End-stage paediatric heart failure in low- and middle-income countries: challenges in surgical management

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, p ~ 0.004), high creatinine (OR 3.6, p ~ 0.06) and high pretransplant right atrial pressure more than 15 mm Hg (OR 4.7, p ~ 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.