OPINION | Range of challenges affect organ transplantation

It can’t harm the international marketing and public relations objectives of Cape Town’s Groote Schuur-University of Cape Town academic hospital complex to hold fast to the memory of pioneering heart transplant surgeon Chris Barnard.

UCT’s division of cardiothoracic surgery is named after Barnard and just one click on the Groote Schuur section of the Western Cape government website takes you to a page titled “Chris Barnard Performs World’s First Heart Transplant”.

Barnard’s legacy in areas removed from the operating theatre, such as his global apologetics on behalf of the National Party’s apartheid policy, is far from being uncontested, but his clinical accomplishments are without blemish.

Yet, it is difficult to see how Barnard’s clinical legacy is reflected in Groote Schuur’s day-to-day operations and outputs.

The hospital does only a handful of heart transplant procedures a year. In 2020 it did no heart transplants, but performed eight lung transplant procedures.

The low heart transplant figures, according to the hospital, are a function of both limited organ donations and potential recipients who are “appropriate” in terms of socio-economic status and comorbidities.

It had more than 10 patients awaiting heart transplant at the end of 2020.

Cardiothoracic surgeon and heart transplant unit head Dr Tim Pennel says there is constant pressure to move resources away from quaternary procedures like organ transplantation.

Pennel and colleague, respiratory physician and lead clinician on the lung transplant programme Dr Greg Calligaro were interviewed at the end of “a tough year” in December 2020.

“Transplantation is the high end of tertiary and quaternary care,” Pennel says. “There are detractors of transplantation based on the resources that they absorb. We and our hospital management feel otherwise.”

The pressure to move resources away from transplantation has been around for decades, he adds.

“In the mid-1990s, there was a move by national and provincial governments to move resources away from tertiary and towards primary healthcare.

“In the mid-1990s and early-2000s, there were a number of bed cuts and theatre allocation decreases. Hospitals like GSH were doing almost half the cardiac operations compared to what they were doing in the late-1990s.

“Now we have a more supportive management who believe very strongly in tertiary and quaternary care in general. Our services are improving but it takes a long time to regain something that was there before.”

GSH has rapidly developed expertise in performing lung transplants and in post-operative management for former cystic fibrosis patients who, in SA, have a median survival age of only 28 without transplantation treatment.

“For a doctor, having [transplantation as] another option allows you to look after patients in the best way possible,” Calligaro says.

The last lung transplant performed in 2020 was on a young person from an informal settlement in Cape Town.

“The fact that a South African not on a medical aid from her socio-economic group can get a lung transplant, the pinnacle of quaternary medicine in the world, in SA in 2020 in the middle of Covid-19 is a great source of satisfaction for me and probably the highlight of my year.

“The principle that drives us is that all South Africans should have access to these therapies regardless of their funding status or location.”

Pennel says the interplay between hospital and university is crucial to excellence at this high end of service provision.

“Greg coined the term, the concept of the halo effect — by doing quaternary care you’re growing expertise within the university hospital at all levels, which has a downstream effect to helping other services and improving excellence .

“We also believe it is completely unethical not to offer end-stage therapy to patients.”

When I suggest the halo effect is neither an appropriate nor an effective analogy for reviewing the unit’s output, Calligaro points out that ecmo (extracorporeal membrane oxygenation), a heart-bypass machine perfected for lung transplantation, is now widely used for any patient with respiratory failure. It has been an essential treatment during the Covid-19 pandemic around the world.

Pennel initially states that Groote Schuur’s transplant programme under his and Calligaro’s leadership is an early one, but later acknowledges that the heart transplant component is a well-established programme.

“When Greg and I took over the programme, the first thing we wanted to get right was get our own house in order, which we have done,” he says.

“It’s not that anything done in the past was incorrect but it just takes a fresh approach, a fresh set of eyes on a process.”

I also ask about the unit’s commitment to offering treatment to all South Africans regardless of socio-economic status and where they stay.

The latter factor has become cogent for East London’s Unakho Ntshintshi, who requires a heart transplant but initially faced pressure to relocate to Cape Town with her mother in order to be listed.

Both men point to the need to have patients close enough to the hospital to limit delays in getting them to surgery once a donor heart becomes available.

The ischemic window — the amount of time from when the heart is removed from the donor and without oxygenated blood to when it is transplanted into the recipient — must be kept to an absolute minimum. Most transplant programmes suggest four hours as an optimum time.

Calligaro agrees that the unit has a responsibility to the rest of the country.

“At the moment, I don’t think we’re fulfilling that. What you’re saying is correct. [However] transplantation, logistically, is something that is geographically based.

“In the US, transplant centres are supposed to service an area that’s roughly 500 to 600km around your centre. That’s because of the nuts and bolts of getting donors and recipients in the same hospital for the procedure.

“If you’re looking strictly speaking at the geographical limitations to a transplant centre, for one hospital to service a country as big as ours is logistically quite tricky.

“We have evaluated patients from elsewhere in the country. [But] we get a donor, it’s late in the afternoon, we’re still doing the cross-match, you’re a flight away. How do we get you to the hospital by the next morning to do your transplant if there are no more commercial flights [for the day]?

“To have their chance of a transplant being the highest, they really have to relocate to Cape Town or its surrounds in order to take that donor call and be here quickly.

“We don’t prejudice them if they prefer to stay where they are. We will try to offer them a transplant, it’s just a factor of the distance and the machinations that happen on the night of transplant that the amount of offers will be reduced if you’re not living close by.”

Pennel says the unit attempted in 2018 to improve its outreach connections in Johannesburg.

“We tried to establish an adequate referral pattern at Wits and then help to establish them as a transplant unit, but that’s all been put on ice now.

“We do offer transplants to patients around the country, but it’s difficult because they must relocate. One of the challenges is getting accommodation for these patients.

“It’s something we are looking at, whether we can fly down patients from other provinces on the night of transplant or before, but I don’t know that we’re quite there yet. So at the moment we’re looking at having patients relocate.”

Calligaro says national government must provide the resources to pay for transport of patients from other provinces as it is unrealistic to expect the Western Cape administration to pick up the tab.

Having worked in the Eastern Cape, Pennel agrees that there’s no reason why transplantation cannot be done in the province’s hospitals, but states firmly that first you have to get cardiac surgical services happening and that takes years to establish.

“Transplantation can be our ultimate goal — that is our mandate as a teaching hospital to help and facilitate outreach into the other provinces as well”.