| Abstract|| |
In this report we attempt to demonstrate the efforts involved in establishing and organizing the heart transplant program at the Armed Forces Hospital in Riyadh, Saudi Arabia. From 1986 to date, 25 orthotopic heart transplants were performed at this center. Patient age ranged from 22 months to 57 years; 4 patients were below 12 years of age and 4 aged 50 years and above. The incidations for transplantation were cardiomyopathy in 15 patients, ischemic heart disease in 6 patients, and valvular heart disease in 4 patients. Fourteen recipients have died. Three of them were classified as hospital deaths, occuring before the patient could be discharged after the procedure; the reminder died from rejection and associated problems. Eight patients of them died within the first year. The longest survival period was almost 8 years. The overall 8 years survival rate was 45%, which is comparable to the international figures. Shortage of donors may affect the future of the transplant programs. Increasing the awareness of the public about the importance of organ donation and transplantation is crucial in this regard.
Keywords: Heart transplantation, Cardiac center, Saudi Arabia.
|How to cite this article:|
Al Fagih MR. Orthotopic Heart Transplantation in the Prince Sultan Cardiac Center. Saudi J Kidney Dis Transpl 1996;7:185-8
|How to cite this URL:|
Al Fagih MR. Orthotopic Heart Transplantation in the Prince Sultan Cardiac Center. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2020 Feb 21];7:185-8. Available from: http://www.sjkdt.org/text.asp?1996/7/2/185/39525
| Introduction|| |
Although the technical performance of the orthotopic heart transplant operation is not exceptionally challenging to the competent cardiac surgeon, it was not until the introduction of cyclosporin into the therapeutic management of rejection that heart transplantation was placed firmly in the category of routine treatment for end-stage cardiac disorders, with the achievement of acceptable 5 years survival rates. During the early 1980s this led to increasing numbers of Saudi patient with end-stage cardiac diseases being referred to cardiac centers abroad for this procedure, since no Saudi heart transplant center existed at that time, To meet this clear need for a cardiac transplant service within the country, and to complete the Spectrum of cardiac surgical procedures available within the Armed Forces Cardiac Center in Riyadh, (now the Prince Sultan Cardiac Center), a cardiac transplant service was begun in February 1986; when a 3 years old girl became the first child to receive a heart transplant in a Middle Eastern center. This successful first procedure was performed by an entirely Saudi team of surgeons, anesthetists and operating room technicians. Since then a total of 25 orthotopic heart transplants have been performed at the Prince Sultan Cardiac Center (PSCC).
| Organization and Training|| |
Preparation for the introduction of the heart transplant program began in 1984 and continued for the next two years. Special equipment was required, and the necessary packs of instruments were assembled to prepare for possible heart harvesting in other centers. Arrangements were made for the Armed Forces hospital laboratory to perform cyclosporin level assays and for the provision of required histopathological expertise.
The emphasis in the planning phase was concentrated first on training for the medical, technical and nursing personnel involved, both for the operative procedure and the postoperative management of the recipient, and secondly on the policies and procedures, including the all-important selection criteria for both donors and recipients, and the management of potential donors before harvesting the heart. The PSCC heart transplant policies, procedures and guidelines were adapted from those in general use, since they were known to have been proven successful in many centers across the world.
Cardiac surgeons, cardiologists and operating room nurses visited centers abroad to study, and gain experience of the pre-operative management of potential donors, the operative techniques, and all aspects of postoperative recipient management-including myocardial biopsy and especially the identification and control of rejection in all its manifestations. The consultant histopathologist spent a period of attachment at a well-known transplant center to become very familiar with the various microscopic pictures of early and late rejection.
One member of the medical staff was given the task of co-ordinating the program. Lists of potential recipients were created using a PC database to ensure that the recipient/ donor matching process could begin without delay when a potential donor was identified. Peripheral hospitals were informed of the intention to start the transplant program and the need for identification of potential donors and their management according to the protocol provided.
The establishment of the Saudi Center for Organ Transplantation (SCOT) provided the means to collaborate more fully with other hospitals for harvesting organs and matching of recipients. The PSCC now has a nurse transplant co-ordinator to liaise with the SCOT in all aspects of the transplantation program.
| Patients and Results|| |
From 1986 to date, 25 orthotopic heart transplant procedures have been performed at the prince Sultan Cardiac Center. Patient age ranged from 22 months to 57 years; 4 patients were below 12 years of age and 4 aged 50 years and above. The end-stage diagnoses were cardiomyopathy in 15 patients, (including all the children), ischaemic heart disease in 6 patients and valvular heart disease in 4 patients.
Fourteen recipients died [Table - 1]. Three were classified as hospital deaths, occurring before the patient could be discharged after the procedure; the reminder died from rejection and associated problems. Eight patients of them died within the first year. The longest survival period was almost 8 years. [Figure - 1].
| Discussion|| |
The twelfth official report (1995) of the registry of the international society for heart and lung transplantation  indicates an 8 year overall survival of around 45% in 27,977 patients and this center has the same rate. The report also acknowledges the continuing improvement in cardiac transplantation outcomes, noting that transplants performed since 1988 have a 70% 3 year survival. The report also shows that the performance of less than 9 transplants/year in any one center is a very significant risk factor for 1 year mortality.
It was thought to be more practical to transfer the potential donors to the PSCC for harvesting the heart after a propable donor/recipient match has been determined; the Ministry of Defense & Aviation Medevac service has been successfully utilized for this purpose-and we are grateful for their co-operation and support.
The hospital survival in our series is good, indicating that the recipient selection process has been satisfactory. However, the management of the patients after discharge does present problems that need solution; 8 patients died during the first year after transplantation. Supervision and support for the patient in the community is almost nonexistent. Consequently, close, regular and frequent contact with the recipients and their families is suboptimal in the critical first few months after the transplant, and adequate control of the anti-rejection therapeutic regimen has proved difficult to monitor in these circumstances. Further survival of patients after the first year was reasonably good.
Since this number of heart transplants performed in the PSCC indicates a slower rate of progress than could be hoped for, we must ask the question, why? The unfortunately high vehicular accident rate in this country should mean that there is certainly no shortage of potential donors, but to obtain agreement to the removal of organs has proved very difficult.
World-wide, reluctance to agree to organ donation in general and heart donation in particular, with its obvious emotional overtones- is acknowledged to be the principal obstacle to the greater deployment of organ transplantation for the end-stage for heart, kidney and liver diseases. In Western countries the concept is gradually being absorbed into their culture; now the relatives will usually comply with the wishes of potential donors that are expressed on the donor cards in increasing numbers by the under 40 years age groups. However, it is clear that the number of heart transplantations performed world-wide has shown little, or no, overall increase since 1991, and actually declined during 1994 compared to 1993. Since the falling, there is presumably a problem in obtaining donors  .
Although the Saudi population has accepted with complete confidence the full range of medical and surgical developments during the past 20 years, here too the reluctance of relatives to permit the removal of organs of suitable brain-dead potential donors is difficult to overcome. Religious objections may not be the principal cause, but in this society the cultural perception of the integrity of the body is particularly powerful.
In addition, the concept of "irreversible brain death" is difficult for most people to understand. The patient's family, shocked by the sudden events that have taken place, are told that their loved one is dead: but how can this be death, they ask, when they can see that the patient still appears to be breathing, (though in reality mechanically ventilated), and the heart still beating? In their confusion and their grief they are then asked to agree to the removal of parts of the body. All this is largely incomprehensible and, so far, usually unacceptable to them. Further efforts in the education of the public in these matters are required, but the time scale needed to bring about the necessary acceptance of this whole concept by the population here will be long. One encouraging feature is that the introduction of the concept of carrying of a donor card has been well received by the younger members of our society. As the carrying of the card becomes more widespread it should play a major part in bringing about the necessary change in public opinion.
In conclusion, it can be stated that the PSCC transplant programme has been largely successful, but there is the need for further improvement, in the hospital management of donors and recipients, the administrative management of the coordination of organ transplant centers and in the encouragement of the families of potential donors to agree to the removal of the heart, and in the post-transplant management of the recipient in the community. The Saudi Center for Organ Transplantation must play a leading role in the management of the co-ordination of centers and in the continuing education of the public in accepting the concept of organ donation.
| References|| |
|1.||The Registry of the International Society for heart and lung transplantation: twelfth official report. J Heart Lung Transplant 1995; 14(5):805-15. |
Mohamed R Al Fagih
Department of Cardiac Surgery, Prince Sultan Cardiac Center, P.O. Box 99911, Riyadh 11625
[Figure - 1]
[Table - 1]