Inside our chests is an organ we talk about endlessly in song and poetry. The heart is a set of fist- sized muscles that pulses around 70 times a minute, less often if you are an athlete.
Heart transplant surgeon C. Sivathasan still gets a rush from holding the throbbing organ
Dr C. Sivathasan was a part of Singapore's first heart transplant in 1990, lung transplant in 2000 and robot-assisted heart operation in 2005. -- ST PHOTO: DESMOND WEE
Inside our chests is an organ we talk about endlessly in song and poetry. The heart is essentially a set of fist- sized muscles that pulses around 70 times a minute, less often if you are an athlete. It will beat more than two billion times during an average 66-year lifespan, sending blood around the vessels, which, if laid out in a line, would circle the earth twice.
We equate it with life and love, but hardly ever think about it as an organ.
Dr C. Sivathasan, 60, has seen this pump of life throbbing in a patient's open chest and has held it in his hands during transplant surgery. It sometimes gives him pause. 'Suddenly, you see a hollow in the chest cavity. It's a body without a heart, but the person is still living. You are taken aback by it,' he says.
Then there are the dozen or so people in Singapore who live without a pulse. Inside them is a tiny turbine that helps the heart do its job, but which robs the patient of heartbeat. Rotor blades push blood continuously around the body 'like a jet engine', he says.
A lot has happened in the last two decades to extend and improve the quality of the lives of patients with heart failure in Singapore, and one doctor has been a central figure in the drama.
For more than 20 years, Dr Siva, as his co-workers call him, has been there when medical history was being made in Singapore and for that, he was given the National Outstanding Clinician award in July by the Ministry of Health. It is given to individuals who have made exceptional contributions to clinical work that advance the safety and quality of patient care and who have supported research.
Dr Sivathasan was in almost all the teams that performed the 53 heart transplants and 10 lung transplants carried out at the National Heart Centre Singapore so far.
In 1990, he helped carry out the first heart transplant in Singapore, followed by the first lung transplant in 2000. In 2005, he helped perform the first robot- assisted heart operation in which the surgeon remotely pilots electronic surgical arms. In 2009, he helped carry out Asia's first heart-liver transplant.
The Sri Lankan-born doctor came to Singapore in 1983 after his post-graduate studies and helped set up the heart transplant programme, which by 1990 was ready for its first operation.
A key development occurred two years before that first transplant. In 1988, he understudied at St Vincent's Hospital in Sydney, then the only hospital performing heart transplants in Australia. His mentor was heart surgeon Victor Chang. In his 19 months there, he was involved in 105 heart and lung transplants.
One of the perennial problems with heart transplants is the shortage of donor organs, he says. Previous reports have recognised that Singapore has a low organ donation rate for a developed country.
Organ transplants here are governed by the Human Organ Transplant Act, which allows for the removal of the kidneys, liver, heart and corneas upon death. All Singapore citizens and permanent residents of sound mind are automatically included under the Act once they reach 21 years of age.
Despite the act, there is still a shortage of donor organs. As medicine advances, reducing the number of the young dying, the supply of donor organs shrinks - that is the irony of science.
When Dr Sivathasan started in the 1990s, 60 per cent of donor organs came from road and industrial accident victims, who tended to be younger. This has shrunk to 20 per cent because safety standards have improved, along with better emergency room procedures that save more lives.
Now, the organs come from older donors who die of non-cancer and noninfectious causes such as a stroke. The organs of people who die in their 60s and 70s, however, are considered too old to be useful as donor material.
'The pool is getting smaller and smaller,' he says.
During his time at St Vincent's, he was involved in more transplants than in the 20 years he has spent here, he notes ruefully. Australians have different attitudes towards organ donation.
Last year, there were just three heart transplants in Singapore.
He was speaking to Life! at his office at the National Heart Centre Singapore, where he is a visiting consultant and also co-director of the Heart and Lung Transplant Programme. He divides his time between the centre, a public hospital and a private group practice at Mount Elizabeth Medical Centre.
Just two days before, he had implanted a heart-assist pump for a patient. The entire procedure, including post-operative care, took 12 hours. If he is tired, he does not show it.
The tall man - he stands at 1.87m - speaks in a low-key, calming manner, always preferring the more precise medical term over the more general everyday one.
He says he is not comfortable with the spotlight and tries to steer the interview towards medical topics, skimming over the details of his personal life where he can.
Dr Sivathasan was born in Sri Lanka (then called Ceylon) in 1950, the youngest of four sons. He has a younger sister, a housewife. Of his brothers, two are doctors and the third is an engineer. His siblings now live in the United Kingdom and the United States.
He lives in Bukit Timah with his wife, Varadha, a housewife. He has a daughter, who works in Melbourne in the health profession, and a son, also in Melbourne, who is planning to be an entreprenuer.
His father was an engineer, but his uncles were doctors, as was his grandfather, who worked in the medical service in Penang under the British until the Japanese invasion of Malaya in 1941 forced him to return to Sri Lanka.
As a boy, he attended St Joseph's College in Colombo, a Catholic school that has produced one cardinal and the late Ranasinghe Premadasa, a former prime minister and president of Sri Lanka.
Dr Sivathasan studied medicine at the University of Ceylon in Colombo. He then worked at public hospitals in Sri Lanka before going to London to earn his post-graduate specialist stripes.
This was in the late 1970s and early 1980s. There, he met Dr Tan Ngoh Chuan, the former head of the department of cardiothoracic surgery, who recruited him to work in Singapore.
'I was doing well in England and could have stayed there. But when I came here, there were many positive factors. The place looked vibrant and I liked the Asian culture here. I thought it looked like a good place,' he said. He became a Singapore citizen in 1984 and all his family members are citizens.
A typical day for him starts with a breakfast of oat bran and fruit. He has a sandwich for lunch - it might be tuna or vegetable - and his main meal is dinner, which he takes at home. It can be anything from Sri Lankan food to Indonesian noodles, he says.
He avoids foods with saturated fatty acids. While genes do play a role in determining blood cholesterol, bad diets are also a factor, he cautions.
He spends a fair amount of time working with mechanical devices that take over the functions of weakened hearts while the patients wait for donor organs. This is why he is pleased that these machines have come of age. The hardware does not completely replace the heart, but rather, works alongside it, helping to do the job of pumping.
The current model, the HeartMate II, is small enough to be sewn up inside a patient's chest. A power cable runs out of the skin, plugging into batteries and a controller unit that fit into waist and chest holsters, allowing formerly bedridden patients to walk, climb stairs and hold jobs. 'These devices keep them going until a suitable heart becomes available,' Dr Sivathasan says.
The pre-heart assist device days were darker ones for him. There would always be six to eight patients on the waiting list. Given that the demand for donor hearts outstrips the supply, one would expect to see the waiting list grow. But it would not: The grim formula would dictate that about a third would die of heart failure while in the queue.
'You feel sad to see them die. They might have small children and they could be breadwinners,' he says.
In the two years the HeartMate II has been allowed for use here, 15 patients have received it. Of these, only two have received a transplanted heart, so any indication that the device extends lifespans for those on the wait list would be welcome. So far, the news is encouraging.
Around the world, thousands of people are users and one American patient holds the record for longevity: He has had one for seven years. Last year, the US Food and Drug Administration approved the device as an alternative to transplantation, rather than just as a stop-gap measure for those waiting for a donor heart.
At $160,000, the HeartMate II is not the cheapest option, but for many, it is the only one. Government subsidies of up to 80 per cent are available for those who meet the means test criteria.
Dr Tan Teing Ee, senior consultant at the Department of Cardiothoracic Surgery, National Heart Centre Singapore, thinks Dr Sivathasan has been present at so many surgical firsts because he stepped forward.
'He was not 'chosen' for the jobs, he created the jobs through his hard work, vision and passion. These pioneering events would not have happened without him,' says the doctor, who has known Dr Sivathasan for more than 10 years.
His personality is also a factor. 'It is rare for him to raise his voice and I have never heard him swear. He pays attention to details and trains us to do the same,' he says.
Dr Sivathasan is now paying attention to positive news coming out of Europe and the US about heart-assist devices and talks about a Dutch woman who last year suffered a massive heart attack after giving birth to her third child in Singapore.
She has since gone back to the Netherlands with an assist device he helped implant in her chest. She was put on a transplant waiting-list there and considered her options. There are the quality- of-life tradeoffs - a transplant, for example, would mean a lifetime of drugs and side effects, versus living with a battery pack.
In the Netherlands, there are people who have been on the transplant waiting list for so long that the stop-gap mechanical solution has become a de facto permanent fix. She opted to keep the pump for as long as possible.
Says Dr Sivathasan: 'She decided, 'No transplant, for the moment'.'
Although he has carried out dozens of transplants, there is still a special feeling he gets during an operation, especially when he sees a transplanted heart start beating for the first time in a recipient's chest.
'It's a feeling of amazement at what human science can achieve and it makes you wonder what life is about.'
my life so far
Dr Sivathasan with his first Heart Mate II patient, Ms Salina Mohamed So'ot
|'Relatives think that when a person dies, he should look lifeless and blue. But often, they don't look like that because they are on life support to keep the organs functioning' |
Dr C. Sivathasan, on why some people object to the removal of organs from a brain-dead relative
|'We can't take a heart from a 40kg person and put it into a 70kg man. There's not enough horsepower. It's like taking an engine from a Mini and putting it into a Mercedes' |
On the tricky issues of matching donors to patients when it comes to transplants
|Dr Sivathasan (far right) and other doctors with Singapore's first lung transplant patient, Mr Thanvanthri (centre, holding his daughter), in 2000. -- PHOTOS: NATIONAL HEART CENTRE SINGAPORE |
|||'By the 1980s, bypass surgery and complex heart operations had become routine. We were looking at the next stage of development. We were seeing more patients with heart failure. The heart gets weaker and can't pump enough blood for the functioning of the organs. So these patients become bedridden, breathless and have a short life expectancy. This is where transplants come in' |
On why Singapore had to move to heart transplant surgery in 1990
Dr Sivathasan operating in Asia's first heart and liver transplant in April 2009. -- PHOTOS: NATIONAL HEART CENTRE SINGAPORE