Global and Country-Level Impact of COVID-19 on Heart Transplant Volumes

Funding AcknowledgementsType of funding sources: None.IntroductionMassive demand for healthcare services worldwide following the emergence of coronavirus disease 2019 (COVID-19) has limited the availability of healthcare resources needed for certain high-complexity procedures, including orthotopic heart transplantation (OHT). Whereas the negative impact of COVID-19 pandemic on several elective procedures has been well-documented, data on regional changes in OHT volumes after COVID-19 are limited. Therefore, we aimed to quantify the impact of COVID-19 pandemic on OHT volumes in Asia and Oceania.MethodsUsing data from the Global Observatory on Donation and Transplantation (GODT), the world"s most comprehensive source of data on organ donation and transplantation, we recorded the number of OHT procedures performed in years 2019 (pre-COVID-19 era) and 2020 (COVID-19 era). The analysis was limited to countries with reported OHT data within Asia and Oceania (Australia, China, India, Iran, Israel, Japan, New Zealand, Russian Federation, Saudi Arabia, Thailand, Turkey, and the United Arab Emirates). OHT rates were reported for each country per million population (PMP), and change in the COVID-19 era was reported as percentage of the pre-COVID-19 rates. The association of total COVID-19 cases with relative reduction in OHT was evaluated using linear regression.ResultsAcross the Asia/Oceania region, number of OHT in COVID-19 era (median 0.64 procedures PMP, IQR 0.28, 2.15) was significantly lower compared with the pre-COVID-19 era (median 1.18 procedures PMP, IQR 0.49, 2.50), with a median change of -0.29 (IQR -0.70, -0.08; P = 0.04). The impact of COVID-19 on OHT was most pronounced in Turkey, United Arab Emirates, and India, where OHT volumes decreased by 75.4%, 60.8%, and 53%, respectively. Country-level reduction in OHT volumes was not associated with total number of COVID-19 cases during the year 2020 in that country (r = 0.31; P-value = 0.3).ConclusionThe number of heart transplants during the early phase of COVID-19 pandemic significantly decreased in ­­­most countries of the Asia/Oceania region. Furthermore, the change in OHT volumes did not correlate with the total number of recorded COVID-19 cases, suggesting the pandemic’s impact on OHT numbers extended beyond limiting availability of resources. Identifying factors leading to OHT deferral during COVID-19 pandemic will advance our understanding of the pandemic’s true impact on the care of advanced heart failure patients in the region. Figure.

Objectives：The purpose of this study was to evaluate whether the diagnostic validity of the Korean version of short form (15 item version) Geriatric Depression Scale (SGDS-K) was maintained well in the community dwelling elderly. Methods：In a face-to-face household survey conducted in Korea, 2,004 subjects aged more than 65 were interviewed by trained interviewers. 63 subjects diagnosed as dementia were excluded. The Mini Mental State Examination (MMSE) and SGDS-K were administered. Major depressive disorder (MDD) and minor depressive disorder (MnDD) were diagnosed with the diagnostic section of depressive disorder of the Korean version of the Composite International Diagnostic Interview (K-CIDI) according to DSM-IV diagnostic criteria. The sensitivity, the specificity and optimal cut-off point estimation and receiver operating characteristics (ROC) curve analysis were performed to investigate the diagnostic validity of the SGDS-K to screen MDD and MnDD. The diagnostic validity tests were also compared between two groups (with cognitive impairment and without cognitive impairment) divided by the MMSE scores. Results：We suggest a score of 8 (sensitivity 0.9365, specificity 0.7603) as optimal cut-off score of SGDS-K for screening MDD and a score of 6 (sensitivity 0.7898, specificity 0.6586) as optimal cut-off score for screening both MDD and MnDD. The area under ROC curve (AUC) was 0.900 for screening MDD and 0.797 for both MDD and MnDD. In the community dwelling elderly suffering from cognitive impairment, the sensitivity and specificity were 0.9500, 0.6870 with a cut off score of 8 for screening MDD and 0.8409, 0.5691 with a cut off score of 6 for screening both MDD and MnDD. The AUC was 0.893 for MDD and 0.767 for both MDD and MnDD. Conclusion：The SGDS-K was useful in screening MDD, both MDD and MnDD in the community dwelling elderly and also useful in the elderly suffering from cognitive impairment.

Countries' Donation Performance in Perspective: Time for More Accurate Comparative Methodologies

Introduction Heart transplant (HT) remains the only cure for patients with advanced heart failure. However, limited supply of donors continues to be the main obstacle to growing transplant programs around the world. Since population changes are not uniform, describing temporal trends in availability of donors and in number of transplanted hearts will provide better understanding of regional variations in organ availability and allocation. Purpose We aim to evaluate temporal and regional trends in number of brain-dead donors (BDDs) and its association with the number of heart transplants (HTs) in Europe between 2000 and 2019. Methods Global Observatory on Donation and Transplantation (GODT) represents the world's most comprehensive source of data on organ donation and transplantation. Available data were collected for all European countries for the years (2000–2019) except for the year 2005. Geographical classification (north, west, central, south) was made according to EuroVoc definition. Trends of HTs and BDDs were assessed using Joinpoint Software of the National Cancer Institute to calculate the annual percentage change (APC) and reported as per million population (PMP). The linear correlation coefficient was assessed using R studio. Results Over the past two decades, there was a 35% increase in HTs PMP rate in Europe from the year 2000 to 2019 with an APC of 1.4% (95% CI [1.1–1.7], P<.0001). This change was more pronounced in Central Europe, where HTs PMP rate increased from 0.65 in 2000 to 2.93 in 2019 (APC 9.9% (95% CI [8.1–11.8], P<.0001)) and in Northern Europe, where HTs PMP rate increased from 2.97 in 2000 to 5.18 in 2019 (APC 2.7% (95% CI [1.8–3.7], P<.0001)) (Figure 1). Despite the increase in BDDs in Europe between 2000–2019 (from 3.62 to 12.25 donors PMP) (Figure 2), the association between increased BDDs and HTs varied between regions, with a very strong association in Central Europe (r=0.95, P<0.0001) and strong correlation in Northern Europe (r=0.64, P=0.003). However, positive correlation between BDDs and HTs was not seen in Southern or Western Europe (r=−0.52, p-value=0.02, r=0.02, p-value=0.94, respectively). Conclusion The number of BDDs has increased in Europe in the past two decades with a concomitant increase in HT volumes. A regional variation in the relationship between the number of BDDs and HTs was observed among European subregions, such that it was most pronounced in Central Europe. Understanding the reasons underlying these disparities can potentially inform improvement in organ allocation systems throughout Europe. Funding Acknowledgement Type of funding sources: None.

It would have seemed that the problem is relatively simple: graft rejection or coronary artery disease after cardiac transplantation induces edema, inflammation, myocyte damage, necrosis, ischemia, and sometimes fibrosis, resulting in ventricular systolic and diastolic dysfunction. These should be detectable by echocardiography; yet, the quest for a sufficiently sensitive, specific, and conclusive echo marker of orthotopic heart transplant (OHT) graft dysfunction has been elusive. Consequently, children with OHT may undergo repeated myocardial biopsies and coronary angiography to diagnose graft rejection and coronary artery disease. Although these procedures are associated with low risk overall, they are not without complications and entail considerable discomfort, especially in children, and may be performed repeatedly over the course of many years. Thus, it would be of substantial benefit to have an echo measure that can be applied simply and repeatedly to diagnose or exclude acute or chronic graft dysfunction. See Article by Nawaytou et al Multiple echo measures have been proposed to address this need. These have included a change in chamber dimensions or wall thickness to indicate ventricular remodeling or edema, ejection phase measures, such as ejection fraction or fractional shortening, development of pericardial effusion, and more recently tissue Doppler and myocardial deformation to more directly assess impaired myocardial function, which underlies graft dysfunction. Impaired myocardial relaxation and increased stiffness induced by graft rejection or coronary artery disease may precede systolic dysfunction.1 Therefore, diastolic measures, such as the E / A ratio, tissue Doppler e ′, and E / e ′ ratio, may be early markers of graft dysfunction.2 Interestingly, some pediatric studies have found right ventricular (RV) parameters to be more sensitive than left ventricular (LV) parameters.3 In addition, our group and others have used provocative testing in children with OHT to detect wall motion abnormalities that may herald coronary …

In the COVID-19 era, it remains of utmost importance for solid organ transplant (SOT) patients and caregivers continue to receive excellent education following transplantation. As a leader in SOT, we recognized the need to enhance patient engagement by implementing a comprehensive pharmacist-driven medication knowledge program encompassing didactics, visual tools, and virtual learning. These initiatives have proven to be particularly beneficial in ensuring optimal patient outcomes following orthotopic heart transplantation (OHT) during the COVID-19 era. One of the first initiatives was a sample discharge medication list as an early step to begin better preparing patients for their discharge. The OHT pharmacist reviews the medication list with the patient once the patient is able to cogently participate in his or her medication education post-transplantation. The template gives patients a preliminary idea of what they will be going home on, orients them to the visuals on the medication guide, and helps them learn the names and dosages of medications. The next initiative to improve our OHT patients' education process was the creation of color-coded flash cards for each immunosuppressive and antimicrobial medication. Each card lists the medications' generic and brand names with pictures of the capsules or tablets and describes key points such as timing of administration, drug interactions, and potential adverse effects. Patients review these cards both individually and during education sessions led by the OHT pharmacist. In order to ensure our efforts to improve our patients' education are effective, an assessment to evaluate understanding of post-OHT medications was created. The assessment consists of eleven multiple-choice questions and gauges the patients' recollection of their medication names, indications, and what to do in scenarios such as a missed dose of medication. The assessment is conducted during the first post-transplant education session and then repeated following at least one more education session during which the educational tools are reviewed. Thus far, patients who have taken the assessments scored averages of 46% on the pre-education assessment and 88% on the post-education assessment, demonstrating significant improvement in their medication knowledge following multiple education sessions with the pharmacist. During the COVID-19 pandemic, many of our institution's services transitioned to a telemedicine approach and patients were provided with iPads to conduct secure, virtual education sessions. A challenge to telemedicine is maintaining a connection and engagement with the patient; however, the pharmacist was able to lead effective education sessions during multiple video visits by utilizing the aforementioned tools. Overall, these innovative educational tools have been highly effective in improving patient education and satisfaction; they can be easily adapted to fit specific program's and institution's needs. Conducting effective, virtual patient medication education sessions aided in the safe and timely discharge of complex OHT patients. This allowed our hospital the space to care for a potential surge of patients affected by COVID-19 and decreased the risk of potential exposure of SARS-CoV-2 to our immunocompromised patients, while ensuring no compromise to OHT recipients' medication education. Our experience demonstrates how pharmacists can continue to effectively provide the necessary medication education to patients in a rapidly evolving healthcare practice. Our team plans to continue to use these educational tools during telemedicine visits throughout and beyond the COVID-19 era. None

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Background: The need to handle a growing number of advanced heart failure (HF) patients has fueled growth in heart transplantation (HT) activities and development of effective strategies to increase the availability of donors in the last two decades. The impact of these changes on global HT volumes has not been previously described. Methods: Using data from the Global Observatory of Donation and Transplantation (GODT) for the years (2000-2019), we obtained the annual number of HT performed in each country per million population (PMP), number of brain-dead donors, and number of officially registered HT centers. We also identified WHO countries with sustained HT activities (HT data in ≥ 5 years). Data on health expenditures and on the prevalence of severe HF were collected from the World Health Expenditure and Global Burden of Disease (GBD) databases, respectively. Average annual percentage change (AAPC) in number of HT PMP was calculated using JoinPoint software. The contribution of the above-mentioned variables on change in HT volumes over time was determined using a linear mixed-effects regression model. Results: In a sample of 55/194 countries with sustained HT activities, the absolute number of HT increased by 92% (from 4504 in 2000 to 8646 in 2019), or 0.05 to 0.09 HT PMP with an AAPC of 3.6% (95% CI [2.7, 4.5]) in HT/PMP. Temporal trends in HT volumes varied considerably among countries, such that as significant growth in HT was seen in 41 (74.5%) countries (AAPC 5.6%; 95% CI [5, 6.2]), while the remaining 14 countries experienced a decline (AAPC -0.7%; 95% CI [-1.1, -0.2]) ( Figure A ). In an adjusted model, donor availability, HF prevalence, and health expenditure, but not the number of HT centers, significantly predicted an increase in HT over time ( Figure B ). Conclusion: Despite near doubling of HT worldwide in the last two decades, there remain unmet needs to face the growing burden of HF, specifically maximizing organ utilization in brain-dead donors.

Transient Left Bundle Branch Block Associated with Septal Edema after Orthotopic Heart and Lung Transplant

The incidence, mechanisms, clinical associations, and outcomes in patients with late-onset (>3 months) atrioventricular (AV) block following heart transplantation are not well known. This study will characterize late-onset AV block following cardiac transplantation. We retrospectively reviewed our databases to identify patients who required pacemakers for late-onset AV block postheart and heart-lung transplantation from January 1990 to December 2007. Orthotopic heart and heart-lung transplantation were separately analyzed. This study included 588 adults who received cardiac transplants over a 17-year period at our center (519 orthotopic, 64 heart-lung transplants, and five heterotopic heart transplants). Of the 519 patients with orthotopic heart transplant, 39 required pacing (7.5%), 17 (3.3%) within 3 months posttransplant, 11 (2.1%) for late-onset sinus node dysfunction (SND), 11 (2.1%) for late-onset AV block. Also, five patients (7.8%) out of 64 heart-lung transplants required pacemakers, two (3.1%) for late-onset SND, three (4.7%) for late-onset AV block. None of the five patients who underwent heterotopic transplant required cardiac pacing prior to or posttransplant. Late-onset AV block occurs in 2.4% of patients with orthotopic heart transplant or heart-lung transplant. AV block is predominantly intermittent and, often, does not progress to permanent AV block. There are no predictable factors for its onset.

Bench Repair of Donor Aortic Valve With Minimal Access Orthotopic Heart Transplantation

Objective: To analyze pre- and post-operation electrocardiograms (ECGs) features of patients underwent orthotopic heart transplantation (OHT), and provide evidences for identifying and analyzing post OHT ECGs. Methods: Nine hundreds and ninty-eight pre- and post- OHT standard 12-leads ECGs from 110 consecutive patients, who underwent OHT in our hospital from May 2008 to May 2014, were analyzed. Results: The mean heart rate(HR)was (86.9±16.4) beats per minute before OHT, and (100.0±0.4) beats per minute after OHT. P wave's amplitude, duration, amplitude multiplied by duration of donor heart in lead Ⅱ were (0.124±0.069)mV, (111.1±17.2)ms, (14.34±9.51)mV·ms before OHT; (0.054±0.037)mV, (86.9±27.0)ms, (5.02±4.03)mV·ms at 1 month after OHT; (0.073±0.049)mV, (93.9±17.5) ms, (7.00±4.81)mV·ms at 6 years after OHT. ECGs rotation occurred in 83.64%(92/110) patients after OHT, and prevalence of clockwise rotation was 76.36%(84/110). Sinus tachycardia was evidenced in 99.09%(109/110) patients after OHT, and incomplete right bundle branch block was present in 60.91%(67/110) patients after OHT. Pseudo complete atrioventricular block mostly occurred at 2 days after OHT. Prevalence of double sinus rhythm was 27.95%(263/941) post OHT, 40% of them occurred between the 1st and the 2nd month post OHT; the atrial rate of recipient hearts was (104.0±10.2) beats per minucte between the 3rd and the 6th month post OHT, and was (95.3±4.2) beats per minucte between the 4th year and the 5th year. P wave's amplitude, duration, amplitude multiplied by duration of recipient heart in lead Ⅱ were (0.066±0.055) mV, (52.8±34.7) ms, (4.67±4.95) mV·ms at 1 month after OHT, (0.043±0.040)mV, (44.4±40.5) ms , (3.11±3.61) mV·ms between the 1st year and 2nd year after OHT. The absolute value of P-wave(originating from the donor heart) terminal force in chest leads increased in 48.99%(461/941) patients post OHT, the P-wave terminal force of V(1) , V(2) and V(3) were -0.044(-0.066, -0.028), -0.060(-0.087, -0.038), -0.035(-0.056, 0) mm·s. Notched P wave in chest leads was presented in 10.31%(97/941) patients post OHT. PR segment depression in chest leads occurred in 60.24%(100/166) patients between the 3rd month and the 6th month, the incidence of PR segment depression in V(1) , V(2) and V(3) was 21.04%(198/941), 37.41%(352/941) and 28.69%(270/941), respectively. Conclusions: OHT is related to significantly changed ECGs. The mean HR increased significantly after OHT, then decreased gradually after half a year to one year, but it was still higher than preoperative mean HR after five or six years; the P waves of donor heart were usually inconspicuous or small in first month after OHT, and they became bigger after 2 months, and their duration and amplitude then became relatively steady afterwards. ECGs rotation, especially the clockwise rotation, was common post OHT. A variety of arrhythmias originating from the donor heart including sinus tachycardia and incomplete right bundle branch block could be found. Pseudo complete atrioventricular block could also be found in the early phase after OHT. With the extension of time, the incidence of double sinus rhythm reduced gradually. The atrial rate and P wave of recipient heart presented with a tendency to become lower. The absolute value of P-waves(originating from the donor heart) terminal force in chest leads (mainly V(1), V(2) and V(3)) increased, notched P waves in chest leads (mainly V(1), V(2)) and PR segments depression in chest leads (mainly V(2), V(3) and V(4)) also belong to typical post OHT ECGs features.

Transplantation in Canada: report of the Canadian Organ Replacement Register

Background Following the guiding principles of World Health Organization (WHO) on organ transplantation and in accordance with cultural traditions and current socioeconomic conditions of the country, China has established a scientific and ethical system to foster sound development of organ donation(OD) and transplantation(OT). A rapid raising trend in the annual number of OD after citizen’s death in China; from 34 cases, 0.03 OD per million population (PMP) in 2010 to 4080 cases,3 PMP, in 2016; more than 10% of total deceased OD worldwide, shows a promising outcome. However, only 1 out of 43 patients can receive kidney transplant in a year. The gap between demand for OT and supply is growing continuously. Meanwhile, only 0.062% of hospital deaths converted to actual organ donors in 2016, indicating a low identification rate of potential donors. To tackle this issue, a joint international approach to train over 1200 Chinese organ procurement professionals in 5 years had been proposed and put into action since December 2014. Methods Adopting TPM methodology, continuous professional trainings were done at national and regional level. Working in conjunction national authorities and local hospitals, a common curriculum was designed. The courses were led by international and local experts who were well-trained overseas. Participants received a 3 to 5-days course composed of theoretical seminars, case studies section and simulation workshops for each step of the OD practices. Interpretation was provided by professional translators with medical background during the course. The knowledge level of participants was evaluated by a final test. To those who successfully passed the evaluation, a recognized certificate was given. In the last two courses, individual self-evaluation tests measuring the level of knowledge acquired were performed before and after the course. These trainings were validated both by European Credit Transfer System and Health care continuous education program of the region organizing the course. Result 610 health professionals (HP)from 30 provinces in China are trained over the last 3 years. 19% of the participants are HP from 88 OPO, 37% are surgeons from 72 Transplant centers, and 39% are physicians from critical /emergency units from 95 donor hospitals. An increasing trend through the years in number of OD were observed in all cities the trainings took place. The organ utilization rate is higher in provinces where the course was repeated. Comparison results performed before-after the course shows greater knowledge, as reflected in the test correct rate increasing from 71.48% to 82.84%. Discussion The sufficiency of skill and knowledge acquired by HP is of essential to boost up the progress of an efficient and healthy OD in China. Therefore; as estimated, in 2019, the number of well-trained HP in this program will be 1200. Of those, if consider, each one performing 6 cases yearly, more than 7200 donations will be performed annually.

Over the decade between 2003 and 2012, the UK has seen major changes in how organ donation and transplantation is delivered. The number of deceased organ donors has increased from 709 (12.0 per million population [pmp]) to 1,164 (18.3 pmp); this increase has been predominantly a result of an increase in donors after circulatory death (DCD) (from 1.1 pmp to 7.9 pmp) while the numbers of donors after brain death (DBD) has remained broadly stable (around 10.5 pmp). The donor population has become older (from 14% 60 years or over to 35%) and heavier (from 14% with body mass index >=30 kg/m2 to 23%). Despite these changes in demographic factors, the number of organs retrieved from DBD donors has risen from a mean of 3.6 to 4.0 per donor and for DCD donors from 2.2 to 2.6. The number of transplants in adults in 2012 was 2,709 (967 DBD, 708 DCD, and 1,034 living) for kidney alone, 246 pancreas (including 172 kidney and pancreas), 792 (611 DBD, 142 DCD, 36 living, and 3 domino) for liver, 136 for heart only, and 179 (145 DBD and 34 DCD) for lung only. Median waiting times to transplant for adult patients were 1,167, 339, 141, 293, and 311 days, respectively. The proportion of adult non-urgent registrants in 2009 (2007 for kidneys) who were removed from the waiting list or died awaiting a graft within 1 year was 3% for kidneys, 6% for pancreas, 19% for liver, 27% for heart, and 24% for lung. Outcomes after solid organ transplants are improving; for adult patients grafted between 2003 and 2005, 5-year graft survival for kidney is 84% (DBD), 87% (DCD), and 92% (living donor), for simultaneous kidney and pancreas 72%, and for pancreas alone 50% (DBD). Five-year patient survival for liver is 77% (DBD) and 68% (DCD), heart 67%, and lung 52% (DBD). Although rates of organ donation and transplantation have increased in the UK, this has been almost solely because of a rise in DCD donation. Although donor age and weight is increasing, graft survival has generally improved. Despite a recent fall in the number of patients on the transplant waiting list, there remains a significant gap between the need for transplantation and the number of organs available from deceased and living donors. The implementation of a new strategy following the recommendations of the Organ Donation Task Force in 2008 has had a major impact in bringing together clinicians involved in both organ donation and transplantation, and these changes and clinical enthusiasm have been instrumental in achieving success. With an emphasis on the need to increase the family consent rate for organ donation, which has failed to show any improvement over the last 5 years, a new UK strategy for organ donation and transplantation, introduced in 2013, will further increase organ transplantation in the UK.