Establishing a Heart Transplantation Program in a Middle East Country: Requirements, Logistics, and Implementation Strategies

Abstract

Heart failure is a chronic condition that many patients must treat with cutting-edge treatments. Worldwide population growth has increased the demand for various treatments, including heart transplantation. In order to meet the rising demand for such therapy, it was necessary to investigate both local and international options to tackle the increasing rate of HF in the Middle East Region. Local attitudes and perceptions regarding organ donation and transplantation are shifting in tandem with this process. This well-established intervention is not very popular in the Middle East as there are only a few centers that provide this service. We hereby discuss the background and Strategies for heart transplantation requirements, logistics, and implementation in Middle East countries.

1. Introduction

Heart transplantation has emerged as a lifesaving treatment for end-stage heart failure patients worldwide [1]. Despite the successful outcomes achieved by established heart transplantation programs, many regions, including Middle East countries, lack comprehensive programs for this critical intervention. This chapter will focus on providing an in-depth analysis of the necessary requirements and logistical considerations to establish a heart transplantation program in a Middle East country, with an emphasis on the unique challenges and strategies specific to the region.

Before we start, it is important to have a vision of the history of heart transplantation in Middle East counties.

Middle East, the lands around the southern and eastern shores of the Mediterranean Sea, encompassing at least the Arabian Peninsula and, by some definitions, Iran, North Africa, and sometimes beyond [2]. According to the published literature regarding the countries providing heart transplant services in Middle East, few countries have this modality of treatment (Table 1). In fact, this shows how important it is to work to find new centers and transfer the service to countries that have not yet started the heart transplant program.

Country	First heart transplantation (HT)
Saudi Arabia	The first HT was performed in 1986 at Riyadh Military Hospital [3]
United Arab Emirates	In December 2017, the first successful HT was performed at Cleveland Clinic in Abu Dhabi by a UAE-based team [4]
Iran	Heart transplantation in Iran was first performed in July 1993 [5]
Jordan	In 1985, the first-ever successful cardiac transplant in the Middle East and the Arab world at the King Hussein Medical Center in Amman, Jordan was performed by Dr. Daoud Hanania [6]
Turkey	In 2001, Turkey performed its first successful heart transplant [7].

Table 1.

History of cardiac transplantation in middle east region.

2. Infrastructure for heart transplantation program

Building a state-of-the-art facility equipped with advanced cardiac surgery units, dedicated transplant wards, intensive care units, and a comprehensive diagnostic laboratory is crucial [8]. The infrastructure should be designed to meet the unique needs of heart transplantation, including specialized equipment, operating rooms, and dedicated post-transplant care units. Additionally, investing in advanced imaging technologies, such as cardiac MRI and echocardiography, will facilitate accurate pre- and post-transplant assessments.

In addition, complex transplant patients need a large infrastructure that includes specialists in advanced circulatory support, cardiac critical care, nutrition, social work, and other fields. Indeed, a robust, comprehensive, cutting-edge heart transplant program should contain the following components to provide the greatest care for heart transplant patients [9]:

1. Care for all oregonians—modern patient care that is based on public service and does not make distinctions based on insurance status.

2. Adult and pediatric capabilities—able to provide the full continuum of care for patients of all age ranges by being able to address complex heart diseases in both adult and pediatric patients.

3. Multi-organ failure capabilities—access to the knowledge and resources provided on-site by other organ transplantation programs, such as those for the liver, kidney, and pancreas, are crucial for successful outcomes in patients with multiple organ failure.

4. Unmatched expertise—A strong team of advanced heart failure transplant cardiologists, critical care specialists, and transplant surgeons with experience in pre- and post-operative care, who are committed to training future cardiologists and surgeons, need to consistently sharing their knowledge, evaluate current services to ensure best practices, and advance that knowledge.

5. Cardiovascular intensive care unit—around-the-clock intensive care facility that only treats seriously ill cardiovascular patients.

6. Level 1 trauma—patients in urgent need of highly specialized cardiovascular care, including those with heart failure, receive the highest level of round-the-clock lifesaving trauma care.

7. Clinical trials—the capacity to instantly link heart transplant patients with a wide range of clinical trials that offer the most cutting-edge options for therapy in order to support and enhance their care.

3. Legal framework for heart transplantation

Establishing a robust legal framework that addresses organ donation and transplantation is essential. This framework should encompass legislation ensuring the legality, consent, and ethical guidelines for organ procurement and transplantation [10]. It should also include mechanisms for organ allocation and distribution, as well as regulations to prevent organ trafficking. Cooperation with international transplantation organizations and adherence to global standards, such as those provided by the World Health Organization (WHO) [11] and the Declaration of Istanbul [12], is paramount.

For example, in a recent article discussing the legal system in Germany [13] for transplantation, Germany has used the recent organ controversy as a chance to develop its processes for allocating and procuring organs, which are built on the principles of openness, quality assurance, and process improvement. This of course led to Increasing organ donation in Germany, as it depends on winning back the confidence and support of all parties, especially those in the healthcare industry. The German Organ Procurement Organization was strengthened, intensive care specialists were involved in the donation and management of organs, a transplant registry was established, and allocation guidelines were updated, Among the accomplishments to date is a focus on structured specialization training with a future 2-year fellowship requirement, a legal framework for transplant center organization, outcome measures, and quality assurance [8].

4. Medical expertise

Developing a highly skilled multidisciplinary team is critical for the success of a heart transplantation program, multiple professions are engaged in the care of heart transplant patients because of their chronic and complex conditions. This team should include transplant surgeons, cardiologists, anesthesiologists, immunologists, psychiatrists, social workers, and specialized nurses [1]. This is important in the preoperative phase and post-operative care and recovery period. Implementation of Regular Multidisciplinary Review Committee (MDRC) meetings and daily multidisciplinary rounds for post-operative patients, and expansion of the attendees for the MDRC meetings improved care related to heart transplantation [14]. Collaborations with experienced transplant centers can facilitate training programs, fellowships, and knowledge sharing to build expertise within the local medical community. Establishing partnerships with international institutions for mentorship and guidance can further enhance the knowledge and skills of the transplant team [8].

5. Organ procurement

For decades, the limited availability of heart donors has been an inherent hindrance to cardiac transplantation. As a matter of fact, establishment of a robust cardiac organ procurement system is the most complex task. Hearts procurement is considered a multi-stage process complimented by a series of different interrelated logistics that does not affect donors or recipients only but their families, friends, caregivers, morals, beliefs, and the whole society. Moreover, it’s been years before agreeing on science and evidence became clear in setting guidelines to improve the donation numbers. The science of transplantation regarding the safety and availability of donors is evolving, and donors who have not been considered as donors in the past are now able to provide the flair of streaming life to others. Additionally, increasing the number of donors is necessary to increase the number of organs accepted for transplantation by carefully and safely taking into account people who were previously excluded from the process [15].

Current practice entitles two different procurement strategies: the classical strategy; donation after brain death (DBD) and recently; heart donation after circulatory death (DCD) [16].

Donation after brain death (DBD) has been the traditional pathway for years from which hearts have been obtained for transplantation. Unfortunately, most of the reasons resulting in brain death may directly affect the heart, in this regard; a very limited pool of donors has been considered suitable for transplantation. Moreover, the management of this pathway of donation after brain death is complex & it includes keeping cardiac and arterial pressures ensuring a protective ventilation strategy, and homeostasis. People with coronary artery disease (CAD) risk factors, such as age greater than 40, hypertension, a history of using cocaine, heroin, or amphetamines, previous or current smoking history, and dyslipidemia, should undergo coronary angiography; also for patients with a family history of premature CAD; or who have suspected wall motion abnormalities on echocardiography [17]. Each center should advocate a clear criterion to be met to facilitate the procurement decision after reviewing each donor using a specific flow diagram that entitles all information about donor history, all current diagnostic information, and previous and current hemodynamic parameters with continuous repeat assessment of ongoing management, diagnostics & vitals status parameters [18].

On the other hand, heart donation after circulatory death (DCD) is usually perceived as ethically more complex as it necessitates at some point fainting of support from the donor, which might be difficult to explain to the donor’s families that a beloved one is kept alive only as a means to convey their hearts to the recipients. Such a concept of keeping and ending life touches on a very sincere tenet in the Middle East society, which values the courtesy of death as much as life. Contradicting misbeliefs and conflicts associated with DCD malefice its implementation in the Middle Eastern world [19].

1. Unfortunately, since organ transplantation was first performed in Egypt in 1976, there has not been a strong legal foundation overseeing it. Organ donation from deceased donors is prohibited by law, so all organ transplant procedures rely on living donors. In addition, a belief that organs cannot be taken from after brain death as life ends with the death of all organs and that as long as the heart still beats, death cannot be declared [20].

1. In the Kingdom of Saudi Arabia, a person is deemed legally dead under two circumstances: (1) irreversible cessation of cardiac and respiratory function, and (2) irreversible cessation of all cerebral function, as per the Islamic jurisprudence resolution dated October 1986. DCD is therefore not in use in the Kingdom of Saudi Arabia or in the nations of the Gulf Cooperation Council (GCC) [20].

2. In Kuwait, only DBD has been in practice since the beginning of deceased donor transplantation in 1996.

3. The Lebanese law No 109/1983 legalizes “donation of human tissues and organs for medical and scientific purposes.” DCD has not yet been attempted in Lebanon. Only corneas are retrieved from DCD donors [21, 22].

4. In Iran, in 1989, it was possible to obtain religious authorization from the Supreme Religious Leader that recognized brain death and permitted deceased-donor organ transplants. Currently, only 1% of donors come from circulatory death [23]. At the Iran University of Medical Sciences, uncontrolled donation after circulatory death (uDCD) was practiced for the first time as of November 2021 [24].

5. Iraq has been pioneering legislation on organ transplantation and donation in the Middle East. Iraq endorsed a precise legal definition of brain death in 1985; it was improved upon in 1989. Articles describing live and deceased donation, donor criteria, (nonpaid) donation, and consent are included in these laws. However, transplant activities are restricted to live donor transplants that are compatible with their blood group and are still only a live donor program.

6. According to the Jordanian Ministry of Health law, To be able to perform the necessary procedures, all hospitals with cases of brain death must inform the Jordanian Centre of Organ Transplantation (JCOTD) Directorate [25].

5.1 Beliefs about heart donation

To proselytize such complex belief in a way to show the nobility of gifting life to others stems from convincing people that this transit interim is not by any means agonizing their beloved ones, on the other hand, it might be an interim of salvation and blessing. Building a network that spreads the virtue of charity that lies within the gift of transplantation and the fact that one life can usher hope to many more lives imitated with the religious and ethical principles that might be the obstacle behind the avoidance of transplantation in the Middle Eastern societies. To start with; assessment of awareness and sentiments toward donation should be the first step that would help to prioritize & plan programs and to pass on awareness and spread correct information at community level. Enlighten that those hearts to be harvested immediately after the declaration of death is very important as some people to most of the participants. This will prevent them from wasting precious time to harvest hearts. By incorporating important information and student activities about heart donation within schools and universities, the educational system can be just as important. Religious scholars can be very important because of their significant impact on Middle Eastern society as advocates for heart donation, highlighting misinformation and misperceptions about the position of heart donation in Islam. Targeted campaigns for healthcare professionals, mainly general practitioners, must also be conducted [26].

5.2 Availability of multidisciplinary transplant programs and role of transplant coordinator

Establishing multidisciplinary teams that work regionally & coordinate together is relevant, for example, the transplant coordinator who plays a keystone in the transplant unit & becomes an integral part of its structure through which all relevant information is conducted. Transplant coordinator is often the first person to meet the recipient and to explain the process and might be the last person he sees at the time of clinical discharge. Transplant coordinator should be experienced in the psychiatric and psychosocial assessments, obtaining a psychosocial history, including background, education, work, and current family circumstances is very crucial to begin with & will pave the road while going along this journey [27].

5.3 Health laws framing heart donation

Starting with donation programs that electively include people to list themselves as donors similar to blood donation programs is another way of spreading the idea of transplantation. The willingness to donate heart should be a standard practice in the region similar to some countries that include this information on ID cards rather than giving the choice to next of kin after death. Creating regional networks that function locally and regionally within regions like the Gulf and North Africa to facilitate the availability of heart donation as death due to motor vehicle accidents and cerebral vascular accidents are common and both considered opportunities for cardiac availabilities from brain-dead donors in these areas. In Qatar, A donor registry is been established as a national confidential list of people who are willing to become organ donors after their death [28].

6. Post-transplant care

A small number of centers—one each in Qatar, Egypt, the United Arab Emirates, and two in Saudi Arabia—offer posttransplant care to heart recipients who have received transplants elsewhere and are returning to the region. The Cleveland Clinic in Abu Dhabi, which primarily handles cases requiring transplantation in the United States, currently has the most experience in the Gulf region. Recently in Qatar, they started to develop an integrated post-transplant program that includes cardiologists, surgeons, transplant specialists, social workers, physiotherapists & coordinators who mostly deal with patients who had their transplants in other countries. Gaining experience & learning lessons from such patients who had their transplant outside is crucial to developing the care for those patients who will carry on their transplantation in the region. Fully comprehensive post-transplant care is vital for successful outcomes. Developing a specialized transplant clinics with expertise in immunosuppressive management, infection control, rehabilitation, and long-term follow-up is essential. Collaborations with local healthcare providers and patient support groups can ensure seamless continuity of care. Furthermore, establishing partnerships with international transplant centers can facilitate knowledge transfer and the adoption of best practices in post-transplant care [29].

Post-transplant care is very critical & even more complex than the pre-transplant period. Certain important points need to be framed & stressed:

6.1 Communication and trust

Objective impartial communication channels to be established between patients, their families, and the medical team including a transparent doctor who is compassionate & committed to take the full time needed to alleviate anxiety and build trust from the pre to post-care periods. Centers should offer comprehensive post-transplant care programs. A program that includes support services, education, and counseling to help patients and their families navigate the emotional and physical challenges associated with the transplant process. Full holistic support is critical to address the psychological, emotional, and social aspects of a patient’s well-being. These should include support groups, counseling services, and most importantly financial & charity aid to incentivize the willingness to dispute the remodifications encountered during the post-transplant period till recovery. Expertise, hospital reputation, and the patient experience are very crucial in post-transplant care. Tackling all aspects of the potential risks empowers patients to ensure the best possible consequences for such a huge transformative impact on their future lives. Ensuring that post-surgery care does not stop upon discharge but in fact continues at home with check-in appointments, conducting calls with transplant coordinators, and cardiac rehabilitation programs which are all feasible in most of Middle Eastern countries [30].

7. Implementation strategies

A phased approach to program implementation is recommended. Engaging stakeholders early on, conducting feasibility studies, and garnering political and financial support are crucial first steps.

Collaborations with established transplant centers for mentorship and guidance, participation in international conferences and workshops, and leveraging existing resources are effective strategies to accelerate program development [8]. Additionally, establishing partnerships with international organizations, such as the International Society for Heart and Lung Transplantation (ISHLT), can provide valuable guidance and support throughout the implementation process.

This comprehensive overview of the requirements and logistics involved in establishing a heart transplantation program in a Middle East country. It underscores the importance of a multidisciplinary approach, legal frameworks, infrastructure, organ procurement systems, and post-transplant care for successful program implementation. By addressing these key elements, Middle East countries can enhance their healthcare systems, improve patient outcomes, and offer life-saving treatments to individuals suffering from end-stage heart.

8. Ventricular assistant devices

Despite multiple logistic challenges, Ventricular Assistant devices (VADs) as bridge to transplantation have been adopted in many countries across the Middle East region in parallel with other regions in the world. From the real-world data analysis, Heart pumps in Middle East and Africa region are expected to grow with the highest growth rate in the forecast period of 2022 to 2029 due to the upsurge of growing heart awareness campaigns. The heart pump segment in Saudi Arabia is dominating the Middle East and Africa’s left ventricular assist device (LVAD) market due to the increasing implantation of mechanical circulatory support devices.

For example, mechanical circulatory support (MCS) program was launched at King Faisal Hospital in Saudi Arabia, 20 years ago. Along with the other two centers that have implanted durable MCS devices as destination therapy, reaching almost a total of 45 durable LVADs per year. Besides, it remains the main heart transplant center in the Middle East, reaching 35 transplants per year with 89% 1-year survival. Other Gulf countries namely Qatar & UAE surged to embrace VADs as treatment strategies as well [31].

In Lebanon, Beirut Cardiac Institute is considered the main local institute that has the widest experience in LVAD in Lebanon, from 2010 to December 2019, 78 patients had different types of VADs, a total of 82 pumps with 4 patients needed an exchange of the pump the reported 12-month survival was 80%, with 75% survival at 18 months, an outcome like the IMACS (International Registry for Mechanically Assisted Circulatory Support) data [32].

Meanwhile, unique challenges complicating the flourishing of such programs also might affect the outcome is the fear of device management at home, on the other hand, in Europe and the US almost every patient is discharged from the hospital awaiting heart transplantation. Also, the burden of other health-related quality of life such as social interaction and Job stability are other important factors that impact decision-making and the future after VADs implantation [33].

9. Conclusions

Heart transplantation services in the Middle East could be improved further if different medical committees in the region worked together to develop a legal framework and share experience and expertise.

Conflict of interest

The author(s) acknowledged no potential conflicts of interest with regard to the research, authorship, and/or publication of this work.