Introduction

Cardiac transplantation has evolved significantly since the first successful human heart transplant in 1967 Over the past few decades, advancements in immunosuppressive therapies, surgical techniques, and post-operative care have dramatically improved patient outcomes, making cardiac transplantation a viable option for patients with end-stage heart disease. ^, According to the International Society for Heart and Lung Transplantation (ISHLT), thousands of heart transplants are performed annually worldwide, primarily in the USA and Europe These regions have well-established transplantation programs with comprehensive infrastructures that support donor organ procurement, patient selection, and long-term follow-up care.

Recent advancements in this field have further improved the success and accessibility of cardiac transplantation Innovations such as ex-vivo heart perfusion, which preserves donor hearts for longer periods and improves their viability, have expanded the potential donor pool. Furthermore, the development of more effective and targeted immunosuppressive therapies has reduced the incidence of transplant rejection and improved long-term survival rates Additionally, advancements in genomic medicine are beginning to tailor treatments to individual patient profiles, minimizing side effects and improving outcomes

On the other hand, the Middle East and North Africa (MENA) region presents unique challenges and opportunities for the development and implementation of cardiac transplantation. ^, For instance, the MENA region experiences a high prevalence of cardiovascular diseases, which significantly contributes to the burden of end-stage heart failure on affected individuals and healthcare systems. ^, This highlights the potential utility of implementing cardiac transplantation programs in the MENA region, possibly improving patient outcomes and reducing the growing burden of cardiovascular disease.

In recent decades, the MENA region has seen considerable advancements in cardiac transplantation. Nations including Saudi Arabia, Turkey, the United Arab Emirates, and Jordan have notably developed and expanded their heart transplant programs. ^, Furthermore, physicians and heart transplant institutions in the MENA region have adopted advanced surgical techniques and enhanced post-operative care protocols, which has led to improved patient outcomes. Additionally, regional collaborations and partnerships with international medical institutions have facilitated the transfer of knowledge and expertise in the field of cardiac transplantation in this region

Despite these advancements, the MENA region continues to face challenges related to donor organ shortages, immunological rejection, and high associated costs. These challenges are compounded by specific regional factors. For instance, cultural and religious beliefs about organ donation can significantly hinder donor registration rates. ^, In addition, there is also a lack of public awareness and education about the benefits and processes of organ donation. ^, Healthcare infrastructure disparities mean that while some countries have advanced transplantation programs, others lack the necessary facilities and expertise. Furthermore, political instability and economic constraints in parts of the region further exacerbate these challenges, making it difficult to establish and maintain advanced transplantation programs. ^,

This review aims to provide a detailed overview of the current status and challenges of cardiac transplantation in the MENA region. This includes exploring the developments and advancements made on cardiac transplantation programs in the MENA region, and the specific barriers faced in different countries. Additionally, our review aims to highlight the outcomes of cardiac transplantation procedures in the MENA region, comparing them to global standards. By identifying both successes and areas for improvement, we aim to inform policymakers, healthcare providers, and researchers about the critical factors that influence cardiac transplantation in this diverse and dynamic region.

Methodology

Current status of cardiac transplantation in the MENA region

Overview of programs and institutions

Cardiac transplantation in the MENA region has grown significantly, with key programs established in countries such as Saudi Arabia, Lebanon, the UAE, and Egypt. Tables 1 and 2 outline the results of our literature search for studies focusing on cardiac transplant in the MENA region. For instance, leading institutions, such as King Faisal Specialist Hospital in Riyadh, have developed comprehensive transplant programs that include pre-operative, surgical, and post-operative care for both. ^, Furthermore, Prince Sultan Cardiac Center Saudi Arabia has performed an average of five heart transplants annually according to data available from (1986-1996). During this period, a total of 25 heart transplants were conducted. The center achieved an overall eight-year survival rate of 45 %, which is comparable to international standards The American University of Beirut Medical Center AUBMC is another prominent center, recognized for its advanced cardiac care and transplant services In 2017, the Children’s Heart Center AUBMC achieved a significant milestone by performing Lebanon’s first successful heart transplant in a pediatric patient, with promising signs of recovery shortly after the operation

Table 1

Literature search results on studies investigating cardiac transplant in MENA region.

Authors, Year	Study Design	Country/Countries of Study	Sample Size	Population Characteristics (e.g., age, gender, ethnicity)	Indication for Cardiac Transplant	Key Findings relating to cardiac transplant outcomes	Challenges/limitations relating to cardiac transplant in MENA region	Future Study Recommendations	Notes
Feras Bader et al. 2018	Editorial	The study focuses on the Gulf Cooperation Council (GCC) countries, including Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates	NA	mean recipient age was 33 ± 13 years. Adult and pediatric recipients. Ethnicity: transplant recipients were Saudi citizens, with most heart donors being non-Saudi expatriates	Advanced heart failure unresponsive to other treatments. The main cause of heart failure in the region is ischemic heart disease	Five-year survival for transplanted patients in Saudi Arabia was 78 %, similar to international outcomes.	A significant deficit between supply and demand for donor hearts. Cultural and religious considerations affecting organ donation. Lack of deceased donors and dedicated advanced heart failure and transplant programs	Establishing regional collaboration for organ procurement. Intensified international collaboration with North American and European programs. Exploring new avenues to provide local advanced therapies for more end-stage heart failure patients	The first heart transplant in the Gulf region was performed in 1986 in Riyadh, Saudi Arabia. Legal misconceptions and insufficient donor registrations are major barriers to organ donation.
Aziz El Matri et al. 2015	Review	Tunisia	NA	Age: Both adult and pediatric patients. Gender: Includes both males and females. Ethnicity: Predominantly Tunisian	End-stage organ failure, primarily kidney failure.	Structured and advancing organ transplantation program with positive kidney transplant outcomes comparable to international standards.	Scarcity of donors. Cultural and religious barriers. Limited financial and infrastructural resources.	Establish regional collaborations to increase donor availability. Aim to reach 400 annual transplants to meet the needs effectively.	Emphasis on the importance of legal and ethical frameworks supporting transplantation programs. Tunisia’s experience showcases potential for successful programs in the MENA region despite challenges.
Deema A Almutawa er al. (2020)	Retrospective study	Saudi arabia	90	Gender: 77.78 % males Age: Not specified directly, but implies diverse age due to mentioning younger patients compared to other studies. Ethnicity: Not specified, primarily Saudi.	Dilated Cardiomyopathy (DCM) – 52.22 % Ischemic Cardiomyopathy (ICM) – 32.22 %	The prevalence of malnutrition in the preoperative phase by NRI was 60 % (7.78 % severe, 40 % moderate, 12.22 % mild). Significant increase in BMI and NRI after one year post op. (p < 0.001). Recipients with postoperative moderate or severe nutritional risk (NRI < 97.5) had significantly shorter survival in the first-year post-transplantation (HR = 0.82; 95 % CI, 0.75–0.89; p < 0.001).	High prevalence of malnutrition risk pre-transplant. Diverse healthcare systems and heart transplant protocols. Long waiting periods until transplantation. Improper nutritional management during the pre-transplant period.	Address the nutrition care process (NCP) in the management of patients undergoing transplantation. Develop specific data about the prevalence of malnutrition among heart failure patients living in Saudi Arabia.	Malnutrition among heart-transplant patients is a significant concern affecting survival rates. The study emphasizes the importance of nutritional assessment and management both before and after heart transplantation.
Waleed AlHabeeb et al. (2017)	Survey using questionnaire	Saudi arabia	1202	Saudi nationals above 18 years of age Gender: 620 males (49.6 %) and 630 females (50.4 %) Age: Mean age 31.5 years (range 18-75 years) <30 years: 56.4 % 30-50 years: 37.6 % 50 years: 6 % Marital Status: 757 married (60.6 %)	NA	91 % agreed with the concept of organ transplantation 17 % did not agree with heart transplantation; 42.4 % of these cited religious reasons 43.6 % were willing to donate their heart 58 % would consent to the donation of a relative’s organ after death 59.7 % believed organ donation is regulated 31.8 % feared doctors might not try hard to save their lives if they consented to organ donation 77 % believed the heart is removed while the donor is alive	Misconceptions about brain death and the state of the donor during organ removal Fear that healthcare professionals may make less effort to save lives of potential donors Low rate of family consent for organ donation Cultural and religious reservations	Increase public awareness and education about organ donation and brain death Implement strategies to build trust in the organ donation system Consider opt-in or opt-out strategies at the time of obtaining national IDs or driver’s licenses Adopt successful practices from countries with higher organ donation rates	The study’s limitations included a reliance on ‘yes’ or ‘no’ responses, which may not capture the full complexity of attitudes and potential actions Future efforts should align with religious decrees that support organ donation and transplantation
Mehrdad Salehi et al. (2014)	Observational	Iran	69	Recipient age: Mean age 31.3 years with a range of 7–57 years. Donor age: Mean age 24.6 years with a range of 9–46 years. Gender distribution: Approximately 75 % of recipients were male, and among donors, 68.1 % were male.	End-stage heart diseases	1-month and 1-year survival rates: 82.6 % and 70 %, respectively. Increased donor age had a significant negative effect on survival rate. Sex differences between donor and recipient had no association with transplant outcome and survival rate. ICU stay had a significant negative effect on survival rate. Recipient’s status before transplantation, determined according to UNOS classification, was significantly related to transplant survival rate.	Hospital mortality was relatively higher (21.7 % 1-month mortality) compared to reported rates (5 %–10 %), possibly due to the lack of ventricular assist devices in Iran. Renal dysfunction and its severity affected early mortality. Right ventricular dysfunction was a significant cause of hospital death.	future studies should focus on evaluating long-term survival rates (5-, 10-, and 20-year) and improving outcomes, especially in the context of developing countries with limited health budgets and resources	The limitations of the study include the inability to evaluate long-term survival rates due to the recent establishment of the heart transplantation department
Mohammad Mahdavi et al. (2023)	Retrospective study	Iran	59	Pediatric heart transplant recipients, with a median age of 14 years, predominantly male (62.7 %)	dilated cardiomyopathy, COVID-19-related haemophagocytic lymphohistiocytosis syndrome, arrhythmogenic right ventricular cardiomyopathy, restrictive cardiomyopathy, hypertrophic cardiomyopathy, and congenital heart disease post-operation	Heart transplant rate reduced by 34 % in the first year of the pandemic but increased by 19 % in the second year. In-hospital mortality rate during the 2-year pandemic was 11.8 %, with one death related to COVID-19 acute respiratory distress syndrome. In-hospital COVID-19 infection rate was 18 %. Overall 30-day survival rate was 88 %, with a 30-day rejection rate of 10 %	Limited resources and facilities during the COVID-19 pandemic, uncertainty about safety protocols, need for immunosuppression regime changes during infection period, challenges in donor assessment, long-distance travel, and postoperative care with unknown complications	: Further studies to evaluate the long-term effects of COVID-19 in pediatric transplant recipients, collaboration efforts, clinical studies, and evidence-based procedures to address challenges in pediatric heart transplantation during the pandemic
Sepideh Taghavi et al. (2020)	descriptive cross-sectional study	Iran	48	Age >18 years – <60 years old	End stage heart failure along with ineffective medical treatment	The majority of patients had high spiritual health, with a better score in the religious dimension compared to the existential dimension. Most patients reported a poor quality of life based on the Minnesota Living with Heart Failure Questionnaire. There was a significant relationship between spiritual health and quality of life in both the Minnesota and Iranian quality of life questionnaires. Specifically, higher spiritual health was associated with better quality of life, particularly in physical and psychological aspects. Quality of life was affected by factors such as age, functional class, and ejection fraction	There is an influence of cultural belief on post-transplant patients but that needs to be explored more. Along with that low sample size, study duration and diverse set of populations are some noteworthy limitations of the study	Paying attention to patients’ spiritual needs, particularly focusing on their religious beliefs, can improve their physical and mental health. Therefore, spiritual care should be integrated into nursing alongside other medical services. Nurses should work with counseling and expert groups to ensure patients’ spiritual needs are met, and document these interventions in their medical records.
Hamid Peyrovi et al. (2014)	hermeneutic phenomenological interview	Iran	11	Median age 30, (Range 21-55). Total 9 Males (82 %) and 2 (18 %) females. Ethnicity: Iranian	idiopathic dilated cardiomyopathy, hypertrophic cardiomyopathy, coronary artery disease, or postpartum dilated cardiomyopathy	6 main themes. A new life: Recipients viewed the transplant as a second chance, feeling reborn with a new appreciation for life. Living with Vigilance: Post-transplant life involves strict adherence to medical follow-ups and lifestyle changes to ensure graft survival. Living with New Concerns: Recipients face challenges such as potential marital and financial issues, the pressure of medication adherence, and relationships with the donor’s family. Bearing Others’ Behaviors: Recipients deal with societal stigmatization, myths, and unsolicited advice, often feeling misunderstood. Paradoxical Emotions: They experience mixed emotions, balancing hope with despair and grappling with the dual nature of their medication. Prominent Role of God in Life: Many develop a deeper faith, feeling a closer connection to God, which helps them cope with their new reality.	Limited number of female participants. Culturally specific to Iran only. Lack of psychological support in country. Limited scope of themes.	Warrants policy makers attention in this area. Researchers believe that explaining what life means to a heart transplant recipient could enhance public awareness and understanding of the experience
Shirin Sayyahfar et al. (2019)	Cross sectional	Iran	50	mean age of the patients were 8.18 ± 4.27 years (1-16 years).40 (80 %) above 5 years of age. 10 (20 %) below 5 years of age. 24 males. All had received BCG vaccine	Pediatric candidates for heart transplantation, particularly focusing on latent tuberculosis infection (LTBI) screening	TST had an accuracy of 94 % in diagnosing Mycobacterium tuberculosis infection in comparison with IGRA. No active tuberculosis was documented during the 24-month follow-up in transplanted cases. Negative TST could rule out LTBI with an accuracy of 94 %-96 % in comparison with QFT.	Small sample size. Lack of positive QFT results. Study could not calculate agreement between TST and IGRA due to no positive QFT results. Limited comparison to other pediatric studies as there were few similar studies in the pediatric field	Larger studies needed to confirm findings Further comparison between TST and IGRA in different populations Consideration of resource limitations in poor-resource countries when selecting diagnostic tests for LTBI	This study provides important insights into the screening of LTBI in pediatric heart transplant candidates. TST remains a viable option in poor-resource settings due to its cost-effectiveness and high accuracy in negative results
Osama Omrani et al. (2018)	Retrospective cohort study	Saudi Arabia	127	Mean age: 36 years (SD 14 years). Gender: 76 % male. Recipients’ BMI: Mean 23.9 (SD 6.12). Donors’ BMI: Mean 25.2 (SD 3.86).	End-stage heart disease	34 % of patients developed donor-specific antibodies (DSA). HLA-DQ antibodies were the most common type detected. DSA-positive patients had significantly higher rates of: Treated acute cellular rejection (P=0.011) Reduced left ventricular ejection fraction (P < 0.001) Cardiac allograft vasculopathy (P=0.003) All-cause mortality (P=0.01)	Retrospective design with inherent biases. Single institution study. Young cohort which may not generalize to broader populations	Importance of HLA-DQ matching. Monitoring for DSA formation to minimize post-transplantation immunological risk.	The study highlights the significant role of HLA-DQ antibodies in poor outcomes post-cardiac transplantation, emphasizing the need for better matching and monitoring to improve patient outcomes
Khaled D. Algarni et al. (2020)	Retrospective cohort study	Saudi Arabia	30	Mean age: 36.73 ± 13.5 years. Gender: 83.33 % male.	Dilated cardiomyopathy (72.41 %), ischemic cardiomyopathy (26.67 %), hypertrophic cardiomyopathy (3.45 %)	37 % of patients had severe tricuspid regurgitation postoperatively. Severity of tricuspid regurgitation significantly decreased after 6 months (p=0.011). Survival at 10 years was 90 % in patients with less than moderate tricuspid regurgitation compared to 43 % for those with moderate/severe tricuspid regurgitation (log-rank p = 0.0498).	Limited to a single center with a small sample size. The study’s retrospective nature limits the ability to draw causal conclusions	Larger studies are warranted to confirm findings. Consideration of concomitant tricuspid valve repair at the time of heart transplantation for patients with dilated cardiomyopathy	Tricuspid regurgitation is a common issue after heart transplantation and negatively affects survival outcomes
Zahra Sheikhalipour et al. (2018)	hermeneutical phenomenological approach	Iran	11	Gender: Male, Female Age: Median 53 years, Range 34-63 years Marital Status: Single, Married	End-stage organ failure, specifically heart failure among the studied candidates	Participants experienced significant stress during the pretransplant waiting period. Religious and cultural beliefs, especially reliance on God, helped them cope with stress. Six themes emerged: “the misty road of organ transplantation,” “to accede to organ transplantation despite religious conflict,” “one step away from death,” “the master key of liberation,” “fear of the unknown,” and “reliance on God’’	Differences in how end-stage organ failures (kidney, liver, heart) manifest during the pretransplant waiting period. Poor health of participants sometimes required interviews to be conducted in multiple sessions, potentially affecting data quality	Additional research should include Shia Muslim participants from other regions and Islamic backgrounds to better understand their pretransplant experiences. Further studies should focus on the influence of religious and cultural beliefs on patient health and well-being	The study provides new insights into the religious and cultural factors influencing Shia Muslim patients awaiting organ transplantation. Findings can help develop culturally sensitive nursing care plans
Charles C. Canver et al. (2014)	Retrospective review	Saudi Arabia	76	61 men (80 %) and 15 women (20 %). Mean age of 35 years (range, 13–57 years)	End-stage heart failure with New York Heart Association class IV symptoms, peak oxygen consumption during exercise <15 mL/kg/min, and no contraindications.	Major complications included infection (10 patients), low-grade rejection (9 patients), reoperation for hemorrhage (8 patients), and sternal dehiscence (2 patients). 30-day mortality rate was 7.8 % (6/76). Actuarial survival rates were 87.4 % at 1 year and 81.5 % at 3 years	Scarcity of donor hearts. Poor infrastructure for donor procurement and logistical challenges. The small number of heart transplants performed annually, which increased early mortality rates compared to higher-volume centers.	Need for improvements in donor procurement infrastructure and logistics to sustain and enhance cardiac transplant programs in the region.	Most donor hearts (94 %) were from non-Saudi expatriates; only 6 % came from Saudi nationals. Strict criteria were applied for donor and recipient selection to ensure compatibility and reduce complications.
H. Ghadimi et al. (2005)	Retrospective pathology report review	Iran	45	(14 females and 31 males) aged 29.6 ± 12 years (range 11- 54 years)	End stage heart failure	One-month, 1-year, and 5-year survival rates: 80 %, 59.5 %, and 50 %, respectively Rejection grades: High incidence of severe rejection episodes, with 26.6 % at grade 3A and 7 % at grade 3B	Lower survival rates compared to international statistics High incidence and severity of rejection episodes possibly due to noncompliance with follow-up biopsy schedules Surgical techniques, immunosuppression regimens, and patient compliance as contributing factors	Consider compliance with follow-up programs in candidate selection for better outcomes Improvement in patient management and follow-up protocols recommended	Findings based on pathology reports of endomyocardial biopsies. Noncompliance of patients referred from distant regions noted as a significant issue
Seyed Mohsen Mirhosseini et al. (2012)	Prospective non-randomized controlled trial	Iran	30	Mean age 37 ± 12.4. 18 males and 12 females	Heart transplant recipients with postoperative kidney insufficiency and volume overload	Continuous renal replacement therapy (CRRT) significantly improved estimated glomerular filtration rate (eGFR) compared to furosemide. CRRT group: eGFR after intervention 61 ± 4.5 ml/min/1.73 m² vs. furosemide group 55 ± 8.5 ml/min/1.73 m² (P = 0.02) eGFR at discharge: CRRT group 72 ± 7.3 ml/min/1.73 m² vs. furosemide group 58 ± 7.4 ml/min/1.73 m² (P < 0.001) Mortality: 40 % in CRRT group vs. 26.6 % in furosemide group (P = 0.43)	Non-randomized design and small sample size Short follow-up period Limitations of the MDRD equation for renal function evaluation Sole use of furosemide as the loop diuretic, limiting comparisons with other diuretics	Larger, multi-centric randomized controlled trials (RCTs) needed Comparison of CRRT or intermittent hemodialysis (IHD) vs. other diuretics in similar patients
Carlos Mena et al. (2006)	Review article	NA	Not applicable (review)	Mean recipient age 49 years, 76 % males	Heart transplantation and subsequent allograft rejection diagnosis	Echocardiography and Doppler imaging (DI) have limitations in detecting allograft rejection High false-negative rate of endomyocardial biopsy	Small sample sizes in studies reviewed Poorly defined populations limit generalizability Lack of detailed reporting and standardized methodologies	Need for studies with adequate sample size, detailed methods, and prespecified end points Standardized diagnostic approaches and reporting formats
Zohreh Rahbar et al. (2024)	Cross-sectional single-center study	Iran	39	(15 female, 24 male), mean age of 39.6 years (range 13–70)	Hear transplant recipients undergoing endomyocardial biopsy	Key echocardiographic predictors of LVEDP included lateral E/e′ (r = 0.64) and average E/e′ (r = 0.60), with significant correlations also noted for septal E/e′ and LA volume. Left ventricular end-diastolic pressure (LVEDP) averaged 18.1 mmHg, with higher mean values in females compared to males.	The MENA region faces significant healthcare resource limitations, which can impact the availability and quality of post-transplant care, including advanced diagnostic tools and consistent follow-up protocols.	Conduct large-scale, multicenter studies within the MENA region to gather extensive data on HTx outcomes, focusing on both short-term and long-term survival rates and complications. Develop and implement clinical guidelines and management protocols that address the unique challenges and healthcare dynamics of the MENA region, ensuring they are culturally and regionally relevant.	Lateral E/e′ and average E/e′ were found to be the most reliable echocardiographic predictors of LVEDP, suggesting these parameters should be prioritized in routine post-transplant evaluations.
Mohammed Mahmoodurrahman et al. (2021)	Retrospective analysis	Saudi Arabia	99	Age at transplant 34, , 76 males (77 %)	End stage heart failure	31 out of 150 coronary angiographies (20.6 %) were positive for CAV. 24 cases of Grade 1, 4 cases of Grade 2, and 3 cases of Grade 3. Dobutamine Stress Echocardiography (DSE): Sensitivity: 3.2 ± 3.3 % Specificity: 94 ± 2.9 % In comparison with invasive coronary angiography DSE was not predictive of outcomes in the patient cohort studied.	Large interval time between DSE and invasive coronary angiography reduces the study’s statistical power. Lack of use of intravascular ultrasound (IVUS) may underestimate the true prevalence of CAV. availability and adoption of advanced diagnostic modalities is an issue in MENA region	Consider alternative imaging modalities for the evaluation of CAV post-orthotopic heart transplant (OHT) as DSE has low sensitivity. Further research to validate the findings in larger and more systematically assessed patient populations.	The study emphasizes the need for more reliable non-invasive diagnostic tools for detecting CAV in heart transplant recipients.
Noura Alturaif et al. (2024)	Editorial	NA	153 (main study)	NA	right ventricular (RV) dysfunction, which is associated with increased mortality and morbidity after heart transplantation.	NA	Single-center study with a relatively small sample size. Exclusion Rate: 64 % of the initial cohort was excluded, raising concerns about selection bias and the generalizability of the findings. RV Assessment Complexity: Challenges due to the RV’s complex geometry and the limitations of 2-dimensional transthoracic echocardiography (TTE).	Prospective studies are needed to better define RVLSF thresholds in diverse cohorts and to understand its prognostic significance across different patient populations. More research comparing RVLSF with other RV assessment parameters to establish the most effective methods for monitoring and risk assessment in heart transplant patients. Exploration of three-dimensional TTE and cardiac magnetic resonance imaging (MRI) for more accurate RV assessment.

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