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).