastha · Accepted Answer

For a heart, the median waiting period is about a year, not more.

Question 3

So the family would typically have to stay in India and wait for an organ to become available?

Dr. Biswarup Purkayastha · Accepted Answer

That is where the socioeconomic aspect of transplant comes in: the patient needs to stay in a different country with very different food, and a large part of northern and western India is vegetarian. The situation today may be a lot better than it was five or six years ago, when it all started.

Question 4

How many days of admission does an LVAD require?

Dr. Biswarup Purkayastha · Accepted Answer

The workup takes about a week, after which the numbers are run through a transplant or VAD meeting or a heart failure clinic and we can tell you whether you are a good candidate for a VAD. Truth be told, with a battery of basic blood tests and a very good echocardiogram you can more or less tell whether a person is a VAD candidate. But to adhere to regulations you need a right heart catheterisation, a coronary angiogram and a CT scan of the chest to measure size, size the device and determine the pocket size.

Question 5

Indian law gives Indian citizens preference when an organ becomes available, and India itself faces an organ shortage. How does that affect a foreign recipient?

Dr. Biswarup Purkayastha · Accepted Answer

There are two ways of looking at it. If the foreign recipient is an in-hospital patient at, say, Kims or Artemis, and an organ is being offered by that same hospital, then the moment the state organ transplant organisation refuses the organ, or nobody from that region is able to come and procure it, the in-hospital patient automatically goes to the top of the priority. The hospital does not need to go to every regional organisation for no-objection certificates; it only informs NOTTO that the organ has been refused by the state body, which covers hospitals within roughly a 150 km radius, and that a foreign national in-hospital patient is waiting. If the organ is at another hospital, it has to go through NOTTO and every regional organisation, each of which must give a no-objection certificate, and by then the organ is often lost. Kims takes in foreign patients and promotes in-hospital donation activity in its trauma and neurology units, where grief counsellors, intensive care nurses and intensive care specialists talk to families facing brain death about donation.

Question 6

A heart transplant candidate is already medically complex, and the wait can run to a year. How do patients get through that uncertainty if their condition worsens?

Dr. Biswarup Purkayastha · Accepted Answer

One answer is temporary VA-ECMO and, if the condition deteriorates, reassessing the patient for a VAD. A patient on a VAD who wanted a transplant and did not get one is almost unheard of, because a VAD lets you wait for years. Five years ago a VAD was a five-year solution; today it is a decade-long solution, and some patients live on a VAD for a decade or more.

Question 7

Setting aside stay and logistics, what are the hospital treatment costs for a patient waiting for a transplant?

Dr. Biswarup Purkayastha · Accepted Answer

A heart failure patient staying in the country would probably need to visit the hospital once every fortnight. Hospital and medication expenses run to around $1,500 a month, if not more. Over 12 to 14 months, that comes to about $20,000 in pre-transplant medication and costs for foreign nationals with heart failure waiting for a heart transplant.

Question 8

What does the heart transplant surgery itself cost a foreign national, given the added legal requirements?

Dr. Biswarup Purkayastha · Accepted Answer

For a foreign national, with all the legalities, it is in the range of $50,000, a little less. I think the package Artemis offered is $45,000 for the transplant and $5,500 for the workup.

Question 9

What factors would stop a patient from being an LVAD candidate, so that patients can be investigated locally and not travel to India if they will not qualify?

Dr. Biswarup Purkayastha · Accepted Answer

You need a right heart catheterisation and need to tell us the pulmonary pressures: the transpulmonary gradient, the pulmonary arterial pressure index to body surface area, and the pulmonary vascular resistance. For a heart transplant, the pulmonary vascular resistance should be below about five Wood units or reactive to pulmonary vasodilators; a raised, fixed resistance does not rule out an LVAD, which can bring it down and make the patient a transplant candidate later. For an LVAD, what matters most is the right heart: patients without intractable arrhythmias, and without more than moderate tricuspid regurgitation with congestive symptoms such as congestive hepatopathy and other signs of right heart failure, whose failure is confined to the left heart with ischaemia-related complications, are still candidates for LVAD therapy. If there is one investigation we would ask for in every LVAD patient, rather than a series of echocardiograms, it is a right heart catheterisation study with all the pressures, gradients, the oxygen step-up and pulmonary vascular reactivity to vasodilators. With that, we are in. The discussion should happen at the beginning of the heart failure journey, not near the end: if the ejection fraction is already 10% and the right heart has completely failed, a right heart catheterisation no longer makes much sense.

Live Discussion with Dr. Biswarup Purkayastha