The Canary Islands are a Spanish territory with slightly over 2 million inhabitants, distributed over 7 islands. Located in the Atlantic Ocean, west of the coast of Morocco, the Canary Islands are at a distance of >1700 km from Madrid (Figure 1). Because the Canary Islands have no heart transplant (HT) program at this time, their inhabitants are usually referred to Madrid. The distance between patient’s home and the transplant center in Madrid requires a very careful follow-up and coordination between cardiology departments in addition to a complex logistical organization when it comes to the transplant.1
Here, we present how those inherent challenges impact accessibility and outcomes of cardiac transplant recipients residing in the Canary Islands.
HT FOR A DISTANT ISLAND POPULATION
In 1991, the Advanced Heart Failure Unit in Madrid entered into a relationship with one of the main hospitals on the Canary Islands and established a patient referral for cardiac transplantation and a coordinated follow-up between centers. Subsequently, we gradually included patients in cardiogenic shock with mechanical circulatory support devices (MCSDs). Based on the European Society of Cardiology recommendations, we have implemented a “hub (Madrid) and spoke (Canary Islands)” network.2 In detail, patients are referred from the specialized heart failure units of the 4 main island hospitals to our Advanced Heart Failure Unit (hub center) coordinating the transplant evaluation and follow-up. It should be stressed that this network is based on the existence of a rapid and fluid communication between all participating institutions to ensure continuity care. Furthermore, many cardiology fellows from the Canary Islands are trained in heart failure and cardiac transplant at our hospital.
In general, patients are electively referred for a cardiac transplant evaluation and brought to the mainland hospital by a commercial flight. Once patients are approved for transplant, they will stay in proximity to the center until the transplant is performed. The median wait time for cardiac transplant in our institution has been 74 days (26–293) in 2018, including elective and urgent transplants. With frequent visits and a higher probability of complications during the initial post-transplant period, patients must remain close to the transplant center for the next 2 months. Once the 2-year follow-up period has been completed in Madrid, scheduled visits on a biannual basis are alternated between the program in Madrid and the referral center in the Canary Islands.
Notably, a different approach is selected for patients in cardiogenic shock. After an initial stabilization with or without MCSD in referral hospital, potential cardiac transplant candidates are transferred for urgent transplantation by air ambulance. After arrival in Madrid, an immediate evaluation is performed and, if approved, patients are urgently transplanted.
ACCESSIBILITY AND OUTCOMES
Based on Organización Nacional de Trasplantes data collected between 1994 and 2018, 215 HTs were performed in patients from the Canary Islands. The vast majority (75.8%) of those were performed at the Hospital Universitario 12 de Octubre in Madrid, Spain. Rates of HT per million population have been comparable in Spain and the Canary Islands during recent years (Figure 2).
From 1991 to 2018, a total of 590 HTs have been performed at the center in Madrid, including 10 retransplants that have been excluded from our analysis. Baseline characteristics and transplant-related data are summarized in Table 1. Notably, patients from the Canary Islands have been slightly younger, with lower incidences of ischemic heart disease and previous cardiac surgery.
Median follow-up after HT was 99 months (22–176 mo). Patient survival rates by 5 years were slightly, albeit significantly, better in patients from the Canary Islands (P = 0.026); by 10 years, survival rates were comparable (P = 0.105) (Figure 3). A multivariate analysis showed comparable survival rates by 5 years (P = 0.051) with recipient age and previous cardiac surgery representing significant risk factors (P = 0.049 and P < 0.001, respectively).
Logistics for patients in refractory cardiogenic shock requiring urgent transplantation have been performed in >37% of recipients from the Canary Islands. Indeed, long distance air transfers for patients in cardiogenic shock supported by MCSD have been shown to be feasible and safe.3-5 Comparable experiences have been reported in a series of 19 patients transferred on venoarterial extracorporeal membrane oxygenation support from Reunion to Paris (10 000 km distance) for urgent HT evaluation, in which no deaths occurred.6 In our series, we transferred 4 patients in cardiogenic shock with intra-aortic balloon pump device and 2 patients on venoarterial extracorporeal membrane oxygenation, one of these also assisted with an Impella CP. We also performed our first air transfer with a short-term ventricular assist device (Levitronix CentriMag) in 2015 and transplanted this patient successfully.7 Subsequently, another patient was transported with a Levitronix CentriMag. No patient died during transport. Five of these 8 patients transferred on MCSD were successfully transplanted.
Our program has provided excellent short- and long-term outcomes.8 Although transport and housing are frequently supported by government and patient associations, we recognize the burden placed on patients and families during the time spent away from familiar surroundings. Although the Madrid Canarian Island cooperation on heart transplantation has been quite successful, the viability of a local, Canarian HT program is currently explored, building on the success of existing kidney, liver, and pancreas transplant programs on the Canarian Islands. Canarian cardiologists have certainly benefitted from training received at the Cardiology Department, Hospital Universitario 12 de Octubre in Madrid, Spain.
The collaboration between the Cardiology Department, Hospital Universitario 12 de Octubre in Madrid, Spain, and Cardiology Centers on the Canary Islands over >2 decades has successfully provided cardiac transplantation for a distant island population with outcomes comparable to those in local patients. With the progress of MCSD, it has been feasible to transport patients in refractory cardiogenic shock over long geographic distances. A current initiative explores the feasibility of local cardiac transplants on the Canary Islands.
The authors thank the Organización Nacional de Trasplantes, particularly María Padilla, for editing the article and selfless validation of the data.
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