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Heart Transplantation in the Middle East Gulf Region

Bader, Feras, MD1; Atallah, Bassam, PharmD2; Rizk, John, BS3; AlHabeeb, Waleed, MD4

doi: 10.1097/TP.0000000000002211
In View: Around the World

1 Cleveland Clinic Abu Dhabi, Heart and Vascular Institute, Al Maryah Island, Abu Dhabi, United Arab Emirates.

2 Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi, United Arab Emirates.

3 School of Pharmacy, Lebanese American University, Byblos Campus, Byblos, Lebanon.

4 Department of Cardiac Sciences, College of Medicine, King Saud University, Saudi Arabia.

Received 30 October 2017. Revision received 23 November 2017.

Accepted 18 January 2018.

The authors declare no conflicts of interest.

Correspondence: Feras Bader, MD, Heart and Vascular Institute Cleveland Clinic, Abu Dhabi Al Maryah Island, PO Box 112412, Abu Dhabi, United Arab Emirates. (baderf@clevelandclinicabudhabi.ae).

Heart failure (HF) is a progressive disease that requires advanced therapies in many patients. With numbers growing worldwide, the need for such therapies including heart transplantation (HT) is also on the rise. The rate of HF in the Middle-East Gulf Region has necessitated exploring both local and international means to meet the increasing demand for HT. This process is paralleled by changing local attitudes and perceptions toward organ donation and transplantation. Here, we highlight the historical progress, current status, as well as the future challenges and opportunities for HT in the region.

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Advanced HF in the Gulf Region

The Gulf Cooperation Council (GCC) countries include Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates (Figure 1). The estimated population of the GCC countries is approximately 50 million.1 It is estimated that 2% of any population have HF with approximately 5% of those having advanced HF.2 Those estimates will translate to 1 million HF patients in the GCC with approximately 50 000 patients having advanced HF. Based on these figures and using US statistics as a reference, we can extrapolate that annually, at least 500 patients in this region will qualify for HT (Figure 2).3 These numbers could potentially be higher as preexisting risk factors tend to be elevated in younger patients in the region, thus increasing the probability of reaching end stage cardiac failure.

FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

Ischemic heart disease is the main cause of HF and the number one cause of death in the Middle East region.4,5 The incidence of concomitant diabetes has been reported to be over 50%, and HF patients in the Gulf region are generally around a decade younger compared with major western HF registries.4,5 Moreover, HF patients from the Gulf are not always managed by specialized programs and may thus either be on a less than optimal pharmacotherapy or may not be on target doses.4,5

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HT in the Gulf Region

HT in Saudi Arabia

The first HT in the Gulf Region was performed in 1986 at Riyadh Military Hospital.6 Currently, the only sizable heart transplant center in this region is King Faisal Specialist Hospital (KFSH) in Saudi Arabia. The first HT performed at KFSH has been performed in 1989.7 By the end of 2016, a total of 339 have been performed inside the kingdom, the majority (250 heart transplants) at KFSH with more than 95% of the recipients being Saudi citizens.6-10 Most heart donors have been non-Saudi expatriates with only 1% to 6% coming from Saudi nationals.10,11 The mean recipient age was 33 ± 13 years, thus significantly younger compared with that in the International Society For Heart and Lung Transplantation (ISHLT) registry (55 years).11,12 Five-year survival for transplanted patients was 78%, in line with outcomes in the ISHLT registry.7,13,14 During the recent 3 years, a significant increase in the number of heart transplants has been observed at KFSH with an average annual 30 heart transplants (into both adult and pediatric recipients).9 However, this activity reflects a rate of only 0.5 per million persons per year, thus remaining significantly lower than rates in the United States and not meeting the need in the region. The existing deficit between supply and demand is reflected by an estimated 15 to 20 incident patients on the waiting list per million populations (PMP), whereas hearts are only available at 1.5 organs PMP resulting in a gap of 14 to 18 hearts PMP.15 The only other center in Saudi Arabia that has performed HT, albeit at a much slower rate than KFHS, is Prince Sultan Cardiac Center, which was previously known as the Armed Forces Cardiac Center in Riyadh. This center has been performing an average of 5 transplants per year during the last few years and data are available on outcomes from the first 10 years of transplantation only. During those years (1986-1996), a total of 25 HTs were performed with an overall 8-year survival rate of 45%, comparable to international results. However, it is important to note that 8 of these 25 recipients died within the first year.16

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HT in Other Gulf countries

Despite the relative success of HT at KFSH, other centers in the region have not been able to establish comparable activities mainly linked to a lack of deceased donors. The United Arab Emirates recently passed laws in support of deceased donor organ donation. In December 2017, the first successful heart transplant has been performed at Cleveland Clinic in Abu Dhabi by a UAE-based team.

Posttransplant care of heart recipients that have been transplanted elsewhere and returning to the region is currently limited to 3 centers in the region, 2 in Saudi Arabia, and 1 in the United Arab Emirates. The largest experience in the Gulf Region outside of KFSH is currently at the Cleveland Clinic in Abu Dhabi where we currently follow close to 20 heart transplant recipients (Table 1). Those patients have been sent by our multidisciplinary program for heart transplants in the United States, or, more commonly in the recent past, to India. Although following with us afterward, none of those patients was diagnosed with more than a mild degree of cellular rejection (ISHLT grade 1R). Accordingly, we never had to treat them after their routine biopsies done at our center with more than a short course of oral steroids, or just slowing down their originally scheduled steroid taper. Our immunosuppression regimen consists of tacrolimus, mycophenolate, and a standard prednisone taper to allow a steroid-free regimen by 6 months in many patients. Antimicrobial prophylaxis to prevent opportunistic infections and statin therapy to prevent cardiac allograft vasculopathy are initiated according to evidence-based medicine. Pharmacotherapy including patient counseling, drug levels, and drug-drug interactions are monitored and evaluated by dedicated pharmacotherapy specialists.

TABLE 1

TABLE 1

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HT of GCC Patients Abroad

Until recently, out-of-region heart transplant for GCC citizens have almost exclusively been performed in the United States. During the period 2010 to 2014, 72 patients from the GCC countries were listed in the United Network for Organ Sharing (UNOS), the majority adults (44 patients; 61%).8 Approximately, 50% of these patients had a UNOS status 2. The average time on the waitlist was 164 days, as opposed to the 283 days waiting period for patients from the United States. This is reflective of the fact that nonresidents have the same priority as residents per the UNOS guidelines, and, perhaps that the gulf patients were sicker at the time they were listed. The average listing to discharge wait time in the US was 6 months for GCC patients. Patient survival had been 88% and 79% by 1 and 2 years, respectively.8 Because of the progressively increasing waiting time at US centers and reduced costs in Indian transplant centers, a referral shift has been observed.

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Challenges in Establishing Advanced HF and Transplant Programs in the Region

Attitudes and Perceptions of Organ Donation and Transplantation

Although organ transplantation has been one of the success stories in medicine over the last few decades, the field continues to battle with emerging legal and ethical questions surrounding organ procurement or continued life support. This is particularly relevant in a region with strong cultural and religious considerations. Although the concept of brain death is accepted by most Islamic scholars and societies, the middle-eastern culture as a whole is less comfortable with this concept. Families of very sick patients in the Middle East tend to wish for more life prolonging therapies in the face of terminal diagnosis particularly as the concept of brain death remains less well accepted compared with the arrest of circulatory and respiratory functions.

Several surveys from the region have shown that there is a gap in knowledge about organ donation and transplantation among both Gulf nationals and residents.17,18 Individuals with more knowledge are more likely to have a favorable attitude toward donation and transplantation. For example, many responders in surveys remain under the impression that religion opposes the practice of procuring organs from brain dead donors.17 Other contributing factors include legal misconceptions, insufficient donor registrations, a lack of knowledge that transplantation across sexes is possible, and wrongly thinking that the heart is removed while the donor is still alive.17,18

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Laws and Regulations Pertaining to Organ Donation

Documenting the willingness to donate organs is not a standard practice in the region compared with some western countries where such status is noted on identification cards. Thus, the decision on organ donation rests solely on the next of kin. Unfortunately, only 33% of approached families in Saudi Arabia provided consent in such cases.9 Moreover, results of surveys have also shown that even when individuals had a favorable view of organ donation, they were still not willing to make this decision on behalf of a family member.19

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Availability of Multidisciplinary HF and Transplant Programs

An important challenge on the way to establish HT in the region is the availability of dedicated advanced HF and transplant programs. Lack of resources or allocation of support is the most relevant obstacle. Ongoing efforts focus on the education of healthcare providers, administrators, and policy makers on the value of such programs to progressively grow the field in the region.

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Opportunities and Future Directions for HT programs

More patients with advanced HF in the Middle East Gulf Region need transplants. In addition, many HF patients need better care as shown by the less than optimal utilization of evidence-based medical therapy in the Gulf HF registries. This is particularly relevant because motor vehicle accidents and cerebral vascular accidents are common in this region, both of which presenting an opportunity for organ donation from brain dead donors. The Saudi Center for Organ Transplantation is a good example of providing education, organ allocation, coordination and procurement. Close to 75% of all intensive care units in KSA collaborate with the Saudi Center for Organ Transplantation, an integral component to the success of such initiatives and similar collaborations applied to other GCC countries.15

Institutions in the Gulf region need to be creative in overcoming current challenges through establishing regional collaboration. Moreover, an already existing cooperation council in the Gulf region could be used as the basis for an integrated organ procurement initiative. Such an approach should include sharing waitlists and management protocols. Moreover, an intensified international collaboration with North American and European programs is needed to compensate for necessary services that are missing locally. This is in addition to international collaboration with new heart transplant centers outside North America and Europe.

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CONCLUSIONS

The growth of HT in the Middle East Gulf Region continues to rely on the success of regional and international collaborations. Moving forward, it will be essential to use available resources and to explore new avenues to provide local advanced therapies for more end-stage HF patients. Establishing an effective organ procurement system in the region will be critical for the success of cardiac transplant programs.

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