Last month, a team of surgeons at Sydney's St Vincent's Hospital managed to transplant "dead" or DCD [donation after cardiac death] hearts into patients for the first time in medical history. This landmark feat was achieved after two decades of research and four years of intensive groundwork. Avantika Bhuyan speaks to Kumud Dhital, the cardiothoracic surgeon who performed these surgeries, about the challenges the team faced and the way forward
What have been the key learnings from your landmark surgery?
Foremost, we have managed to translate our extensive laboratory and translational research into a reality. This will significantly increase the pool of available donor organs.
Finally, there have been many technical and strategic lessons we can use to continuously improve our procedure - be it retrieving a heart for donation after circulatory death or how best to resuscitate it on the portable ex-vivo organ care system, which allows us to transport the donor heart in a beating state back to the transplanting hospital.
What were the challenges you faced and how do you plan to address them?
The major challenge when attempting to do something new is taking that calculated courage to do it. It is doubly hard in a clinical setting when a patient's life is at stake. A wrong decision could also have jeopardised or significantly derailed the programme of transplanting DCD hearts. If you wait for perfection or start to worry about your reputation, then that courage will never materialise. What is important is to have the conviction that due diligence has been done.
The other challenge was to make sure that our technique of retrieving the heart would not put the liver and kidneys at risk. All the organs were successfully transplanted, which was reassuring. We are hopeful that continued dialogue with our abdominal surgical colleagues will allow us to improve our collective techniques to make it even safer for organs to be transplanted.
What is the way forward?
We should consolidate and add to the clinical evidence by carrying out more transplants. We need to push the boundaries of research to make this more commonplace, through facilitating its acceptance and adoption by other transplanting units globally. For this, we continue our laboratory research and seek funds for research and the expensive technology it needs.
Is the solution and "heart-in-the-box" machine developed by St Vincent's being fine-tuned after these surgeries?
The preservation solution for the heart has been developed at St Vincent's Hospital with all the basic research carried out at the Victor Chang Cardiac Research Institute. The so called "heart-in-a-box", or more accurately the Heart-Organ Care System (OCS), is a commercially available device developed by Transmedics, a biomedical device company in Boston, USA. It has been around for roughly eight years and has been used for the preservation and transportation of hearts in some heart transplant units, but the cost, or at least the perceived cost, has meant that it has not been widely adopted. Its use in resuscitating marginal brain-dead donor hearts is gaining recognition through a growing number of successful transplants that are being achieved with organs that would have been otherwise rejected. We are improving the preservation solution and the technology in the OCS.
In developing nations such as India, what challenges do doctors face in trying to attempt such surgeries?
Before considering such transplants in isolation, it is imperative to have in place several key components: a strong network of heart failure services with dedicated personnel, a local administrative environment that supports and funds a heart failure/transplant programme, a community programme at informing and seeking organ donation, an educational programme at school and work-places, and finally, being a champion to stay the distance in making it all happen.
What would it cost to perform such a surgery in India?
Successful heart transplant programmes in India are entirely possible, and I would say imperative, given the incidence of heart failure and the size of the population. It doesn't have to have a research component at the start. The equipment is expensive with the basic OCS console costing around $150,000 (Rs 90 lakh). And then each disposable (one per transplant) module is priced at $35,000 each. The technical expertise available in India could easily be guided in developing such organ preservation systems locally at a fraction of the cost. Even if local governments find it hard to justify the cost of such technology, I am mindful of the philanthropic individuals and agencies in India. A collaborative support from this quarter, assuming community and government partnership, could help establish successful transplant units in India.
What have been the key learnings from your landmark surgery?
Foremost, we have managed to translate our extensive laboratory and translational research into a reality. This will significantly increase the pool of available donor organs.
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Secondly, we have learnt the value of early engagement of the multi-disciplinary staff involved in the entire process - from the physicians who look after the donor and coordinators who seek permission for organ donation to abdominal surgical colleagues with whom we need to work efficiently and all members of the surgical team and transplant cardiologists.
Finally, there have been many technical and strategic lessons we can use to continuously improve our procedure - be it retrieving a heart for donation after circulatory death or how best to resuscitate it on the portable ex-vivo organ care system, which allows us to transport the donor heart in a beating state back to the transplanting hospital.
What were the challenges you faced and how do you plan to address them?
The major challenge when attempting to do something new is taking that calculated courage to do it. It is doubly hard in a clinical setting when a patient's life is at stake. A wrong decision could also have jeopardised or significantly derailed the programme of transplanting DCD hearts. If you wait for perfection or start to worry about your reputation, then that courage will never materialise. What is important is to have the conviction that due diligence has been done.
The other challenge was to make sure that our technique of retrieving the heart would not put the liver and kidneys at risk. All the organs were successfully transplanted, which was reassuring. We are hopeful that continued dialogue with our abdominal surgical colleagues will allow us to improve our collective techniques to make it even safer for organs to be transplanted.
What is the way forward?
We should consolidate and add to the clinical evidence by carrying out more transplants. We need to push the boundaries of research to make this more commonplace, through facilitating its acceptance and adoption by other transplanting units globally. For this, we continue our laboratory research and seek funds for research and the expensive technology it needs.
Is the solution and "heart-in-the-box" machine developed by St Vincent's being fine-tuned after these surgeries?
The preservation solution for the heart has been developed at St Vincent's Hospital with all the basic research carried out at the Victor Chang Cardiac Research Institute. The so called "heart-in-a-box", or more accurately the Heart-Organ Care System (OCS), is a commercially available device developed by Transmedics, a biomedical device company in Boston, USA. It has been around for roughly eight years and has been used for the preservation and transportation of hearts in some heart transplant units, but the cost, or at least the perceived cost, has meant that it has not been widely adopted. Its use in resuscitating marginal brain-dead donor hearts is gaining recognition through a growing number of successful transplants that are being achieved with organs that would have been otherwise rejected. We are improving the preservation solution and the technology in the OCS.
In developing nations such as India, what challenges do doctors face in trying to attempt such surgeries?
Before considering such transplants in isolation, it is imperative to have in place several key components: a strong network of heart failure services with dedicated personnel, a local administrative environment that supports and funds a heart failure/transplant programme, a community programme at informing and seeking organ donation, an educational programme at school and work-places, and finally, being a champion to stay the distance in making it all happen.
What would it cost to perform such a surgery in India?
Successful heart transplant programmes in India are entirely possible, and I would say imperative, given the incidence of heart failure and the size of the population. It doesn't have to have a research component at the start. The equipment is expensive with the basic OCS console costing around $150,000 (Rs 90 lakh). And then each disposable (one per transplant) module is priced at $35,000 each. The technical expertise available in India could easily be guided in developing such organ preservation systems locally at a fraction of the cost. Even if local governments find it hard to justify the cost of such technology, I am mindful of the philanthropic individuals and agencies in India. A collaborative support from this quarter, assuming community and government partnership, could help establish successful transplant units in India.