A surgical feat

Doctors at the Chennai-based Madras Medical Mission Hospital perform a second heart-lung transplant procedure.

TWO years after conducting its first heart-lung transplantation, the Chennai-based Madras Medical Mission has performed the complex surgical procedure once again. Coimbatore-born Balamurugan Williams received a new heart and lungs on September 21, a day after he turned 31.

What a relatively simple surgical procedure to close a hole in the heart could have corrected, had, after 30 years, left Balamurugan's heart and lungs so damaged that only a transplantation could save him. He was diagnosed as having a hole in the heart when he was hardly three months old. From then on life became difficult for the poor family, of which Balamurugan was the only son, after four daughters. His parents consulted faith-healers and quacks, para-medics and doctors, and had to contend with such absurdities as "the hole will close by itself as the boy grows", and "surgery cannot be done on the small boy". Balamurugan's condition became increasingly unstable as he grew up and he could not attend school regularly. When he was 13, Balamurugan lost his father.

The hole in the ventricular septum led to the reversal of shunt, causing the mixing of impure and pure blood in the heart. This was followed by Eisenmenger's Syndrome, a disorder more commonly known as primary pulmonary hypertension, in which the blood pressure in the pulmonary (lung) arteries is abnormally high. Although its occurrence cuts across age and sex, it is more prevalent among women in the 20 to 45 age group and its incidence is low, affecting only eight in 100,000 people. While its exact cause is not known, it manifests itself in the form of increased resistance to blood flow. Diffused narrowing of the pulmonary arterioles enlarges the right side of the heart owing to the increased work load of pumping blood against the resistance to flow, and progressively damages the heart. Says Balamurugan's mother Kannamma: "His whole body would turn blue now and then and he would have to be rushed to the hospital for emergency treatment."

According to Dr. K.M. Cherian, Director, Institute of Cardio-Vascular Diseases, Madras Medical Mission, who has performed seven heart, one lateral lung and two heart-lung transplants in the last six years at MMM Hospital, there is no treatment for such a condition except a heart-lung transplantation.

Two years ago at a free health camp conducted by KG Hospital in Coimbatore, Balamurugan was advised a heart-lung transplantation. He was directed to MMM. From then on MMM took him under its care until a donor was found. The hospital did not charge him for the surgery. Says Dr.Cherian: "As in the case of the first heart transplantation we did in 1995, this surgery was also fully sponsored. The idea is to initiate such procedures in India and show that they can be a success." Neverthe-less, he says the hole in the heart could have been cured by a simple surgery early on if it had been attended to by a specialist. Balamurugan needed a donor. His wait ended when the family of Sankari (41), road accident victim, decided at the Apollo Speciality Hospital to donate all her organs after she was declared brain-dead. Balamurugan was one of the six recipients of Sankari's organs. Her corneas and kidneys were donated to four persons in Chennai, and liver to a patient at the All India Institute of Medical Sciences, New Delhi.

As soon as the MMM Hospital got a call from the Apollo Hospital at 2-30 a.m. on September 21, a team of doctors comprising N. Madhu Shankar, Vijit K. Cherian and N. Kanagarajan (anaesthetist), went there to harvest the heart and lung after identifying; the blood group and the size of the lungs for compatibility. The most crucial aspect of the procedure, said Dr. Madhu Shankar, was time, as the harvesting of the organs and their transplanting took place in different hospitals and the latter procedure had to be completed within four hours of the former.

Even as the team was heading back to MMM with the donor heart and lungs kept in cold saline solution, another team, headed by Dr. Cherian, was removing Balamurugan's diseased lungs and heart. He was put on the heart-lung machine. First the donor lungs were sewn in place in Balamurugan's chest cavity, followed by the heart, which was attached to the opened back walls of the atria. The blood vessels were then connected and blood allowed to flow through the heart and the lungs. As the heart warmed up, it began to pump blood. The doctors checked all the connected blood vessels and the heart chambers for leaks before taking Balamurugan off the heart-lung machine. Sankari's heart began to beat in Balamurugan's body at 5.30 a.m.

Says Dr. Madhu Shankar: "The transplant, which took about three hours, is technically demanding as care must be taken to preserve important nerves and to control bleeding." The success of heart-lung transplants is determined by the incidence of infection and rejection. It is important to guard against infection as lungs, unlike the heart, are directly exposed to the atmosphere. Says Dr. Madhu Shankar: "It is because of infection that we lost our first heart-lung transplant patient in 1999, 36 days after the procedure was performed. But this time, we are very careful." Balamurugan will be on medication for protection against infection and may remain in the hospital for about four months.

Chronic lung rejection, which comes in the form of a progressive narrowing of the small airways, is another major problem. Left unchecked, the auto-immune cells, which recognise transplanted organs as a foreign body, will damage the cells of the grafted heart and the lung tissues and eventually destroy them.

The incidence of rejection is monitored by a lung biopsy using a fibre-optic bronchoscope. As rejection can occur anytime after the transplant, immunosuppressive drugs are administered to transplant patients for the rest of their lives. Balancing the dosage of immunosuppressants is crucial because though the grafts need to be protected against the immune system, care must be taken to ensure that the immune system does not shut down completely as that would leave the recipient open to infections.

The drug regimen is expensive. But Dr. Madhu Shankar is sure of getting sponsors for Balamurugan.

The first heart-lung transplant ever was performed in 1981. Since then there have been 2,698 such procedures across the world. In South Asia only two heart-lung transplants have been performed till now, and both were at MMM.

The survival rate of the recipients is encouraging - 90 per cent of them survive for over one year, 85 per cent for five years and 75 per cent over 10 years. One recipient is alive 16 years after the transplant. With developments in drug and technology, the survival rate is sure to improve.

According to Dr. Cherian there is no dearth of expertise or technology in India, but the problem lies in the lack of initiative among doctors, the high cost of the procedure and patient care, and the difficulty in finding donors. The donor had to be a non-smoker and the size of the lungs should match that of the recipient's. The lungs of accident victims are usually damaged or tend to contract infection while receiving emergency care.

The organ registry set up in 1999 by the MGR Medical University in Chennai is yet to take off. There are 140 people waiting for heart and heart-lung transplant at MMM. There is an urgent need to generate public awareness on organ donation. There is also an added problem for speciality hospitals such as MMM as they do not get trauma cases. They rely on other multi-speciality hospitals for the supply of organs from the brain-dead. Government hospitals, says Dr. Madhu Shankar, do not have enough ventilators to sustain the brain-dead until the organs can be harvested.

In order to reduce post-transplantation costs, Dr. Cherian suggests that the government abolish import duty on nitric oxide, a well-known mediator of biological functions and an important therapeutic agent.

MMM is one of the few institutions in the country that attempt complex surgical procedures. It set up the Chennai Transplantation Centre in 2000 and sent its coordinator, A.R. Krishnaswamy, for training in transplant management in the United States. Its transplant team has trained in several well-known medical centres of the world. According to Dr. Cherian, the government, philanthropists and the public can do a lot to sustain the hospital's initiative and help patients like Balamurugan who wait for a fresh lease of life.