Heart Transplantation in the Middle East Gulf Region

Current status and challenges of cardiac transplantation in the MENA region: A narrative review

INTRODUCTION

Cardiac transplantation has progressed markedly since 1967, with advances in immunosuppression, surgical techniques, and postoperative care that improve outcomes. However, challenges persist in the Middle East and North Africa (MENA) region due to unique cultural, economic, and infrastructural barriers. This review explores the status, innovations, and challenges of cardiac transplantation within MENA countries, comparing outcomes with global standards.

METHODOLOGY

A comprehensive literature search was conducted across PubMed, Web of Science, and Cochrane databases, including studies from inception to May 2024. Search terms targeted heart transplantation practices, challenges, and innovations in the MENA region. Articles not in English, non-human studies, and duplicates were excluded. Data extraction focused on patient demographics, transplantation outcomes, and barriers specific to the MENA context.

RESULTS

Cardiac transplantation in MENA has made strides, with established programs in Saudi Arabia, the UAE, and Lebanon. Innovations like ex-vivo perfusion and Left Ventricular Assist Devices (LVAD) are improving transplant outcomes, yet organ shortages remain critical. Cultural and religious beliefs influence donation rates, and infrastructure varies widely, with disparities in healthcare resources across countries. Key barriers include low donor registration, inconsistent brain death definitions, and limited public awareness. Economic and infrastructure limitations further complicate access to advanced transplantation techniques.

CONCLUSION

While cardiac transplantation has evolved in MENA, significant barriers hinder widespread adoption. Enhancing public awareness, developing regional networks, and implementing standardized protocols can improve outcomes. Targeted immunosuppressive therapies and continued innovation in organ preservation are essential to advance cardiac transplantation in MENA.

Advanced heart failure therapies in the Eastern Mediterranean Region: current status, challenges, and future directions

While there has been a global decrease in rates of heart failure (HF) prevalence between 1990 and 2019, the Eastern Mediterranean region (EMR) is experiencing an increase. In 2019, approximately 1,229,766 individuals lived with moderate to severe HF in the EMR. Despite the growth in the utilization of advanced heart failure (AHF) therapies in the EMR in the past two decades, current volumes are yet to meet the growing AHF burden in the region. Heart transplantation (HT) volumes in EMR have grown from 9 in the year 2000 to 179 HTs in 2019. However, only a few centers provide the full spectrum of AHF therapies, including durable mechanical circulatory support (MCS) and HT. Published data on the utilization of left ventricular assist devices (LVAD) in the EMR are scarce. Notably, patients undergoing LVAD implantation in the EMR are on average, 13 year younger, and more likely to present with critical cardiogenic shock, as compared to their counterparts in the Western world. Furthermore, AHF care in the region is hampered by the paucity of multidisciplinary HF programs, inherent costs of AHF therapies, limited access to short and long-term MCS, organ shortage, and lack of public awareness and acceptance of AHF therapeutics. All stakeholders in the EMR should work together to strategize tackling the challenging AHF burden in the region.

Acceptance, Awareness, Attitude, and Practices Toward Heart Transplantation: A Saudi Based Survey

Introductions

The awareness of brain death and heart donation (HD) among the Saudi population remains limited, coupled with negative attitudes toward heart donation, resulting in a significant gap between the demand for donor hearts and the available supply. This study aimed to comprehensively understand the current perceptions, attitudes, and practices of the Saudi population regarding HD, as well as identify the obstacles. The ultimate goal was to strengthen the local donor pool.

Methods

A cross-sectional study was conducted from March to May 2023, employing a self-administered internet survey. The survey collected demographic information, assessed awareness, attitudes, and practices related to HD, and was completed by 1820 participants from various regions in Saudi Arabia. Data was analyzed using SPSS version 25 (SPSS Inc., Chicago, Illinois, USA). Chi-square test, Independent-samples t-test, one way analysis of variance test (ANOVA) and Spearman correlation coefficient was performed with the significance level set at p < 0.05.

Results

A significant portion of the population (out of 1820 participants) lacked organ donation cards and were uncertain about the registration process. Participants displayed a moderate level of knowledge about HD, with roughly half holding unfavorable attitudes toward HD. A considerable percentage of participants 62.0% were unwilling to register as heart donors, but a majority (79.9%) were willing to contribute by disseminating information about HD. The study identified significant associations between knowledge scores and several factors, including age (p = 0.002), career (p = 0.000), possession of an organ donation card (p = 0.000), and a history of transplantation or organ donation among relatives (p = 0.000). A significant relationship was observed between attitude scores and several factors, including career (p = 0.001), Saudi region (p = 0.025), possession of an organ donation card (p = 0.000), and a history of transplantation or organ donation among relatives (p = 0.000).

Conclusion

The study highlights the urgent need for increased awareness to bolster the number of local heart donors. The involvement of healthcare professionals and social campaigns is essential to enhance public knowledge and potentially boost the willingness of individuals to become donors.

Organ Donation and Transplantation among Non-US Citizens: Opportunities to Improve Global Equity in Heart Transplantation

BACKGROUND

Non-US citizens/non-US residents (NCNR) are a unique and growing population. Patterns of heart donation and heart transplantation (HT) within this subgroup have not been described fully. The purpose of this study was to evaluate the use of organs from NCNR donors and the characteristics and outcomes of NCNR HT recipients.

METHODS

All adult donors whose hearts were recovered for HT and all primary adult HT recipients from 2013 to 2020 were identified using the United Network for Organ Sharing. Donors and recipients were categorized as citizens, residents, or NCNR. NCNR were further categorized by reason for travel to the United States. Outcomes included mortality, infection, and rejection at 1-year after transplantation.

RESULTS

NCNR accounted for 0.4% (n = 77) of heart donors. Most NCNR donors identified as Hispanic (61%), were predominately recovered from the South and Southwest United States, and were less likely to express written documentation to be a donor compared with citizens and residents. NCNR accounted for 0.7% (n = 147) of all HT recipients. The majority identified as non-Hispanic White individuals (57.1%). Compared with citizens and residents, NCNR recipients seemed to be sicker, as evidenced by higher intra-aortic balloon pump use before HT and higher priority United Network for Organ Sharing status. Of NCNR recipients, 63% traveled to the United States for HT, predominately from Kuwait (29.9%) and Saudi Arabia (20%). At 1-year after transplant, there were no differences in mortality, infection, or rejection between the groups.

CONCLUSIONS

A growing subgroup of NCNR travel from countries with low HT rates to the United States for HT. This finding highlights the need for strategies to improve equitable access to HT domestically and abroad.

A systematic approach to transplanting non-resident, non-citizens in an established US pediatric lung transplant program

Introduction

Methods

Results

Conclusion

Traveling for heart transplantation and returning with COVID-19: a logistical, clinical, and pharmacotherapeutic challenge from the Middle East

Heart transplantation (HT) has become a standard option for patients with end-stage heart failure (HF). However, the scarcity of donor availability remains a major hurdle for receiving this novel therapy, especially in the context of the rapidly spreading severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; COVID-19) pandemic. We report the case of a patient in the United Arab Emirates (UAE) with advanced HF who was glucose-6-phosphate dehydrogenase deficient and had a history of type 2 diabetes mellitus with diabetic retinopathy and nephropathy, chronic kidney disease stage II, and hyperlipidemia. He was referred for HT abroad and was subsequently caught in the midst of the COVID-19 pandemic in New York, the US state most affected by the crisis at the time. Despite limited experience with favipiravir, we judged it to be the most appropriate agent with this patient’s complex history given the lower risk for QT prolongation, no need for renal-dose adjustment, and no reported drug–drug interactions. Given the limited clinical experience with this agent, particularly for our patient, we decided to adopt strategies to mitigate and monitor the potential for QT prolongation. We outline the logistical, clinical, and pharmacological challenges that the poly-morbid patient and our HT program in the Middle-East faced under those novel circumstances.