The year 1994 is important for transplant surgeons in India as the first human heart transplant was done in Delhi and India claimed a spot in the world transplant map. As such we were late, and the venture of cardiac transplantation in a government setup is daunting. The first step consists of the preparation of papers with interaction with officials to make them understand and impress upon them the need for such a massive venture: a venture that is life-saving for moribund patients and gives the patients a 2nd chance with a better quality of life. This is an uphill task and the associated media attention is an important factor for swaying the opinion of administrative authorities.
Feats of Baarnard, Shumway, Lower and a host of others, including the stalwarts behind the iron curtain, helped in understanding the intricacies of the surgery. Similarly, a host of laboratory workers, in different types of research facilities, continued their work silently to improve upon the immunosuppression, follow-up monitoring, early detection of rejection features, and features prolonging the health of the implanted organ and postimplantation quality of life.
A succession of organ donation organizations are involved in a country and the availability of an organ for donation has to be mandatorily informed to the state. The regional organ donation organisation then decides the allocation of the organ to a licenced hospital with a waiting list of heart failure patients, graded according to severity and need, requiring an orthotopic transplant, This global support was instituted mainly to do away with unfair trade practice involving harvested organs and to ensure that the organ unfailingly goes to the most needy subject.
The process of cardiac transplantation starts with an inspection of the facilities by important beaurocrats of the health ministry, who also search for the laboratories intimately involved in the performance of transplant-related tissue matching, human leucocyte antigen (HLA) scores, cell grouping and coúnts, and the recent bead technology of antigen-antibody interactive score. Additionally, a Cardiology backup for endomyocardial biopsy should
always be present as it is most important for the assessment of transplant rejection.
In the concerned cardiothoracic unit, apart from the operating theatre, a close adjacent room where the patient with the implanted heart can be seamlessly transported, should be present. This room needs barrier nursing and all facilities for monitoring and emergency resuscitation, blood gas analysis, and other dry biochemistry tests. Portable ultrasound and wireless view of digital x-ray images on the computer screen have further made entry and exit to the room restricted to authorised personnel only.
Simultaneous preparedness of other departments with the intent and will to respond on call is assessed.
All the above procedures demand the filling up of voluminous forms, which must be done by the surgeons interested in implantation.
The people in the ministry take their own sweet time to issue the required license and it is better to get the license for a lung transplant at the same time as situations may necessitate a heart and lungs transplant in one sitting such as in Eisenmenger's patients.
An idea about the modification in the concepts of death and the realisation that a window is available after brain death with an attendant irreversible vegetative state is necessary for organ transplantation. Laws, legislatures, and guidelines are laid down to determine the ethical principles.
The decision of acceptance of the heart to be implanted depends on the transplant team leader, and the final decision of acceptance for implantation is taken by the organ harvesting team leader after an inspection and palpation of the heart. Thus two teams, one for organ harvesting and transport and the second for explantation of the failing diseased heart followed by implantation of the harvested organ, are kept ready. Each team should consist of a group of skilled anaesthetists and perfusionists. There should always be adequate communication between the two teams and Police ensure green corridors for uninterrupted transport of the heart to be transplanted.
The actual surgical procedure is not complex. The basic surgical rule consists of a continuous suture of the left atrium, reconnecting the inferior vena cava (IVC) and then the superior vena cava (SVC), and then re-alignment of the aorta and the pulmonary artery (PA). Marker stitches are taken whenever necessary and the first few stitches are taken in a parachute manner, keeping and holding the donor heart at a distance to align the region of the left atrial appendage and left superior pulmonary vein. The donor's heart is then lowered into the empty pericardial well of the recipient. Continuous, equidistant, hemostatic stitches are taken with polypropylene double-armed sutures of sufficient length and the gauge of the suture should match the thickness of the structure to be joined. The goal is to minimise the number of sutures and knots. Everting sutures with sufficient tightening ensure both leak-proof anastomosis and non-compromisation of the cavity. Modifications frequently happen and depend on the implanting surgeons.
Implanting a pediatric heart implies closer stitches with sutures of a smaller gauge. Cavitary compromise is not acceptable and any minor twist in the alignment of structures may lead to a non-sustainable heart due to gradients.
The team leader is most often the senior surgeon and has to have the basic knowledge and grasp of a large team comprising several surgeons, anaesthetists, perfusionists and nursing personnel. The transplant coordinators interact with the authorities, donor and implant teams, and the party.
Organ transplantation is monumentous and authorities always try to implant as many viable organs that can be harvested from a single brain-dead donor in several matched individuals. This way several patients are benefited. There has been a gradual evolution in the concept, care, and surgical technique since the beginning of transplant surgery. Every change has improved and simplified the method and ischemic time management is not a worry anymore. From 2019 to 2021, our team at the SSKMH & IPGME&R, Kolkata, performed 5 cardiac transplants - this even included a prosthetic valve replaced patient. The following clip shows how a bi-caval orthotopic heart transplant was done in our unit.
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