Dr Cheng Lik Cheung
Heart transplantation beyond 2011- continuous evolution and new challenges in Hong Kong
The first heart transplantation was performed by Professor CK MOK in December, 1992. Up to May 2011, a total of 113 patients underwent heart transplantation in Hong Kong. There were 89 men with a mean age of 43.8±12.5 years. The cumulative 1 year survival rate is 92%. In Hong Kong the two leading causes for end-stage heart failure required heart transplantation are dilated cardiomyopathy and valvular heart disease. In contrast to developed countries, ischaemic heart disease is third on the list. Due to limited organ availability, donor and recipient selections are being continuously reviewed and updated so as to encourage better utilization of donor heart that may go unused. Criteria for heart donors were revised in 1997 to include those up to the age of 60 years and marginal donors who have had previous cardiopulmonary resuscitations or high-dose inotropic therapy, provided that transthoracic echocardiograms performed by cardiologists are satisfactory. No significant coronary artery disease must be demonstrated on coronary angiogram for those donors over 45 years old and with known risk factors for ischemic heart disease. Since 2008, the recipient’s criteria were extended to include patients up to 65 years old and those who were chronic Hepatitis B carrier (low infectivity and without evidence of liver injury).
Adult congenital heart disease represents a growing population of patients being referred for heart and combined heart-lung transplantation (5% of total). This group of patients presents multiple unique surgical and medical challenges to transplantation owing to their complex anatomy, multiple prior palliative and corrective procedures and often debilitated conditions. We have performed our first pediatric heart transplant in 2009 for a 6 year old girl with dilated cardiomyopathy and reached another mile stone in 2010 with the first combined heart-liver transplant in Hong Kong for a young patient with familial polyneuropathy amyloidosis.
Because of limited donor pool, up to date, we have only performed 4 patients for heart-lung transplantation en bloc. The first patient died of a rare graft versus host disease and the second patient died of chronic rejection years after operation. The unfortunate 3rd patient committed suicide nearly 3 years after transplantation because of maritual problem. The 4th patient is surviving well up to now.
Mechanical circulatory support program using left ventricular assist device (LVAD) are being developed as an auxillary program to the existing heart transplant program in 2010 as “bridge-to- transplant” for those who are deteriorating rapidly without a timely available donor heart. On 31st August, 2010, we performed the first implantable LVAD ( Heartmate II ) on a 32 year old gentleman. He did very well after the operation. On 31st January, 2011 and 21st February, 2011, two more patients benefited from the LVAD implantation. All these 3 patients were with INTERMAC level II at the time of LVAD implantations. Our local experience with LVAD in Paediatric patients was limited to two children. The 9 year old girl who suffered from dilated cardiomyopathy received the first LVAD [the Berlin Heart] at GH. Although the operation was successful, after weeks of satisfactory circulatory support, the girl succumbed to the known complication of cerebral vascular accident. Our second patient was a 7-year-old Jewish boy presented with intractable heart failure and multi-organ failure secondary to fulminate viral myocarditis. The Jewish community in Hong Kong raised the necessary fund; a second Berlin Heart was implanted at GH. After a week of circulatory support, the boy’s myocardium recovered and he was successfully weaned from the device. At recent follow-up, he is alive and well.
Fortunately or unfortunately depends on one’s view, the fund of all these five LVADs implanted ever in Hong Kong was raised by the Department of Cardiothoracic Surgery and friends of the department. We all realize the fact that sporadically perform such kind of operation is futile. All of us are still waiting for the timely support from the health authority. At this moment, the expectation from both the medical colleagues and society in general clearly no longer considered heart transplant is the only option for end-stage heart failure. Sooner or later the option of mechanical circulatory support has to be provided and if it is to be provided it has to be in a centre with the availability of thoracic organ transplantation. A centre with thoracic organ transplant without a mechanical circulatory support is going to be regarded below bar by major centres in developed countries nowadays.