Balakrishnan Komarakshi
Institute of Heart and Lung Transplant, MGM Healthcare, Nelson manickam road , Chennai, India.
Indian J Thorac Cardiovasc Surg. 2025 Jun;41(6):768-783. doi: 10.1007/s12055-024-01853-z. Epub 2024 Nov 25.
To define the challenges faced in the surgical treatment of end-stage heart failure in low- and middle-income countries and offer possible solutions.
The World Bank definition of low- and middle-income countries (LMIC) is gross national income less than US $1085 and US $4255 respectively. In this list, India is the only country with a significant paediatric heart transplant and mechanical circulatory support programme. Hence, the Indian experience was used as an example in this study. A total of 141 children less than or equal to 18 years underwent a heart transplant over a 10-year period in a single surgical unit. The youngest was 8 months old. Twenty children were younger than 5 years of age and 58 were less than 10 years. The major problems to overcome were shortage of paediatric donors, challenges in organ transport, challenges in keeping sick recipients alive while awaiting a donor heart and dealing with cost implications and long-term care. A third of these patients were Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) I or II. Fourteen percent were on mechanical circulatory support prior to transplant. Hospital mortality was defined as death within 90 days of transplant. The follow-up was up to 10 years.
The 90-day survival was 85.11%. The risk factors for hospital mortality were low INTERMACS (odds ratio - OR 0.3, ~ 0.004), high creatinine (OR 3.6, ~ 0.06) and high pretransplant right atrial pressure more than 15 mm Hg (OR 4.7, ~ 0.03). The Kaplan-Meier survival curve showed a survival of over 70% at 10-year follow-up. The donors were typically older and the donor to recipient weight ratio was also significantly more than in published literature. Donor age more than 25 years had poorer outcomes long term. The economic challenges of running a programme in LMIC economies are enormous and need several innovative solutions including routine use of commercial aircrafts for organ transport.
Despite numerous challenges, a successful paediatric heart transplant programme is possible in LMIC countries with outcomes comparable to published data.
The online version contains supplementary material available at 10.1007/s12055-024-01853-z.
明确低收入和中等收入国家终末期心力衰竭外科治疗面临的挑战，并提供可能的解决方案。
世界银行对低收入和中等收入国家（LMIC）的定义分别是国民总收入低于1085美元和4255美元。在此名单中，印度是唯一拥有重要小儿心脏移植和机械循环支持项目的国家。因此，本研究以印度的经验为例。在一个单一手术单元中，共有141名18岁及以下儿童在10年期间接受了心脏移植。最小的患儿为8个月大。20名儿童年龄小于5岁，58名儿童年龄小于10岁。需要克服的主要问题包括小儿供体短缺、器官运输挑战、在等待供体心脏期间维持患病受者生命的挑战以及应对成本影响和长期护理问题。这些患者中有三分之一属于机械辅助循环支持机构间注册系统（INTERMACS）I或II级。14%的患者在移植前接受了机械循环支持。医院死亡率定义为移植后90天内死亡。随访时间长达10年。
90天生存率为85.11%。医院死亡率的危险因素包括INTERMACS分级低（比值比 - OR 0.3，约0.004）、肌酐水平高（OR 3.6，约0.06）以及移植前右心房压力高于15 mmHg（OR 4.7，约0.03）。Kaplan-Meier生存曲线显示，在10年随访时生存率超过70%。供体通常年龄较大，供体与受体体重比也显著高于已发表文献中的数据。供体年龄超过25岁长期预后较差。在低收入和中等收入国家开展该项目面临巨大的经济挑战，需要多种创新解决方案，包括常规使用商用飞机进行器官运输。
尽管存在诸多挑战，但在低收入和中等收入国家仍有可能开展成功的小儿心脏移植项目，其结果与已发表数据相当。
在线版本包含可在10.1007/s12055-024-018
