Korean J Transplant.  2022 Dec;36(4):267-277. 10.4285/kjt.22.0038.

Trends in contemporary advanced heart failure management: an in-depth review over 30 years of heart transplant service in Hong Kong

• Fan YYK
• Wong KL
• Cally Ho KL
• Daniel Chan TL
• Lee OJ
• Yung CY
• Lun KS
• Elaine Chau MC
• Chiu SWC
• Cheng LC
• Timmy Au WK

• KMID: 2537538
• DOI: http://doi.org/10.4285/kjt.22.0038

Abstract

Background
The year 2022 marks the 30th anniversary of heart transplant service in Hong Kong (HK). In this study, we describe prevailing trends and outcomes of advanced heart failure (AHF), including heart transplantations (HTx), in HK over the past 30 years.
Methods
Trends in heart failure prevalence in HK from 1993 to 2021 were analyzed based on data from the Hospital Authority Clinical Data and Reporting System. All AHF patients referred for HTx consideration between 1992 and 2021 were reviewed. The bridge-to-transplant (BTT) utilization of short-term mechanical circulatory support (ST-MCS) devices, including venoarterial extracorporeal membrane oxygenation (VA-ECMO) and durable left ventricular assist devices (LVADs), from 2010 to 2021 was reviewed.
Results
Overall, 237 heart transplants were performed in HK, with 10-year posttransplant and median survival of 68.1% and 18.7 years, respectively. An increase in AHF clinic referrals was correlated with increasing heart failure prevalence (R²=0.635, P<0.001). In total, 146 referrals were made for ST-MCS, and an observed increase in ST-MCS referrals was correlated with increasing VA-ECMO utilization (R²=0.849, P<0.001). Among 62 patients accepted for AHF therapy, those with durable LVAD implementation had better 1-year survival (71.5%) than those receiving an extracorporeal CentriMag (Levitronix) device as BTT (40%, P=0.008). In total, 143 LVADs were implanted, with 130 as BTT or bridge-to-candidacy (BTC) methods. The survival rate among the 130 BTT/BTC LVAD patients resembled that of HTx recipients (73.8% vs. 69.8% at 9 years, P=0.296).
Conclusions
The burden of AHF management has increased and gained complexity over the past 30 years in Hong Kong.

Keyword

Heart transplantation; Heart-assist devices; Heart failure

Figure

• 

  Fig. 1 Hong Kong heart failure statistics in 1993–2021. (A) Long-term survival after the first diagnosis of heart failure in Hong Kong in 1993–2021 (n=292, 667). (B) A significant difference was observed across the examined eras in long-term survival after the first diagnosis of heart failure in Hong Kong (P<0.001). (C) A significant difference was also seen across eras in cardiovascular mortality after first diagnosis of heart failure in Hong Kong (n=271, 241; P<0.001).

• 

  Fig. 2 Hong Kong heart transplant statistics in 1992–2021. (A) Trends in number of new heart transplantations, new advanced heart failure clinic referrals, active patients on the heart transplant waiting list, and heart failure prevalence in Hong Kong from 1992 to 2021. (B) Long-term survival after adult and pediatric heart transplantations in Hong Kong (HK; n=237) and the International Society for Heart and Lung Transplantation Registry (ISHLT; n=114,783). (C) Long-term survival after adult and pediatric heart transplantations in Hong Kong by era.

• 

  Fig. 3 Mechanical circulatory support statistics in Hong Kong in 2010–2021. (A) Trend in the utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR) in Hong Kong from 2010 to 2021. (B) Trend in VA-ECMO or percutaneous microaxial left ventricular assist device (Impella; Abiomed)-related referrals to the heart transplant service as well as total background numbers of VA-ECMO and ECPR cases in Hong Kong from 2010 to 2021. ICU, intensive care unit; QMH, Queen Mary Hospital; CTS, cardiothoracic surgery; ECPELLA, extracorporeal membrane oxygenation and impella.

• 

  Fig. 4 (A) Survival of patients referred for advanced heart failure therapy related to the use of short-term mechanical circulatory support devices. A significant difference in survival was observed by decision after patient referral to the advanced heart failure service related to short-term mechanical circulatory support (P<0.001). (B) Survival of patients accepted for advanced heart failure therapies by different bridging strategies. Significantly better survival (71.5%) was observed at 1 year after durable left ventricular assist device implantation compared to 40% at 1 year after CentriMag (Levitronix) left ventricular assist device implantation as bridging strategies for transplantation/candidacy (P=0.008). LVAD, left ventricular assist device.

• 

  Fig. 5 (A) Survival after durable left ventricular assist device implantation in Hong Kong between 2010 and 2021 (n=143). (B) Comparison of survival after durable left ventricular assist device implantation as a bridge to transplantation/candidacy strategy and survival after heart transplantation in Hong Kong (P=0.296).

Reference

1. Reyes EB, Ha JW, Firdaus I, Ghazi AM, Phrommintikul A, Sim D, et al. 2016; Heart failure across Asia: same healthcare burden but differences in organization of care. Int J Cardiol. 223:163–7. DOI: 10.1016/j.ijcard.2016.07.256. PMID: 27541646.

2. Braunwald E. 2015; The war against heart failure: the Lancet lecture. Lancet. 385:812–24. DOI: 10.1016/S0140-6736(14)61889-4. PMID: 25467564.

3. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021; 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 42:3599–726. DOI: 10.1093/eurheartj/ehab368. PMID: 34447992.

4. Ammar KA, Jacobsen SJ, Mahoney DW, Kors JA, Redfield MM, Burnett JC Jr, et al. 2007; Prevalence and prognostic significance of heart failure stages: application of the American College of Cardiology/American Heart Association heart failure staging criteria in the community. Circulation. 115:1563–70. DOI: 10.1161/CIRCULATIONAHA.106.666818. PMID: 17353436.

5. Wong KL, Ho KL, Lee OJ, Lun KS, Bhatia I, Tam WY, et al. 2021; Emerging roles of left ventricular assist device therapy as bridge to transplant in an Asian city with scarce heart transplant donor. J Thorac Dis. 13:5717–30. DOI: 10.21037/jtd-21-298. PMID: 34795921. PMCID: PMC8575832.

6. Rose EA, Gelijns AC, Moskowitz AJ, Heitjan DF, Stevenson LW, Dembitsky W, et al. 2001; Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med. 345:1435–43. DOI: 10.1056/NEJMoa012175. PMID: 11794191.

7. Xanthakis V, Enserro DM, Larson MG, Wollert KC, Januzzi JL, Levy D, et al. 2016; Prevalence, neurohormonal correlates, and prognosis of heart failure stages in the community. JACC Heart Fail. 4:808–15. DOI: 10.1016/j.jchf.2016.05.001. PMID: 27395350. PMCID: PMC8450920.

8. Chu SH, Hsu RB, Wang SS. 1999; Heart transplantation in Asia. Ann Thorac Cardiovasc Surg. 5:361–4. PMID: 10637384.

9. Hai JJ, Chan PH, Huang D, Ho MH, Ho CW, Cheung E, et al. 2016; Clinical characteristics, management, and outcomes of hospitalized heart failure in a Chinese population-the Hong Kong Heart Failure Registry. J Card Fail. 22:600–8. DOI: 10.1016/j.cardfail.2016.03.007. PMID: 27002944.

10. Pathadka S, Yan VK, Li X, Tse G, Wan EY, Lau H, et al. 2021; Hospitalization and mortality in patients with heart failure treated with sacubitril/valsartan vs. enalapril: a real-world, population-based study. Front Cardiovasc Med. 7:602363. DOI: 10.3389/fcvm.2020.602363. PMID: 33553256. PMCID: PMC7855850.

11. Wong AY, Root A, Douglas IJ, Chui CS, Chan EW, Ghebremichael-Weldeselassie Y, et al. 2016; Cardiovascular outcomes associated with use of clarithromycin: population based study. BMJ. 352:h6926. DOI: 10.1136/bmj.h6926. PMID: 26768836.

12. Chan EW, Lau WC, Leung WK, Mok MT, He Y, Tong TS, et al. 2015; Prevention of dabigatran-related gastrointestinal bleeding with gastroprotective agents: a population-based study. Gastroenterology. 149:586–95. DOI: 10.1053/j.gastro.2015.05.002. PMID: 25960019.

13. Mosterd A, Hoes AW. 2007; Clinical epidemiology of heart failure. Heart. 93:1137–46. DOI: 10.1136/hrt.2003.025270. PMID: 17699180. PMCID: PMC1955040.

14. Redfield MM, Jacobsen SJ, Burnett JC Jr, Mahoney DW, Bailey KR, Rodeheffer RJ. 2003; Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. JAMA. 289:194–202. DOI: 10.1001/jama.289.2.194. PMID: 12517230.

15. Cowie MR, Wood DA, Coats AJ, Thompson SG, Poole-Wilson PA, Suresh V, et al. 1999; Incidence and aetiology of heart failure; a population-based study. Eur Heart J. 20:421–8. DOI: 10.1053/euhj.1998.1280. PMID: 10213345.

16. Khush KK, Cherikh WS, Chambers DC, Harhay MO, Hayes D Jr, Hsich E, et al. 2019; The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: thirty-sixth adult heart transplantation report - 2019; focus theme: donor and recipient size match. J Heart Lung Transplant. 38:1056–66. DOI: 10.1016/j.healun.2019.08.004. PMID: 31548031. PMCID: PMC6816343.

17. Stehlik J, Kobashigawa J, Hunt SA, Reichenspurner H, Kirklin JK. 2018; Honoring 50 years of clinical heart transplantation in circulation: in-depth state-of-the-art review. Circulation. 137:71–87. DOI: 10.1161/CIRCULATIONAHA.117.029753. PMID: 29279339.

18. Shroff S, Mittal K, Navin S. 2020; Heart transplantation in India-looking back as we celebrate 25 years of the transplant law. Indian J Thorac Cardiovasc Surg. 36(Suppl 2):215–23. DOI: 10.1007/s12055-020-00957-6. PMID: 33071487. PMCID: PMC7538491.

19. Peek GJ, Clemens F, Elbourne D, Firmin R, Hardy P, Hibbert C, et al. 2006; CESAR: conventional ventilatory support vs extracorporeal membrane oxygenation for severe adult respiratory failure. BMC Health Serv Res. 6:163. DOI: 10.1186/1472-6963-6-163. PMID: 17187683. PMCID: PMC1766357.

20. Thiele H, Zeymer U, Thelemann N, Neumann FJ, Hausleiter J, Abdel-Wahab M, et al. 2019; Intraaortic balloon pump in cardiogenic shock complicating acute myocardial infarction: long-term 6-year outcome of the randomized IABP-SHOCK II trial. Circulation. 139:395–403. DOI: 10.1161/CIRCULATIONAHA.118.038201. PMID: 30586721.

21. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2019; 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J. 40:87–165. DOI: 10.1093/eurheartj/ehy394. PMID: 30165437.

22. Teuteberg JJ, Cleveland JC Jr, Cowger J, Higgins RS, Goldstein DJ, Keebler M, et al. 2020; The Society of Thoracic Surgeons Intermacs 2019 annual report: the changing landscape of devices and indications. Ann Thorac Surg. 109:649–60. DOI: 10.1016/j.athoracsur.2019.12.005. PMID: 32115073.

23. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al. 2016; 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 37:2129–200. DOI: 10.1093/eurheartj/ehw128. PMID: 27206819.

24. Kormos RL, Cowger J, Pagani FD, Teuteberg JJ, Goldstein DJ, Jacobs JP, et al. 2019; The Society of Thoracic Surgeons Intermacs database annual report: evolving indications, outcomes, and scientific partnerships. Ann Thorac Surg. 107:341–53. DOI: 10.1016/j.athoracsur.2018.11.011. PMID: 30691584.