And the beat goes on
S.K. Jain, 59, could hardly walk up the stairs a year ago. His heart was in such a bad state that he felt nauseated and breathless all the time. A diagnosis in 1999 showed his heart's left ventricle was swollen, and he has undergone a number of treatments since, eventually leading to the installation of a pacemaker in Mumbai in 2003. However, his condition kept getting worse, so his doctor recommended a heart transplant in 2008. With a donor heart hard to come by, Jain was on the edge of death last year.
Fortunately, a cutting-edge medical device came to his rescue. Doctors at Queen Mary Hospital installed a left ventricular assist device (LVAD), which takes over the left ventricle's job of pumping and supplying blood to the body. The surgery and the pump cost a hefty HK$2 million, but Jain is grateful for his second chance at life.
'I felt and breathed better a day after the surgery,' he says. Without nausea, he now also eats very well.
Jain, an information technology professional, is one of eight patients who have had the surgery since the LVAD was introduced in Hong Kong in 2010. The device gives a glimmer of hope to those on the waiting list for a heart transplant. There are now 18 patients on the list, according to cardiologist Cheng Lik-cheung.
'Some patients die because no timely donor heart is available,' says Cheng. For young end-stage heart patients, the LVAD can serve as a bridge to eventual transplant surgery. For those aged over 65 and not qualified for a heart transplant due to illnesses such as cancer, he says it can be destination therapy, as a last-resort treatment.
There are 200 to 300 patients diagnosed with terminal heart disease every year in Hong Kong - and only one in 10 eventually gets a heart transplant, according to Elaine Chau Mo-chee, a cardiologist at Hong Kong Sanatorium and Hospital, which has so far conducted one LVAD surgery.
The remaining 90 per cent are almost certain to die because therapy, such as the installation of a pacemaker and defibrillator, no longer works. 'But an LVAD can give them medium- to long-term survival with a good quality of life,' says Chau.
Heart failure develops when one or more of the four chambers of the heart fails to keep up with the volume of blood flowing through them. It can be caused by a variety of underlying diseases and health problems.
Each side of the heart has two chambers - an atrium (upper chamber) and a ventricle (lower chamber). The left side of the heart is crucial for normal heart function; the left atrium receives oxygen-rich blood from the lungs and pumps it into the left ventricle, the heart's largest and strongest pump, which supplies blood to the body. This left side is usually where heart failure begins. More than 90 per cent of those with terminal heart disease have left ventricular failure, says Chau. The LVAD works by pumping blood from the left ventricle to the aorta, the body's largest artery. Data collected on patients worldwide who have received the LVAD shows that the pump can be used for up to seven years after implant, says Cheng.
Although it first appeared in 1970, it was not until the 1990s that the device was small enough to be implanted into the chest cavity. This third-generation model weighs only 290 grams and is silent and vibration-free.
The surgery is a routine procedure in the West. In 2010 alone, there were about 2,500 LVADs implanted in the US, according to Henry Ford Hospital in Detroit. But Chau says it's been a 'steep learning curve' in Hong Kong.
Heart surgeons in the city are experienced in heart transplants, with more than 100 done since the first in 1992. But Chau says an LVAD surgery is more 'technically' complicated. About four years of preparation were needed for the first surgery last year, he says. Twenty-two medical personnel worked on the procedure, which lasted 12 hours.
'Post-operative care is also of much importance,' says Chau. 'An infected wound will affect the patient's survival, and the amount of warfarin [blood thinner] the patient takes should be properly calculated. An overdose will give rise to the risk of bleeding, and an insufficient dosage will lead to blood clots and stroke.'
A healthy heart pumps out between 55 and 70 per cent of its blood with each beat. Heart failure is diagnosed when the ejection fraction (a measure of pumping efficiency) drops below 45 per cent.
Mr Ng, 44, the second patient to get an LVAD in Hong Kong, says his ejection fraction dropped to 10 per cent before he received the surgery in 2010 at Queen Mary Hospital.
'My life was a constant struggle. I didn't have the strength to play with my two kids or even wash my hair. I needed to rest five times if I walked 500 metres,' says Ng, the owner of a trading firm, who blames his 30 years of drinking and smoking for his heart disease.
A small cable connects an external control unit and batteries to the internal LVAD unit. The open incision on the skin that the cable goes through must be kept dry, clean and bandaged at all times to prevent infection.
The pump is operated by a pair of batteries that last around 10 hours. If the batteries run down, the patient can die within minutes.
Cardiologist Cheng says both patient and caregiver have to complete a test on patient care before being discharged from hospital.
The artificial heart cannot be exposed to water, and so showering and going out when it's raining are impossible, Jain says.
Instead, he takes sponge baths every day. Each morning after waking up, he records his temperature, blood pressure and heart rate in a logbook, and checks that the device is running properly.
When sleeping or working in his room - Jain works from home from 9am to 6pm - the device is plugged into a socket. But as the cable is only four metres long, he switches to batteries when he moves around his home. He visits the doctor about every five weeks.
Ng says he can't exercise too much, as sweating will increase the chance of wound infection, and has to wear shoes with plastic soles to prevent static electricity from interfering with the device.
He also carries a letter wherever he goes: it states that no external cardiac compression can be done on him in case of a medical emergency, and that he must be sent to only Queen Mary Hospital or Hong Kong Sanatorium and Hospital, the only two hospitals that have facilities to deal with LVAD patients.
Patients in the West are advised to make end-of-life decisions before the LVAD is installed.
If the heart pump patient suffers multiple organ failure or brain damage, ethical or legal problems over whether and when the artificial pump should be disconnected might arise.
But Chau says there's no such concern in Hong Kong. 'We assume a patient dead if his brain is dead,' she says. 'We won't keep him alive with the artificial device.'
To minimise his health risks and ensure quick access to proper medical care in case of emergencies, Ng says he avoids taking long trips.
'I needed to visit the mainland three to four times every week for business in the past,' he says. 'I don't do that now. I would rather earn less money.'
In return, he gets to spend more time with his family. 'In the past, as I spent too many days away from home, my wife was estranged from me and my kids avoided me,' he says. 'Now I have my family back.'
Number of hours the LVAD batteries last before they need to be recharged
A left ventricular assist device (LVAD) helps the heart pump blood around the body when it is no longer able to. Some LVADs pulsate, mimicking the action of the heart, while others such as the one shown here provide a continuous flow of blood, leaving the user with no pulse.
Aorta carries oxygen-rich blood to the rest of the body
External battery pack
Weighs about 500g and lasts about 10 hours before needing recharging
Installation of the device
The point the device will enter the skin is punctured with a needle, and the wire threaded through
The line must not be bent too sharply, and should leave some slack in case it is tugged on
How it works
The largest artery, it receives blood pumped from the left ventricle and carries it to the rest of the body
Blood from here enters the LVAD
Straightens the flow of blood as it enters the pump
Tiny spinning propeller-like screw provides the flow of blood
Spins at around 7,000 revolutions per minute
Pumps blood throughout the body at up to 10 litres per minute, the output of a healthy heart
Wire to system controller
Controller gives a warning or an alarm if power is low or device is not working properly
Note: specifications here based on Heartmate II by Thoratec; other models may vary