1. 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

2. 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

3. 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 Oct; 34(10):
JHLT. 2014 Oct; 33(10):

4. 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

5. 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`

6. 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

7. 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 Oct; 35(10):

8. 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

9. 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

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

13. 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

14. 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

15. 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

17. 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

29. 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

30. 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

31. 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

32. 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

36. Cause of death in ACHD population
Verheugt C L et al .Eur Heart J :

37. 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.

38. 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

39. 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

43. 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

44. 56 million Dollars

45. 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

46. But is it an unrealistic perception

47. But is it an unrealistic perception

48. But is it an unrealistic perception

49. 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): doi: /j.ejcts
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

50. 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

51. 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

52. 1987

53. 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?

54. 1987
2000

55. 2017
1987
2000