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The Challenges and Early Successes of an MCS Program at The Fortis Memorial Research Institute (Gurgaon, India)


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Sandeep Attawar, MD
Fortis Memorial Research Institute
Gurgaon, India
Attawar.sandeep@gmail.com



I was a late adopter of mechanical assist devices as far as heart failure or thoracic organ transplantation was concerned. Given the available modalities of practicing cardiac surgery in India, I have felt a longstanding, personal frustration at the inability to support failing hearts, both post-cardiotomy and following acute heart failure. I do not believe I am alone as this has been a source of contention for my contemporaries across India.

The origin of this issue may stem from out-of-pocket payor system. Our nation's private healthcare infrastructure presents patients with a host of obstacles, most notably that patients must pay (mostly) upfront money for all major surgeries and hospitalizations. Private medical expenses are a source of financial ruin to individuals in middle- and lower-income groups, especially given the patchy coverage and inconsistent quality of the nationalized health service.

In late 2011, the relocation of my practice to Chennai with the Global Hospitals group coincided with a sudden and fortuitous surge in organ donations in the state of Tamil Nadu. I say fortuitous, because it proved an opportunity to push for solutions that had hitherto been absent from an Indian healthcare context. We made some early inroads, securing promising results with both heart and lung transplantation - our success the result of observing the strength and organizational nous of first-world healthcare systems and strict implementation of fundamentals. Our goal was to isolate lessons that would inform our attempts at setting up a robust program of our own. On the heels of my work in Chennai, I spent three months at a Heart Failure, Transplantation and MCS program at the Allina Health System in Minneapolis - an invaluable experience that has informed my current vision for cardiac care in my home country.

Since relocating to the Fortis Memorial Research Institute in Gurgaon, I have worked in my capacity as Head of Cardiac surgery to set up a robust, quality center for transplantation. Though my location may have changed, I noted that many of the obstacles and issues that I had faced in Chennai remained: stubbornly low rates of organ donation and doubts over advanced therapy for donation. If anything, problems were even more deeply seated. Yet, at the same time, the rising tide of medical tourism to India, especially from the Middle East and Africa, buoyed my long-term vision of mechanically-assisted circulatory support as a viable and reliable, albeit expensive, solution. The existing shortage of available organs coupled with state and national laws effectively blocking access to foreign nationals in need of a transplant meant that prospective patients with terminal and end-stage heart failure were implanted with a HeartMate II ventricular assist devices.

One procedure on an Iraqi male in mid-2014, in particular, was covered extensively by the Iraqi media, and ultimately paved the way for many more patients to come to our center for destination therapy. Our link with ReliantHeart Inc. enabled us to implant 5 HA5 Axial Pumps successfully. Furthermore, our confidence in carrying out such procedures was shored up by improvements in telemedicine that have allowed for remote monitoring, ensuring that even the delicate health of an LVAD patient can be maintained by his or her heart-failure specialist - In this sense, the HA5 has well and truly lived up to expectations.

Utilizing a 24/7 telemonitoring tool and an INR tracker - which allows the implant team to monitor a patient's vitals - is a major step in alleviating anxiety for both patients and their relatives, which in and of itself produces improved outcomes. It also helps ensure rigorous patient care and daily reinforcement of caregiver protocol. I anticipate improvements in technology to only diminish the issue of geographical gap further in the coming years.

All in all, it is for a plethora of reasons that I am a strong proponent of the effective and judicious use of MCS, many of which are obvious to the medical community: the limited longevity of transplants, the globally static pool of eligible organs, restricted access to available organs, and the onreous task of postoperative care. With continuous improvements in design and materials, artificial support devices have inched up the performance curve and almost match outcomes and survival rates of post-transplant patients. The accompanying benefits of less medication, less intensive monitoring and consistent blood flow thanks to improved pump designs - not to mention the very real possibility of a TET design - mean that a patient's prospects of an unencumbered lifestyle are greater than ever.

Though I admit my own professional circumstances have shaped my perception, I likewise implore you all to recall the basic truth of treating our patients, which is to leverage the best science and technology available to us to make medical recommendations that will be of greatest benefit to this complex subset of patients. ■

Disclosure Statement: The author has no conflicts of interest to disclose.




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