Dr Z S Meharwal, Director and Coordinator, Department of Cardiovascular Surgery at Fortis Escorts Heart Institute and Research Centre, New Delhi, has 25 years of experience in cardiac surgery with over 15,000 surgeries to his credit, including complex coronary artery bypass grafting (CABG), valve, valve + CABG and redo procedures. He is also Programme Director of DNB (Diplomate of National Board) Cardiothoracic Surgery at Fortis Escorts Heart Institute. He has worked as Consultant Cardiac Surgeon at King’s College Hospital in London. He is among one of the few surgeons performing complicated surgeries like aortic aneurysm and dissection.
Recently, Fortis Escorts did a successful heart transplant operation of a 23-year-old girl suffering from a rare heart disease. In an exclusive interview with India Medical Times, Dr Meharwal spoke about the various challenges they faced in this complex transplant and about awareness and importance of organ donation.
Tell us something about yourself and your journey in this field so far.
I have been in cardiac surgery field for over 20 years now. I started my practice in India some 20 years back and after practising for few years, I went to the US to work in one of the most prestigious colleges of UK — King’s College Hospital — for about 4-5 years and then I came back to India. I came back because I wanted to serve my own society — the society which has given us so much. I came back in 1997 and since then I have been working with the Fortis Institute. I have been practising all kinds of cardiac surgery especially very complicated and challenging ones such as surgery for heart failure, artery bypass, ventricular assist devices etc.
Tell us about the recent heart transplant operation at Fortis Institute.
At this institute we started heart related programmes many years back and we have all the therapies which are required for treating the patients who have advanced stage of heart failure. Primarily two important therapies for patients who don’t have much option are: 1) heart transplantation, and 2) ventricular assist devices. Heart transplant is considered best treatment for heart failure. But there are many patients who cannot go heart transplant for many reasons. For these patients the other option is – ventricular assist devices. We are doing both of these.
Recently, we did a heart transplant in a 23-year-old girl who was suffering from a very rare condition called restrictive cardiomyopathy, where the chambers of heart becomes rigid, and the heart is restricted from stretching and filling with blood properly. Normally, the blood will pump from the atria side from upper chamber to the lower chamber and the chamber dilutes and pumps blood to the body. In this case, the chambers are stiff, they don’t allow the blood to come to the body and because blood flow is restricted it creates a back pressure. That back pressure increases the volume of every part of the body and patients starts accumulating fluid and water in all the organs including the lungs, liver, abdomen, feet, face… everywhere. We have been treating this girl for about 5-6 years; she has been admitted with us many times.
Unfortunately, medicines don’t help much in these conditions. Also, devices such as ventricular assist devices or pacemakers don’t help. The only treatment possible is heart transplant. Though she had been on the heart transplant list for very long, we did not have any donor for her. Luckily, we got a donor one night and called this patient. She was on a very advanced stage when we called her to the hospital. For last 3-4 months, she had been on bed; she could not walk; she could not speak; in fact by only speaking and drinking she would become breathless. She had swollen abdomen, swollen feet; basically she had been on the very advanced stage of heart failure. Her father is a doctor himself. We admitted her and did the transplant and now she made a very good recovery. She can eat, walk, talk and do other physical activities. Hopefully, she will be able to go back to her routine, normal life very soon.
What were the major risks/complications during the heart transplant?
We had challenges at every stage. First, as I mentioned, she was at very advanced stage, she had the dysfunction of lungs, kidney and liver; a lot of fluid accumulation in the body; the body was very weak; nutritionally, she was very deprived, and, of course, these patients have very low resistance in the body. During surgery we faced two major challenges: 1) the patient was very weak, the tissues of the heart and arteries were very weak and 2) when we do operations, we do suturing of the donor heart with recipient part of patient. The suturing was very challenging. The main challenge was the big size of the heart and the arteries of the heart of the donor, who was a 53-year-old man and the arteries and heart size of the recipient patient was small. This was a mismatch. To match the size, we had to implement special technique to do the heart transplant. Also after the operation, because she had such a weak body, we had to put additional attention to her nutrition, physiotherapy, antibiotic and all other things to make sure her natural recovery.
Will there be any complication in future for the recipient patient as the age gap between the donor and the receiver is huge?
There were two aspects of this — 1) The size of the cavity where heart was to be placed was smaller than the donor heart and 2) mismatch of the various chambers and arteries. Since the donor heart was bigger than the recipient’s, we had to do the suturing of the donor heart’s chamber and arteries but ultimately we were able to do it. There will be no complication in future. But obviously, as this donated heart has been in a body for that many years, there are some changes in the heart which are natural. As far as the functioning is concerned, it will function as any normal heart functions.
Fortis Escorts is one of India’s leading heart institutes, though it is the hospital’s second heart transplant operation. What is the reason?
Yes, in terms of heart care, we are largest not only in India but all over Asia. Even in terms of surgical or medical procedures, it has best infrastructure, best manpower and everything. The reason we have not been able to help our patients with heart transplant or ventricular devices is that heart donors are very limited. If you look at the data from India, South is much advanced; there are lots of heart transplants happening in South. There are primarily two reasons for it — awareness among people on organ donation in general, including the heart donation, the people are aware that a patient who is brain dead is dead and that a dead patient can save life of 3-4 other patients who are suffering from advanced stage heart disease or kidney, liver and other disease by donating the organs. The states in South, particularly Tamil Nadu, have taken a very active initiative to not only create awareness in the society but also to help in creating the infrastructure and have assisted in the transport of the heart, also making sure that the heart can be made available to wherever the heart transplant hospital is. Unfortunately, in North India, including Delhi NCR, we are still facing this challenge. We are working very hard on this in collaboration with NGOs, the NCR governments and the health ministry. We are hoping that in the next three years, we would be able to help more and more patients at end stage heart disease by heart transplant.
In heart transplant one of the major challenges is from the time we disconnect a heart from the body, we call it retrieval of heart, till we graft it in a recipient patient’s body, the time period is very limited and we have to complete the procedure in less than four hours. The earlier we do it, the better it is. After four hours this heart may or may not function and if it functions, the functioning will not be normal. So, the transport of heart from one place to the other is very critical. The green corridors, like the one created for this heart’s transport, play a very important role; it makes sure that no obstruction comes on the way the heart is being transported. In western world, the heart transport is through air. They can get the heart from very long distance because helipads are there available at many hospitals.
What is the number of patients waiting for heart transplant at Fortis Institute?
At our own hospital, as of now, we have 23-24 patients on the heart transplant list, who, if they get donors, should have the transplant done. This is actually a very small number as there are lots of patients who are not in that bad state and we are managing them by medical treatment but if not today very soon they too will become candidates for heart transplant. At least 40% of the patients, not at our hospital but in general, die on the waitlist. Even at our own hospital, three patients of this group, one patient died two days before we got the Gurgaon donor heart. Our patients have been in the waiting list for anywhere around four months to more than two years.
What policy changes are needed to facilitate organ transplants in India?
It has to be a joint effort between us — the medical professionals, the healthcare providers, the government and NGOs — to create and increase awareness in the society that organ donation in general is important and convince the society to pledge their organs after death, which is very popular in foreign countries. One person can save many lives after death.
We expect from the government that transfer of the heart from one hospital to another should be very smooth so that we can complete the procedure in the minimum possible time.
by Rajni Pandey