Discussion
Through scientific development, ongoing training, and spreading program formation, HTx is now, to a greater extent, a better opportunity for the treatment of EHF patients around the world (5,13–16). However, only 102 countries report their numbers annually to the International Registry in Organ Donation and Transplantation (IRODaT) database (5). Given this development, some Latin American countries have reported their results, showing that HTx programs are feasible in developing countries (6–8). Approximately nine transplants were performed in Peru during the 1990s in different national centers in Lima (1,7). Although this initiative was bringing unhurried but worthy results, it declined due to the lack of funding and political interest (1). For this reason, it was not until 2010 that the INCOR’s Program was reactivated without interruption until this study was carried out.
In this first decade, a total of 83 HTx were studied. Despite the program’s effort, according to the IRODaT database in 2019, Peru is one of the countries with the lowest rate of HTx, with 14 HTx per year (5). The USA, France, Brazil, Spain, and Argentina led with 3587, 434, 381, 300, and 123 HTx per year, respectively (5). From another perspective, the average HTx frequency in these ten years in Peru was 8.3 HTx per year. In this regard, from 2013 to date, we reported a number greater than or equal to 9 HTx per year. According to Bocchi et al. , this frequency is sufficient not to be associated with an increased risk of death (19). Nevertheless, in 2016 only 5 HTx were performed in total due to institutional management changes. Additionally, Peru had a 0.5 HTx per million population (pmp) rate while the USA, Croatia, Spain, Uruguay, and Argentina had 10.9, 9.3, 6.5, 3.9, and 2.8 HTx pmp, respectively (5). This data also placed us as one of the countries with the lowest HTx pmp regionally and globally in 2019.
In our study, 68.7% were male. Although 76.9% of women had reduced LVEF, there was a significant difference between preoperative LVEF between the sexes. This could be related to the lower number of female recipients and the higher percentage (94.7%) of males with EHF with reduced LVEF. In addition, the low percentage of pediatric HTx is related to the lower rate of pediatric donors, and it is reflected in the significant difference regarding the waiting time, in which adults’ average was 8.9 weeks, and children’s, 40.9 weeks. This phenomenon is widely reported (15,16,18). In our experience, most of them have been children due to the lack of donors and the slowly growing number of HTx in developing countries, coinciding with regional experiences (17,20).
Like ISHLT reports, our main indications were idiopathic DCM in 66.3% of HTx and ischaemic cardiomyopathy in 18.1% (21). Although Chagas disease continues to be a Latin American public health problem, we have no indications for HTx due to Chagas cardiomyopathy (7,22). We consider that this is related to the underreporting of cases, and this local factor should be reevaluated since we are still a Chagas endemic country (23). Regarding pretransplant clinical status, 85.5% had an INTERMACS Profile 1 to 3, similar to ISHLT reports (24). It is a progressive increase of urgent HTx from 36.2% to 46.8% in the last decade in Spain; in our program, the average was 54.2% due to longer waiting times (15). On the contrary, 54.2% of recipients required inotropic support pretransplant, lower than ISHLT’s (24). Since the REMATCH trial, it is well-known that mechanical circulatory support potentially reduces mortality, increases survival, and improves the quality of life of transplanted recipients (25). Consequently, the ISHLT reports a gradual increase in VADs as bridge-to-transplant in 23% by 2005 and 50.3% by 2019 (24). Likewise, Gonzales et al. describe an inverse relationship in the use of IABPs and VADs (15). Our program utilized mechanical support in 14.5% of patients: 6% with IABP and 9.6% with VADs.
Even though having elevated catheterization values and pulmonary hypertension in 25.3% of cases, reversibility of these values was achieved through pretransplant pharmacological and mechanical support avoiding high incidences of graft failure (18). Furthermore, the world’s average waiting time is 10 weeks; our recipients expected an adequate average of 12.7 weeks compared to 25, 22.6, and 4.1 weeks in the USA, Australia-New Zealand, and Chile, respectively (8,26,27). The optimal ischemia time is a maximum of 4 to 6 hours, and we had a mean of 3.1 hours (28). We associate this result with the speed of the system when the National Donor Alert is activated.
Our mean postoperative stays in ICU and hospital were higher than reported in the USA, Brazil, and Chile (8,14,28). Consistent with most reports, infection was the first cause of death after HTx; however, the second cause was acute rejection, unlike other series, which was primary graft failure (2,13,15). Our overall survival rate was slightly higher than that described by the ISHLT at one, five, and ten years after HTx, and the analysis by age group was also higher, especially in children, as they still have a 100% survival (3). Consistently, we neither found significant differences in survival rates between the sexes. These results are subject to a limited number of HTx performed and a still short follow-up, especially in children, so future analyses are required. Although the ISHLT describes significant differences between the survival rates of adults recipients by sex, we did not found them, but a notable decrease in the females’ from 87.9% at one year to 73.3% at five years, while in males, the difference was minor from 87.3% to 83.1% (3). Indeed, Bocchi et al. describe female recipients, in experimental models, may require increased immunosuppression due to higher frequency of rejection, and this may not be related to sex as such but to a previous pregnancy, a variable not considered in this study (19).
The study’s limitations include the lack of data in the clinical histories on the profile of the donors and the short follow-up time concerning the appearance of complications. We agree and suggest that with well-selected donors, a careful evaluation of recipients, and a strict follow-up by a multidisciplinary team, suitable results can be reached in developing countries (18,28).