Heart & Lung Committee Update

This report outlines the background to and actual delivery of a Heart Transplant Workshop at the Cho Ray Hospital, Ho Chi Minh City in June 2018. This pilot program, led by a team from St Vincent’s Hospital, Sydney, Australia, was made possible through the support and majority funding from the TTS for the travel and accommodation expenses of the St Vincent’s team. It was also supported by the Organ & Tissue Donation Services (OTDS) from New South Wales which funded the participation of a Donation Specialist Coordinator and by Cho Ray Hospital for local logistics and transportation.

Background

Almost 4 decades after bitter conflict and reunification, Vietnam has emerged as one of the fastest growing Asian countries. Despite the remarkable speed of its economic success, there remain significant gaps in the delivery of healthcare to its 95 million population. In response, the communist-led government has been increasing the healthcare budget accounting for 7.5% of GDP in 2017 and expected to rise to 12.5% by 2021, a significant figure outstripping several European nations where the average healthcare expenditure is just under 10% of GDP and very short of the 17% in the USA. There is an unquestionable need to direct the bulk of these resources towards renovating old hospitals, building new ones, expanding a modern healthcare workforce and significantly increasing the capacity for local supply of pharmaceuticals and medical devices.

A focused dedication to mitigating the risk factors for and to combating the significant prevalence of Non-communicable Diseases (NCDs) is directed by both national policies and the WHO. NCDs account for 77% of all deaths in Vietnam (1). Cardiovascular disease alone accounts for 31% of deaths with 13% of the population at high risk of CVD or with existing CVD diagnosis (2). Almost 12% of all deaths are attributable to coronary artery disease (1). The prevalence of Heart Failure (HF) is within the global range of 1-3% of population (3).

A substantial proportion of the end-stage HF patients would be eligible for heart transplantation were it not for the many barriers that are still present in respect of developing a mature and viable national heart transplant program based on deceased donation (4). Heart transplantation has been carried out in Vietnam since 2010 but the numbers remain few and opportunistic rather than from a strategically planned national program.

The latest available data (May 2017) indicates that Vietnam has performed a total of 2,425 organ transplants: 2,327 Kidneys, 77 Livers, 18 hearts, 1 heart-lung, 1 lung and single case of combined Kidney-pancreas. In the drive to increase deceased donation, the number of donors registered on the national organ donation registry numbered 8,355.

Vietnamese Heart Transplant Milestones:

  • 2010 1st Vietnamese Heart Transplant at 103 Military Hospital, Hanoi with Taiwanese support
  • 2011 1st Heart Transplant without foreign support at Central Hospital, Hue
  • 2018 Total of 20 heart transplant in 3 Heart transplant centres

Cho Ray Hospital - Ho Chi Minh City:

Originally built in 1900 during French colonial times, the hospital underwent enormous restructuring on a 55,000 m2 site with Japanese aid in 1974. It has now grown to a 1800 bedded facility providing comprehensive multi-specialty care including busy adult and paediatric cardiac surgical programs.

Milestones at Cho Ray Hospital

  • 2008 1st Vietnamese Kidney Transplant from DBD donor
  • 2015 1st Vietnamese Kidney Transplant from DCD donor
  • 2017 1st Institutional Heart Transplant (Total of 3 since)

In 2015, at the invitation of the Vietnamese Transplant Society to their annual meeting and with expert mediation by Professor Richard Allen, a number of surgeons from St Vincent’s Hospital, Sydney, had the opportunity to see Cho Ray Hospital and meet the local Cardiology and Cardiac Surgical experts. There was easy mutual friendship, not least because the cardiac surgical department arose from the initial training delivered locally by the Australian surgeon, Dr Alan Gale and his team in 2000. Continued dialogue over the past couple of years led to the creation of a Heart Transplant workshop to be delivered locally in Ho Chi Minh City by the St Vincent’s Hospital team.

Team Members:

  • Peter Macdonald
    Heart Failure Cardiologist
  • Hong Chee Chew
    Donor Retrieval Surgeon
  • Kumud Dhital
    Transplant Surgeon
  • Michelle Harkess
    Transplant Coordinator
  • Roger Pye
    Cardiac Anaesthesia/Perfusion/ECMO Specialist
  • Suhel Al-Soufi
    Intensive Care Physician
  • Elizabeth Conquest
    ICU Nurse

The group was joined by:

  • Luke Datson
    Donation Specialist Coordinator, OTDS., NSW
  • Richard Allen
    TTS Educational Ambassador

Heart Transplant Workshop at Cho Ray Hospital, Chi Minh City, 8–9 June 2018

The concept was to deliver a comprehensive program including the following:

  • Patient selection
  • Donor Identification & Management
  • Donor coordination
  • Donor retrieval process and surgery
  • Recipient anaesthesia
  • Recipient transplant surgery
  • Management of PGD including ECMO support
  • Post-transplant intensive care from both physician and nursing perspectives
  • Adjunct therapies in ICU
  • Post-operative protocols and in-hospital care
  • Long-term graft and recipient surveillance

In order to put this in perspective, the program commenced with an appraisal of the current situation in Vietnam in regard to Organ Donation, Heart Failure management and transplant activity. These talks were all delivered by the local Faculty.

The event, held at Cho Ray Hospital was well attended by both physicians and allied health staff, with over 150 delegates over the 2 days. Logistical issues and wider dissemination of the event, a task given local responsibility, meant that a greater participation from other transplants units in Vietnam was not achieved.

A detailed tour of the hospital was taken by all the Faculty Staff, in particular through the General and Neurosurgical ICUs, General wards, Clinic areas and Operating Theatres. The volume of work being carried out was impressive and the consequent strains on the infrastructure was obvious. The very crowded neurosurgical unit, with a significant population of young patients with head injuries from road traffic accidents, was overwhelming.

The visiting Faculty all commented on the very positive aspects of the hospital management and physicians wanting to embrace changes to improve on the transplant programs. We were all impressed with the General ICU where 2 patients had been placed on VA-ECMO for myocarditis by the Intensivist and a nurse. The young adult had already been weaned and the child was responding well to therapy. The nature and breadth of cardiac surgical procedures carried out do not indicate anything but excellent technical skills and surgical judgement.

The local feedback was extremely positive and cemented a bilateral desire to try and further improve the local staff expertise and infrastructure towards developing both the environment to facilitate deceased donation as well as to uplift the heart transplant program.

We feel that the workshop was highly successful and that it adds significantly to the commitment by the TTS Executive to expand the Heart & Lung speciality within TTS. This type of clinical engagement allows the TTS to develop this niche further particularly as demand is growing in both India and China.

Recommendations:

  • Develop a strong foundation in deceased organ donation as an over-riding priority over pursuing a DCD donation pathway.
  • The over-capacity intensive care bed status needs to be addressed, particularly in the neurosurgical ICU. The latter should have space for family/relatives and a quiet space for initiating and conducting discussions around organ donation when appropriate.
  • Resources are therefore necessary for improving Donor Identification, management and coordination.
  • The Australian Team to facilitate clinical placements and observer ships in Australia for 3 – 12 months as dictated by the role. The immediate requirement is for a heart failure specialist to spend time in Australia to learn about current HF management, care of pre and post-transplant patients particularly in respect of immunosuppression and most importantly to learn the techniques for endo-myocardial biopsies. Additional expertise required for pathology and to explore back- up double reading in Australia.
  • A proposal for this Australian support with potential hospital placements and amount of funding required will be made available within the first quarter of 2019.
  • To identify relevant staff to travel to Vietnam, if required, around the time of a future heart transplant procedure.

References

  1. World Health Organization. Causes of death 2008: Data sources and methods. Geneva. WHO. 2011, http://www.who.int/healthinfo/global_burden_disease/cod_2008_sources_methods.pdf.
  2. World Health Organization. Non communicable diseases country profiles 2014. Geneve. WHO. 2014, http://www.who.int/nmh/publications/ncd-profiles-2014/en/
  3. Reyes EB et al. Heart Failure across Asia: Same healthcare burden but difference in organization of care. In J Cardiol 2016 15, 223:163-167
  4. Tran SN et al. Current status of organ donation for transplantation in Vietnam. Presented at the
    27th International Congress of The Transplantation Society, Madrid 2018 https://tts.guide/webapp/lecture/1060