Heart Transplantation in Children: Can we do it in Pakistan? It is an intriguing title it goes without saying that this operation has not yet been undertaken in pakistan wheres other solid oragn transplantations are undertaken routinely You may ask what is so unique about the heart transplantation We know that there is something unique about the heart It is one organ we associate with life and death But there are other attributes about the heart more in the domain of metaphysical which fires the imagination of poets There is an element of gestalt about heart transplantation not associated with other organs But you know that there is somethinh unique about it It has attributes attched to it which are put it mildly mythical Poets around the globe focus on it You may ask what i Asif Hasan , Paediatric Cardiac Surgeon, Director of Cardiopulmonary transplantation Freeman Hospital Newcastle , United Kingdom

3rd December 1967 As we rapidly approach to mark the fiftieth anniversary of first heart tx Before I get into answering these questions let us look briefly at the history of heart transplantation as it is more than just a mtter of passing interest as some of the issues raised then are just as valid now.This is an iconic image of twentieth century which inspired a generation of youngsters to do medicine.as it was one of the great medical advancement of twentieth century This photo of cb shaking hand of lw is one of the iconic images of twentith century the operation was undertaken on 3rd dec what is not generally known that only three days later the first paed tx was undertaken in a baby with chd

Adult and Pediatric Heart Transplants Number of Transplants by Year 2015 NOTE: This figure includes only the heart transplants that are reported to the ISHLT Transplant Registry. As such, the presented data may not mirror the changes in the number of heart transplants performed worldwide. JHLT. 2015 Oct; 34(10): 1244-1254 JHLT. 2014 Oct; 33(10): 996-1008

6th December 1967 Let us atart at the beginning The first pediatric heart tx was undertake more thn 40 years ago and only three days after cb It was a remarkable feat by any accounts The whole operation was undertaken without cpb, therefore the icebath for deep hypohermia circ arrest The recipent was an infant with congenital heart disease and the donr an anencephalic baby, donor heart was removed after cardiac death The result was a disaster It wasn’t a successful attempt ant the patient died a few hours later WHAT IS NOT GENERALLY KNOWN IS THAT only three days later there was the first paediatric tx undertaken in new york. Incidentally there baby had been consented a week earlier and might have been the first human heart tx but it was just as well because things did not go well. These are images from the operationsThese are the images from the operation . The baby had ebstiens anomaly and the donor was an anecephalic baby. You can see the baby placed in bath full of ice to cool down to 15 degrees as the operation was undertaken under circulatory arrest The chart ends abruptly because the baby died

This how the newyork times reported the day after The photo is of the suregon ak What followed was sustained criticism both public and professional Ak tried to make sense of it all many years later Central to all the criticism was the question of diagnosis of death something we are still grappling today most famously from Helen Taussig the doyen of pediatric cardiology which ak the surgeon decribed the furore which followed in his article many years later Central to the criticism was definition of death a problem we still have today the criticism was mainly related to ethics in particular to the dilemma of defining death a problem which persists to date, let us come back to this in afew minutes`

Heart Transplantation in Children: Can we do it in Pakistan? It is an intriguing title it goes without saying that this operation has not yet been undertaken in pakistan wheres other solid oragn transplantations are undertaken routinely You may ask what is so unique about the heart transplantation We know that there is something unique about the heart It is one organ we associate with life and death But there are other attributes about the heart more in the domain of metaphysical which fires the imagination of poets There is an element of gestalt about heart transplantation not associated with other organs But you know that there is somethinh unique about it It has attributes attched to it which are put it mildly mythical Poets around the globe focus on it You may ask what i Asif Hasan , Paediatric Cardiac Surgeon, Director of Cardiopulmonary transplantation Freeman Hospital Newcastle , United Kingdom

Adult and Pediatric Heart Transplants Number of Transplants by Year and Location NOTE: This figure includes only the heart transplants that are reported to the ISHLT Transplant Registry. As such, the presented data may not mirror the changes in the number of heart transplants performed worldwide. 2016 JHLT. 2016 Oct; 35(10): 1149-1205

Are there Ethical or Legal barriers Lack of donors Heart failure is not a significant problem Too Expensive Let me articulate a widely held view point Why raise expectation amomgst patients and profession It is too technically challenging

Are there Ethical or Legal barriers Lack of donors Heart failure is not a significant problem Too Expensive Let me articulate a widely held view point Why raise expectation amomgst patients and profession It is too technically challenging

Cadaveric Data in Pakistan... Oct 2017 SUIT 30 kidney tx Shifa 1 Kidney tx Sheikh Zaid 1 Liver tx

Are there Ethical or Legal barriers Lack of donors Heart failure is not a significant problem Too Expensive Let me articulate a widely held view point Why raise expectation amomgst patients and profession It is too technically challenging

Are there Ethical or Legal barriers false Lack of donors Heart failure is not a significant problem Too Expensive Let me articulate a widely held view point Why raise expectation amomgst patients and profession It is too technically challenging

Are there Ethical or Legal barriers There are no donors Heart failure is not a significant problem Too Expensive Let me articulate a widely held view point Why raise expectation amomgst patients and profession It is too technically challenging

So why is the difference So why is the difference. There are several factors which can play role here. Altrhough I have highlighted europe as a model but this is equally applicable universally

Cadaveric Data in Pakistan... Oct 2017 SUIT 30 kidney tx 7 organs from local deceased donors (Mr Naveed, Ms Shamim, Dr A Razzaq Memon, Mr Imran Shah) Shifa 1 Kidney tx Sheikh Zaid 1 Liver tx

Are there Ethical or Legal barriers There are no donors Heart failure is not a significant problem Too Expensive Let me articulate a widely held view point Why raise expectation amomgst patients and profession It is too technically challenging

Are there Ethical or Legal barriers There are no donors True Heart failure is not a significant problem Too Expensive Let me articulate a widely held view point Why raise expectation amomgst patients and profession It is too technically challenging

Are there Ethical or Legal barriers There are no donors Heart failure is not a significant problem Too Expensive Let me articulate a widely held view point Why raise expectation amomgst patients and profession It is too technically challenging

Cause of death in ACHD population Verheugt C L et al .Eur Heart J 2010 31:1220-1229

Predicted UK single ventricle and systemic RV population and functional status So why is that so I do not know But as asurgeon I have to admit that this remains a challenge I know humbleness aand lack of hubris is an unknown trait in surgeons Coats L, O'Connor S, Wren C, O'Sullivan JJ. The single-ventricle patient population: a current and future concern a population-based study in the North of England. Heart 2014; 100: 1348–1353.

Are there Ethical or Legal barriers There are no donors Heart failure is not a significant problem false Too Expensive Let me articulate a widely held view point Why raise expectation amomgst patients and profession It is too technically challenging

Are there Ethical or Legal barriers There are no donors Heart failure is not a significant problem Too Expensive Let me articulate a widely held view point Why raise expectation amomgst patients and profession It is too technically challenging

Are there Ethical or Legal barriers There are no donors Heart failure is not a significant problem Too Expensive True Let me articulate a widely held view point Why raise expectation amomgst patients and profession It is too technically challenging

56 million Dollars

Are there Ethical or Legal barriers There are no donors Heart failure is not a significant problem Too Expensive Let me articulate a widely held view point Why raise expectation amomgst patients and profession It is too technically challenging

But is it an unrealistic perception

But is it an unrealistic perception

But is it an unrealistic perception

Fig. 3 (a) Kaplan–Meier survival overall, (b) survival in CHD versus CM, and (c) survival in era 1 (1987–1998) versus era 2 (1998–2009). From: Outcomes following more than two decades of paediatric cardiac transplantation Eur J Cardiothorac Surg. 2011;40(5):1197-1202. doi:10.1016/j.ejcts.2011.02.054 Eur J Cardiothorac Surg | European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.European Association for Cardio-Thoracic Surgery 49

Are there Ethical or Legal barriers false There are no donors True Heart failure is not a significant problem True Too Expensive True Let me articulate a widely held view point Why raise expectation amomgst patients and profession It is too technically challenging false

Are there Ethical or Legal barriers false There are no donors True Heart failure is not a significant problem True Too Expensive True Let me articulate a widely held view point Why raise expectation amomgst patients and profession It is too technically challenging false What should you do

1987

Will there be enough donors? What are the risks? What would be burden of immunosuppression? Will the heart grow? How many other children would need such transplants? Will there be enough donors? It was really a leap in the unknown there were numerous unanswered questions and I have put some of them here How would it impact on growth and development? What would be the psychological consequences? Will it be worthwhile?

1987 2000

2017 1987 2000