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Khalifa was a junior employee in the Ministry
of Health.
He smoked two packs of cigarettes daily
since he was 20 years old. He was addicted
to nicotine.
In August 1983, at the age of 40 years,
he suffered a massive myocardial infarction
and he was admitted to Hamad General Hospital.
During transport from the Emergency Room
to the Coronary Care Unit (CCU), he had
ventricular tachycardia. Intravenous xylocaine,
100 mg bolus, suppressed his arrhythmia
until he reached the CCU where he had malignant
ventricular fibrillation on arrival that
required full cardiopulmonary resuscitation
(CPR) with repeated defibrillation.
The CPR was successful but he had a stormy
hospital course over the following 20 days
with recurrent ventricular tachycardia,
heart block requiring temporary pacemaker,
severe heart failure with hypotension, dizziness,
restlessness, agitation, and confusion.
The echocardiogram revealed severe left
ventricular dysfunction with akinetic septum
and dyskinetic apex.
Our final diagnosis was severe heart failure
due to coronary artery disease (CAD).
We considered a toxic substance mentioned
in the file as contributory factor to the
cardiac muscle dysfunction. We walked on
a thin rope managing his severe heart failure,
hypotention of 70/60, low cardiac output
and chemical withdrawal.
We eventually succeeded in discharging him
with BP of 100/80 and reasonably controlled
heart failure.
One week later he stopped all his medications
and he was readmitted with heart failure.
It took us one week to get him back on his
feet to go home again. In October 1983,
two months after his first admission, he
was sent to London for evaluation because
of severe congestive cardiac failure.
Cardiac catheterization demonstrated very
poor left ventricular function with diffuse
hypokinesis.
He was kept on medical therapy. The following
year I received the following letter:
Baylor College of Medicine
Houston, Texas,
USA.
Hajar Ahmed, MD
Hamad General Hospital Doha, Qatar
Dear Dr. Ahmed,
As you know, Mr. Khalifa was admitted to
The Methodist Hospital under the care of
Dr.
Michael E. DeBakey on May 21, 1984.
He underwent a limited cardiac catheterization
study in London in 1983 where only a left
ventriculogram was performed without coronary
angiography.
We repeated the study with the following
results:
Pulmonary artery pressure was 100/40, the
mean pulmonary capillary wedge pressure
was 40; extremely elevated left ventricular
end diastolic pressure of 90/45.
The right and circumflex coronary arteries
were completely normal as well as the left
main segment. The left anterior descending
artery showed 95% stenosis just after its
origin with normal distal vessel. Left ventricular
ejection fraction was 17%. The above findings
were discussed with Dr. DeBakey as to the
possibility of cardiac improvement with
either balloon angioplasty to the left anterior
descending artery lesion or coronary artery
bypass to that vessel.
It was the consensus, however, that in view
of the severe dysfunction of the left ventricle,
a simple opening of the left anterior descending
artery will probably not improve function
except to a very small extent.
It was therefore decided to adjust the medical
regimen and to follow the patient outside
the hospital for a few weeks.
One interesting point to mention here is
the fact that the left ventricular dysfunction
is more severe and out of proportion to
the degree of coronary artery disease that
we found by coronary angiography.
Other causes of cardiomyopathy were entertained
but we felt that an endomyocardial biopsy
may be the best way of elucidating the etiology
for this disease.
This was not followed through because the
treatment probably would not have changed.
It was our final conclusion, then, that
since Khalifa could not tolerate an increase
in his cardiac medication his alternative
would be a heart transplant.
This was discussed with him but he felt
that he wanted to continue on his medical
therapy for the coming six months.
He was well aware of his limitations and
risks. I hope this information will help
you, Dr. Ahmad, in the followup of Khalifa.
Reconmendation: Medical therapy and evaluate
the possibility of heart transplantation
if the medical treatment fails.
A month later, on June 29, 1984, he was
again evaluated in London and the recommendation
was to continue medical therapy.
The following month, July 4th, he was admitted
to the Coronary Care Unit in Hamad General
Hospital in Doha for better control of his
heart failure. During his stay in the hospital
he developed pulmonary embolism for which
he was given anticoagulants and maintained
on Warfarin. He was discharged. A month
later, on 20th August, he was readmitted
to control his heart failure. His heart
failure was becoming refractory to medical
therapy.
We decided during morning rounds that the
only option left for him was heart transplant.
No Qatari citizen ever had a heart transplant
or any other kind of organ transplant yet.
He will be the first if he agreed. Obviously
such an operation must be done abroad.
He refused the idea of cardiac transplant
when the topic was discussed in Houston
earlier.
We wondered how he would react to such a
proposal now.
To laymen, heart transplant at that time
was almost synonymous with condemnation
to death.
I decided to talk to him after rounds and
introduce the recommendation gently.
I went to his room before noon and found
him sleeping peacefully. I hated to disturb
his precious sleep. I left him alone. I
returned to the hospital at 5 PM to visit
him. I pulled a chair and sat next to his
bed.
“Khalifa, the reason you are not feeling
better these days is because the drugs have
reached their maximum benefit.
More drugs will not make you feel better,
it is time to consider the other option”,
I said.
“So what else could be done? If a bypass
operation will help me I will take my chance.”
He replied.
“No. That is not an option. Your own heart
is too weak. You need a heart transplant.
It is the only….”
Khalifa’s eye rolled up before I finished
my sentence.
I looked at the monitor and saw that his
heart rhythm was ventricular fibrillation.
I was alone in the room with him. I opened
the door and screamed to the nurses to bring
the defibrillator.
I thumped his chest. The CCU nurse arrived
and I started CPR.
As soon as the defibrillator arrived, we
shocked him with 300j.
His heart reverted to sinus rhythm. He woke
up agitated and very confused.
I calmed down and told him that he fainted
for a short period and now he is back to
his normal state.
He had no memory of our conversation before
his arrest.
I decided not to pursue that topic further
at that time.
I instructed the house officer to watch
him closely that night.
The following morning I visited him after
round to continue the discussion about the
heart transplant with the defibrillator
next to his bed and a nurse standing near
the door.
He said that he remembered that I was talking
to him before he fainted but could not remember
clearly what I told him.
So I started again by saying to him: “Khalifa,
you need a stronger heart”. He took my statement
as a figure of speech.
“I am not scared”, he replied. “I did not
faint because I am afraid of an operation.
If I need an operation, tell me.” “Yes you
do need heart surgery but you need one where
a stronger heart is given to you to pump
blood for you, better than your own heart.”
“You mean a heart transplant.” He said flatly.
“Yes, exactly.” I said. “Where will you
send me?” He asked. “We will send you to
London, where a famous Arab surgeon, Magdi
Yacoub, will perform the operation.”
I told him. “The sooner the better.” He
said. The following week, Khalifa accompanied
by a doctor and a nurse with resuscitation
drugs and defibrillator were in the airplane
to London.
A few months later, I received a personal
letter from a friend, the cardiologist who
saw Khalifa initially in London.
20th
September, 1984
Dear
Hajar,
I thought I would write and let you know
that Khalifa has now been discharged from
Harefield Hospital having had a successful
cardiac transplant operation by Mr Yacoub.
The change in him is quite remarkable -
I wish you could see him! He was very anxious
that I should let you know that he was well
and was very grateful for everything that
you have done for him.
J.D.Stephens,
MD, MRCP
Consultant
Cardiologist
After his heart transplant, Khalifa felt
too insecure to return home.
He stayed in London most of the following
ten years.
In early the 1990s Khalifa’s younger sister,
Afra, presented to our cardiology clinic
with symptoms of heart failure.
Diagnostic tests confirmed that she had
dilated cardiomyopathy.
She was willing to have a heart transplant
like her brother but unfortunately the rules
and regulations in Europe and USA changed
by that time.
Due to organ shortage, available organs
became restricted to each country’s citizens.
In January 1995 when she was 51 years old,
She underwent cardiomyoplasty procedure,
which involves wrapping a skeletal muscle
around the heart and stimulated electrically
to augment cardiac contraction.
Dr. Magdi Yacoub, the same surgeon who carried
out the transplant for her brother, performed
the operation. Unfortunately, she did not
improve. Surgical re-modification later
did not help her. Her heart failure deteriorated
and her ejection fraction went down to 15%.
Her heart failure was refractory to medical
therapy and on May 10, 1999 she had cardiac
arrest and died in the hospital. Her bother
Khalifa was lucky. He is currently living
in Doha 17 years post cardiac transplantation.
He is remarkably in fair health.
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