Current Status of and Opinions on Heart Transplantation in China

Current status and challenges of DCD heart transplantation in the Asia-Pacific region

Heart transplantation remains the definitive treatment for end-stage heart failure, but donor shortages persist globally. This review aims to evaluate the current status, enabling technologies, ethical considerations, and future prospects of donation after circulatory death (DCD) heart transplantation in the Asia-Pacific region. A comprehensive narrative review was conducted using published literature and country-specific reports to assess global and regional trends in DCD heart transplantation. Particular focus was given to enabling technologies (e.g., thoracoabdominal normothermic regional perfusion [taNRP] and ex situ machine perfusion), legal and ethical frameworks, and implementation barriers across countries in the Asia-Pacific. While countries such as the UK, US, and Australia have achieved comparable survival outcomes between DCD and donation after brain death (DBD) heart transplantation, most Asia-Pacific countries remain in early stages. Australia leads the region with over 70 successful DCD heart transplants using the Organ Care System. Japan lacks legal clarity and clinical protocols for withdrawal of life-sustaining therapy, restricting DCD to kidney transplants. China employs a hybrid DBCD model but faces logistical and ethical constraints. In South Korea, India, and others, DCD heart programs are not yet established. High cost and limited availability of enabling technologies, alongside ethical controversy surrounding taNRP, are key barriers. Broader adoption of DCD heart transplantation in Asia-Pacific countries requires legal reform, ethical consensus, cost-effective perfusion strategies, and public engagement. Coordinated efforts across technological, societal, and regulatory domains are essential to expand access to this life-saving modality.

Impact of family socio-economic status on the prognosis of heart transplantation in children

BACKGROUND

Low family socio-economic status is a known factor that can contribute to increased mortality for patients with cardiovascular disease. However, in developing countries, the prognostic impact of socio-economic level on pediatric HTx is unclear.

METHODS

We conducted a retrospective cohort analysis of children younger than 18 years who underwent heart transplantation (HTx) at our center from October 1, 2005, to May 31, 2023. To assess the impact of socio-economic status, we followed up with the discharged children until September 30, 2023, monitoring for all-cause mortality and unplanned readmission events. To evaluate the relationship between socio-economic status and prognosis, we assigned a composite score based on an assessment of household income, parental education level, and occupation. The Cox proportional hazards model and the Kaplan-Meier method were utilized for this analysis.

RESULTS

64 children (median age at operation 14 years, IQR 13-15) were enrolled and one case died in hospital due to primary graft dysfunction, 63 (98.4%) children had a median follow-up of 60 months (IQR 5.9-113.9). During the follow-up period, 10 (15.9%) children died, and 20 (31.7%) children had 25 unplanned readmissions. Children had higher all-cause mortality and more unplanned readmissions in families with low socio-economic status (n = 33) than middle (n = 10) or high (n = 20) family socio-economic status. Hazard ratios were 5.99,(95%CI:2.28-10.64, P = 0.003) for all-cause mortality for low versus high family socio-economic status, and 2.53 (95%CI:1.04-9.43, P = 0.029) for middle versus high family socio-economic status.

CONCLUSIONS

Lower family socio-economic status is associated with a worse prognosis than high family socio-economic status. Measures to alleviate economic disparities are needed to improve the prognosis of pediatric HTx.

Heart transplantation: comparing the impact of modified heart preservation with conventional methods

The purpose of this study was to compare the impact of modified heart preservation techniques with conventional heart preservation techniques on heart transplant recipients. The goal was to determine if these modified preservation techniques could extend the preservation of the donor heart without increasing the risk of recipient mortality. A retrospective analysis was carried out on 763 cases of orthotopic heart transplantation performed at Wuhan Union Hospital and Nanjing First Hospital, from September 2008 to October 2022. Among these, 656 cases underwent modified heart preservation and were assigned to the study group, while 107 cases underwent conventional heart preservation and were designated as the control group. Detailed information from both groups was collected and compared, including demographic and donor characteristics, survival status, disease type, and recipient/donor characteristics. The study revealed that the modified heart preservation method did not increase the risk of mortality compared to the conventional method. However, it was found that patient factors such as diagnostic classification, recipient age, and donor age significantly influenced mortality risk and were strongly associated with patient survival. The preservation time of the donor heart was significantly longer in the study group compared to the control group, without affecting the survival of the transplant recipients. The findings of our study suggest that modified heart preservation techniques hold promise as a potential method for prolonging heart preservation time. Despite extending the preservation period, these modified techniques did not increase the mortality risk in heart transplant recipients. This could potentially allow for more flexibility in the long-distance transport and preservation of hearts, thereby broadening the scope of viable donors for heart transplantation.

Assessing the cost-effectiveness of replacing antimetabolites with mTOR inhibitors in heart transplant immunosuppression in China: a network meta-analysis-based economic evaluation

BACKGROUND

Although several pharmacoeconomic studies have assessed the cost-effectiveness of maintenance immunosuppressive regimens for heart transplant recipients, economic comparisons between various combination drug therapies remain sparse.

AIM

This study used an economic evaluation based on network meta-analysis to assess the cost-effectiveness of four immunosuppressive regimens for adult heart transplant recipients in China.

METHOD

We conducted a systematic search for clinical trials in PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang Data, and VIP database. A validated Markov model was adapted to reflect the Chinese medical landscape. Four maintenance immunosuppression regimens were considered: tacrolimus/mycophenolate mofetil (TAC/MMF), cyclosporine/mycophenolate mofetil (CSA/MMF), everolimus/cyclosporine (EVL/CSA), and sirolimus/tacrolimus (SRL/TAC). The probabilities of health events were derived from a comprehensive literature review. Direct medical costs, adjusted for 2022 values, were from public documents and websites, while utilities for quality-adjusted life-years (QALYs) were taken from previous studies. Primary outcomes were mean lifetime cost, QALYs, and cost-effectiveness, with a willingness-to-pay (WTP) threshold set at three times China's GDP per capita in 2022. Sensitivity analyses were conducted to test the robustness of the results.

RESULTS

The base case analysis identified TAC/MMF as the most cost-effective regimen, producing a mean of 6.31 QALYs per patient at a cost of Chinese Yuan (CNY) 534,182.89. Sensitivity analyses consistently reinforced TAC/MMF as the most cost-effective and robust choice.

CONCLUSION

TAC/MMF is the most cost-effective maintenance immunosuppressive regimen for heart transplant recipients within the Chinese health system. The study findings are reinforced by sensitivity analyses, affirming their robustness amid various uncertainties.

Long-term outcomes of a novel fully magnetically levitated ventricular assist device for the treatment of advanced heart failure in China

BACKGROUND

Left ventricular assist devices (LVADs) are well-established for treating end-stage heart failure, but this therapy is only available to Chinese patients in recent years. The CH-VAD is the first used fully magnetically levitated pump in China. This study reports the long-term outcomes of a cohort supported by the CH-VAD for the first time.

METHODS

From June 2017 to August 2023, 50 consecutive patients received CH-VAD implantation in Fuwai Hospital. Clinical data were collected and retrospectively analyzed.

RESULTS

Baseline characteristics included a mean age of 47.9 ± 13.9 years, 90% male, and 26% ischemic etiology. The Interagency Registry for Mechanically Assisted Circulatory Support profile revealed 12% profile 1, 56% profile 2, 26% profile 3, and 6% profile 4. The mean support duration was 868 ± 630 days (range 33 days-6.4 years). Kaplan-Meier survival rate was 93% (95% CI, 79-98) at 1 year, 93% (95% CI, 79-98) at 2 years, and 89% (95% CI, 71-96) at 3 years. Forty patients (80%) currently remain on support, 3 were bridged to recovery, 2 received transplants, and 5 expired during support. Major adverse events (AEs) included right heart failure (10%), surgical-related bleeding (8%), arrhythmia (8%), and driveline infection (16%). Major hemocompatibility-related AEs were limited to 3 nondisabling strokes and 1 gastrointestinal bleeding. No major device malfunction occurred during the follow-up period.

CONCLUSIONS

The largest single-center experience with the leading LVAD in China shows high survival with low complication rates, demonstrating that CH-VAD is safe and efficient in providing long-term support for patients with end-stage heart failure.

Examining a 12-year experience within Kazakhstan's national heart transplantation program

Kazakhstan has one of the lowest heart transplantation (HTx) rates globally, but there are no studies evaluating the outcomes of HTx. This study aimed to provide a comprehensive analysis of the national HTx program over a 12-year period (2012-2023). Survival analysis of the national HTx cohort was conducted using life tables, Kaplan‒Meier curves, and Cox regression methods. Time series analysis was applied to analyze historical trends in HTx per million population (pmp) and to make future projections until 2030. The number of patients awaiting HTx in Kazakhstan was evaluated with a regional breakdown. The pmp rates of HTx ranged from 0.06 to 1.08, with no discernible increasing trend. Survival analysis revealed a rapid decrease in the first year after HTx, reaching 77.0% at 379 days, with an overall survival rate of 58.1% at the end of the follow-up period. Among the various factors analyzed, recipient blood levels of creatinine and total bilirubin before surgery, as well as the presence of infection or sepsis and the use of ECMO after surgery, were found to be significant contributors to the survival of HTx patients. There is a need for public health action to improve the HTx programme.

Dynamic LVEF Decline and Serum NT-proBNP and Uric Acid Levels before Heart Transplantation are Independent Predictors of Adverse Outcomes in Young Adult Patients with Dilated Cardiomyopathy

Background

The present study investigated the predictors of adverse outcomes in young adult patients with dilated cardiomyopathy (DCM) who underwent heart transplantation (HTx).

Methods

Twenty-four young adult patients (aged 18-45 years) with DCM who underwent HTx in our hospital from January 2012 to December 2022 were included in this retrospective analysis. Pre- and post-HTx data were collected for echocardiography, N-terminal pro-brain natriuretic peptide (NT-proBNP), and uric acid (UA). Data collected at the time of DCM diagnosis were designated as baseline data. Post-HTx assessments were conducted at 1 week and 3, 6, 12, and 36 months post-HTx. The primary endpoint was defined as any adverse event, including left ventricular ejection fraction (LVEF) < 50% (n = 3), 50% increase in right or left ventricular diameter (n = 12), or death (n = 2). Patients were categorized into a non-adverse-event group (n = 12) or an adverse-event group (n = 12).

Results

Baseline NT-proBNP (p = 0.014) and UA (p = 0.012) were significantly higher in the adverse-event group than in the non-adverse-event group. Baseline NT-proBNP > 7390 pg/mL (relative risk (RR) = 7.412, p = 0.046), UA > 542 µmol/L (RR = 8.838, 95% confidence interval (95% CI) = 1.541-50.694, p = 0.014), and sustained reduction in LVEF ( ≥ 3%) over a 2-year pharmacological treatment prior to HTx (RR = 3.252, p = 0.046) were significantly associated with an increased risk of adverse events post-HTx.

Conclusions

In young adult DCM patients post-HTx, heightened baseline levels of NT-proBNP and UA levels and a sustained reduction in LVEF over time prior to undergoing an HTx are significantly associated with an increased risk of adverse events post-HTx. Future studies are needed to observe whether individualized monitoring strategies could reduce the incidence of adverse events following HTx in these patients.

Developments and Challenges in Durable Ventricular Assist Device Technology: A Comprehensive Review with a Focus on Advancements in China

Heart transplantation is currently the most effective treatment for end-stage heart failure; however, the shortage in donor hearts constrains the undertaking of transplantation. Mechanical circulatory support (MCS) technology has made rapid progress in recent years, providing diverse therapeutic options and alleviating the dilemma of donor heart shortage. The ventricular assist device (VAD), as an important category of MCS, demonstrates promising applications in bridging heart transplantation, destination therapy, and bridge-to-decision. VADs can be categorized as durable VADs (dVADs) and temporary VADs (tVADs), according to the duration of assistance. With the technological advancement and clinical application experience accumulated, VADs have been developed in biocompatible, lightweight, bionic, and intelligent ways. In this review, we summarize the development history of VADs, focusing on the mechanism and application status of dVADs in detail, and further discuss the research progress and use of VADs in China.

Heart transplantation: advances in expanding the donor pool and xenotransplantation

Approximately 65 million adults globally have heart failure, and the prevalence is expected to increase substantially with ageing populations. Despite advances in pharmacological and device therapy of heart failure, long-term morbidity and mortality remain high. Many patients progress to advanced heart failure and develop persistently severe symptoms. Heart transplantation remains the gold-standard therapy to improve the quality of life, functional status and survival of these patients. However, there is a large imbalance between the supply of organs and the demand for heart transplants. Therefore, expanding the donor pool is essential to reduce mortality while on the waiting list and improve clinical outcomes in this patient population. A shift has occurred to consider the use of organs from donors with hepatitis C virus, HIV or SARS-CoV-2 infection. Other advances in this field have also expanded the donor pool, including opt-out donation policies, organ donation after circulatory death and xenotransplantation. We provide a comprehensive overview of these various novel strategies, provide objective data on their safety and efficacy, and discuss some of the unresolved issues and controversies of each approach.

Current treatment outcomes of congenital heart disease and future perspectives

China has the largest number of individuals with congenital heart disease (CHD) in the world and a heavy burden of CHD. Therefore, understanding current CHD treatment outcomes and patterns in China will contribute to global progress in CHD treatment and be a valuable experience. Generally, CHD treatment in China has satisfactory outcomes owing to the joint efforts by all relevant stakeholders across the country. However, efforts are needed to overcome the remaining challenges: management of mitral valve disease and paediatric end-stage heart failure needs to be improved; cohesive paediatric cardiology teams should be established and collaboration between hospitals enhanced; CHD-related medical resources need to be more accessible and equitable; and nationwide CHD databases should be enhanced. In the second paper of this Series, we aim to systematically summarise the current CHD treatment outcomes in China, discuss potential solutions, and provide future perspectives.

Lymph-Node-Targeted Drug Delivery for Effective Immunomodulation to Prolong the Long-Term Survival After Heart Transplantation

The chronic rejection responses and side effects of the systematic administration of immunosuppressants are the main obstacles to heart allograft and patient survival. The development of xenotransplantation also urgently requires more efficient immune regulation strategies. Herein, it is demonstrated that lymph-node (LN)-targeted drug delivery can realize LN-specific immunomodulation with attenuated immune suppression on distant peripheral immune organs to effectively prolong long-term survival after heart transplantation in a chronic murine heart transplantation model. A chemokine C-C motif ligand 21 (CCL21) specific aptamer for LN targeting is decorated onto the surface of the hybrid nanoparticular delivery vector mainly composed of CaCO₃ /CaP/heparin. The targeting delivery system can dramatically enhance accumulation of the loaded immunosuppressant, fingolimod hydrochloride (FTY720), in draining lymph nodes (dLNs) for inducing powerful immune suppression. By promoting the generation of endogenous regulatory T cells (T_regs ) and decreasing the proportion of effector T cells (T_effs ) in dLNs after heart transplantation, the LN-targeting strategy can effectively regulate local immune responses instead of systemic immunity, which reduces the incidence of long-term complications. This study provides an efficient strategy to improve the survival rate after organ transplantation by precise and localized immunoregulation with minimized side effects of immunosuppression.