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 Khalifa: Qatari with a Scottish heart

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 characterization demonstrated very poor left ventricular function with diffuse hypokinesis. He was kept on medical therapy.

The following year I received the following letter From Baylor college of Medicine, Houston, Texas:

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. (Hajar) Ahmad, in the followup of Khalifa. 
Recommendation: 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.

- This article was published in Heart Views vol.2 no.2 June-Aug 2001 P.85-87.

- Few years later Khalifa died with Respiratory tract infection while he was traveling as a tourist in South East Asia.


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