Journal of the Practice of Cardiovascular Sciences

: 2021  |  Volume : 7  |  Issue : 1  |  Page : 1--2

25-Year history of heart transplant in India: Lessons learned

UM Nagamalesh 
 Ramaiah Narayana Heart Center, Ramaiah Memorial Hospital, Ramaiah Narayana Heart Centre, Bengaluru, Karnataka, India

Correspondence Address:
U M Nagamalesh
Ramaiah Narayana Heart Centre, Bengaluru, Karnataka

How to cite this article:
Nagamalesh U M. 25-Year history of heart transplant in India: Lessons learned.J Pract Cardiovasc Sci 2021;7:1-2

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Nagamalesh U M. 25-Year history of heart transplant in India: Lessons learned. J Pract Cardiovasc Sci [serial online] 2021 [cited 2021 May 18 ];7:1-2
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Heart failure (HF) is associated with high risk of morbidity and mortality and poor quality of life. HF is a growing clinical and economic issue due to its increasing incidence and unfavorable prognosis. The prevalence of symptomatic HF is 2%–3% in the general population and 20% in the elderly aged >75 years. Nearly 50% of patients die within 4 years of diagnosis. In case of severe/advanced HF, the 1-year mortality rate is as high as 50%.[1],[2]

Over the years, heart transplantation (HTx) has developed from a highly experimental technique to the gold standard treatment for many patients with severe/advanced HF refractory to medical or device therapy.[3] The first human HTx was performed in South Africa by Dr. Christian Barnard in December 1967. After the event, the first HTx in the United States was performed by Dr. Shumway et al. at Stanford University in January 1968. However, during this event, initial patient outcomes of HTx were poor due to complex postoperative problems, such as graft rejection and infection. The first HTx in Asia was performed by Dr. Juro Wada at Sapporo Medical University, Japan, in 1968. Similar to the experiences in the US, the initial surgeries yielded poor outcomes until the introduction of cyclosporine in 1980.[2]

The advances in various areas of HTx, including surgical techniques, recipient–donor management, organ preservation, prevention and treatment of graft rejection, and complication management after HTx, have improved overall survival rate of patients post-HTx.[3] Recipient–donor selection is the most crucial factor for successful patient outcome. Structured multidisciplinary team approach and continuum of care are the key to long-term patient survival after HTx.

However, in India, once patients with advanced HF, such as the New York Heart Association Class IV Stage D HF with 5-year survival rate of zero, experience dramatic improvements after undergoing HTx, they do not often present for follow-up, which presents substantial challenges to healthcare providers, in terms of effective long-term patient outcomes.[4] Notably, even after being discharged, recipients of HTx are at high risk of infection, mainly due to immunosuppression. This is alarming because, given that India is a developing country, certain diseases, including malaria, tuberculosis, enteric fever, and influenza, are extremely prevalent. Moreover, recipients who belong to lower socioeconomic status are more likely to be exposed to communicable diseases on a regular basis.[4]

The waitlist time for patients requiring HTx is remarkably escalating, which could be attributed to several factors, including increasing number of candidates and increase in survival with the use of mechanical circulatory support (MCS) as a bridge to HTx. Therefore, in India, maintaining respectable annual average volume of 12–15 HTx annually per center is difficult. MCS reportedly plays a pivotal role in the treatment of patients with advanced HF. Over the last decade, >15,000 HTx procedures have been in the United States. Technology is advancing rapidly in this field. Although 1-year survival rate now approaches 80%, it is well below the 90% survival rate at 1 year after HTx. The increasing number of patients with end-stage HF eligible for HTx and the substantially low number of donor hearts have led to increased interest in ventricular-assisted devices (VADs).

According to the final report of the MOMENTUM 3 Trial, the HeartMate 3, fully magnetically levitated centrifugal-flow intrathoracic left VAD, was superior to the Heart Mate II axial continuous-flow left VAD, in terms of the survival free of disabling stroke or reoperation for replacing or removing a malfunctioning device. The current strategy for the management of patient with refractory stage D HF with reduced ejection fraction is the initial screening of patients requiring HTx. For those who do not qualify for HTx, VAD is considered as the secondary treatment.[5]

In India, the first successful HTx was performed at the All India Institute of Medical Sciences, New Delhi, on August 3, 1994. The longest surviving recipient at the institute is currently 19-year post-HTx. Eventually, the number of HTx surgeries started to increase in South India, especially in Tamil Nadu. Relatively, more structured organ donation program initiated by respective state government and transplant program started by private hospital play major roles in successful HTx program in South India.

The study, entitled “1-year outcomes following orthotopic HTx at a tertiary care center in India,” clearly shows that survival rate improves annually, which is very much similar to any other transplant program. This is due to better comprehension of patient selection, immunosuppression, and overall knowledge and coordination approach among HTx team achieved with appropriate experience.

The characteristics of the current status of HTx in Korea have been recently described in comparison with the International Society for Heart and Lung Transplantation (ISHLT) and the Japan HTx Registry. In Korea, HTx data for patients with long-term durable MCS were unavailable because of the current reimbursement system.[6] Contrastingly, HTx with concurrent inotropic support is the most common treatment strategy in Korea. The 1-year survival rate (91.6%) for patients in Korea reported by the KOTRY Report was higher than that reported in the ISHLT Registry (85.0%).[6] In addition, 93% of HTx has been performed with concomitant inotropic support; this value is much higher than that reported in ISHLT (40%) and Japanese (5%) data. Notably, a relatively high proportion of patients undergo HTx surgery with the concomitant use of extracorporeal membrane oxygenator in Korea (19%) than that reported in the ISHLT data (only 1%).[6] Probably, this is highly similar to the transplant program in India, where the use of MCS as bridge to transplant is limited.

In the study entitled “1-year outcomes following orthotopic HTx at a tertiary care center in India,” most HTx was performed on economically challenged population. The average cost of transplant was Rs. 1,258,809 ± 141,318. Among these 40 patients, only one was with MCS as a bridge to HTx. The incidence of primary graft dysfunction, cell-mediated rejection, and antibody-mediated rejection was similar to already available data from other centers.

This result is very encouraging among transplant community in India to make HTx as a standard therapy for patients with advanced HF. Structured cadaver organ donation, organ allocation, multidisciplinary team approach, and mandatory follow-up of patients post-HTx are crucial to achieve successful transplant program in India. In India, while developing individual HTx program, a single super-specialty center should consider performing 20–30 HTx annually as it will lead to better patient outcome than 4–5 centers performing 4–6 HTx annually.[4]


1McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in Collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012;33:1787-847.
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5Mehra MR, Uriel N, Naka Y, Cleveland Jr JC, Yuzefpolskaya M, Salerno CT, et al. A fully magnetically levitated left ventricular assist device. New Eng J Med 2019;380:1618-27.
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