Bridge To Heart Transplantation Technology Strengthens Program In South Africa

• Q & A With Prof. Charles Yankah and Dr. Willie Koen
(CY: Prof. Charles Yankah, WK: Dr. Willie Koen)
Q: You and Dr. Koemare, pioneers of implantation of mechanical heart supporting devices in Africa, can you describe to us why they are so important in terms of medical innovation?

CY: It is recognized that end stage heart disease is best managed by cardiac transplantation when medical therapies have failed. Heart transplantation is technically well established and is no more a challenge.

Unfortunately there is simply not enough donor organs to address this problem. Worldwide not even 1% of patients with end stage heart disease will receive a donor heart. This is where mechanical heart technology (Left, Right Bi-Ventricle Assist Device (LVAD, RVAD, BVAD) it so significant.

It is mandatory to develop skills in the application of this life-saving support technology to strengthen a modern cardiac transplant program. It allows us to treat more patients with end stage heart disease for different therapeutic goals; as a bridge to heart transplantation, as a support for recovery of the diseased heart muscle or as a permanent support system life-long, which is called Destination Therapy.

Q: On the African continent, South Africa has become a leader in implanting heart supporting system, the Left Ventricle Assist Device (LVAD). It has been used in children as well.

WK: Although donor organs are very rare, paediatric donor organs are even rarer. As a result, children with end stage heart disease are even less transplanted than adults. The Berlin Heart devices (LVAD: Left ventricular assist device, BVAD: Biventricular assist device) are designed for adults and children, at this pointit can be inserted into children with pediatric sizes.

This technology was only a futuristic concept 55 years ago when the first human heart transplant was performed by Professor Christiaan Barnard in Cape Town. The concerted effort of the implanting team and home nursing is crucial. The child will wait on the device under blood thinner medication (anticoagulation) till a donor organ is available.
Q: You and Dr. Koen, seem to have a very good working relationship, can you tell us about it?

CY: I met Dr. Koen in 2000 at the Groote Schuur Hospital, Cape Town when I was invited by Prof. Von Oppell, Head of the department of Cardiothoracic surgery, who succeeded Prof. Christiaan Barnard to give a lecture on the use of mechanical circulatory support systems to bridge patients in terminal heart failure to transplantation. Dr. Koen, who is a consultant heart transplant surgeon at the Christiaan Barnard Memorial hospital became interested in this technology, and in that same year came to Berlin for training on mechanical heart support technology.

At that stage he was involved with research and animal implantations using mechanical devices at the University of Cape Town, Groote Schuur Hospital.

Dr. Koen is a very intelligent young surgeon who picked up the implantation techniques very quickly. My relationship with Dr. Koen and Cape Town dates back to 2001. In 2001 he started implantation of the artificial heart support (LVAD) using the “Berlin Heart” in Cape Town at the Christiaan Barnard Memorial Hospital with great success.

My relationship with Christiaan Barnard dates back to 1975. I met Christiaan Barnard for the first time in Bombay at an international meeting, “Surgery in the Tropics” organized by my long term friend Prof. Dev Saksena.

The second time of meeting Christiaan Barnard was in 2001 after initiating the first implantation of the Berlin Heart device in Cape Town, South Africa by Dr. Koen. I shared with Chris my ideas about future avenues in the field of cardiovascular treatment for cardiomyopathy patients in Africa and alternatives for heart transplantation.

He was very much attached to his vision on the future application of xenotransplantaion.

My relationship with Dr. Koen deepened as both of us had the idea to train young doctors in Africa on new advances in cardiac technology by organizing rotating seminars (African Heart Seminar) in various African countries and also giving hands-on training on newer cardiac technology such as echocardiography (heart ultrasound or sonography).

We started the African Heart Seminar in 2004/5 in Cape Town. Through these efforts the Pan African Society for Cardiothoracic Surgeons (PASCaTS) was born in 2011 in Berlin. He is the co-founder and is Vice-President of PASCaTS. In 2012 PASCaTS entered into partnership with the two world’s most prestigious societies, the European Association for cardiothoracic surgery and the American Association for Thoracic Surgery to promote cardiovascular surgical education in Africa.

Q: In 2015, for the first time, the LVAD was given to a patient outside of South African borders, why is this milestone so critical to the continent?

WK: The vision was to establish a mechanical heart program in Cape Town and develop it into a centre of excellence which will provide comprehensive treatment options to patients all over the continent. In the beginning this was regarded by many as an unrealistic expectation. However, it took some time and in 2015 we could demonstrate that this is very possible. I foresee that this service can be extended to the rest of Africa and can only grow as this technology improves and becomes more affordable.

WK: The cost of these devices are obviously a massive hurdle, do you foresee that in the future that they will become cheaper and perhaps be more readily available to even patients in public hospitals?

WK: As with all technology, the cost comes down as the demand increases. We already know that two thirds of all cardiac implants worldwide is now mechanical. This has rapidly increased over the past five years. Looking at this increase in demand it is inevitable that the cost will come down with time.

Q: Along with Dr. Koen, what is your vision for HVAD and other mechanical implants on the continent?

CY: We know that this is very expensive technology in emerging economies but it is not regarded as a first choice, priority medical treatment. It is a third choice treatment when all the treatment options have failed and the patient is in a terminal heart failure and in need of respiratory support as well. However, the benefits of this technology will eventually outweigh the cost impact. Governments and individuals realise this and are not adverse to the novel treatment modalities to save lives of children especially. That is why we are patiently waiting for the cost to come down without falling behind in establishing this infrastructure and know-how on the continent.
Q: What is the chance of HTx program in Cape Town if one hears about the low rate of heart transplantation (three transplantions a year) at the Groote Schuur hospital?

CY: Following my lecture at the Groote Schur hospital on this subject in 2001, Dr. WK took up this initiative and successfully developed bridge to heart transplantation program at the Christiaan Barnard Memorial hospital in Cape Town after Professor Bruno Reichart from Munich, Germany, the successor Professor Christiaan Barnard went back to Munich.

He started the mechanical circulatory support system (MCSS) program in Cape Town using the Berlin Heart technology and currently the Heart Mate ventricular device from USA. In children the Berlin Heart device is still the only device used worldwide. He appreciated this technology as mandatory for a modern HTx program for improving the survival rate of patients in terminal heart failure on waiting list.

Dr. Koen continues to be the undisputed flagbearer of HTx with dignity and respect in Cape Town.The management of CBMH has to be congratulated for their professionalism and vision to support the primary and bridge to HTx programs of Dr. Willie Koen in Cape Town.