A Milestone in Cardiac Care in Iraq: One-year Follow-up after the Nation’s First Continuous-flow Left Ventricular Assist Device Implantation, Paving the Way for Heart Transplantation

Abstract

The first successful implantation of the HeartMate 3 LVAD in Iraq represents a transformative achievement in the nation’s medical history. Conducted collaboratively by German and Iraqi teams in December 2023, the procedure addressed end-stage heart failure in a 60-year-old male. Despite significant healthcare challenges, the patient’s functional status improved markedly, moving from New York Heart Association Class IV to Class I within a year. This groundbreaking case highlights the potential for Iraq to integrate advanced cardiac interventions into its healthcare system, paving the way for heart transplantation programs. Ongoing collaboration and investment in healthcare infrastructure will be pivotal for sustaining these innovations.

INTRODUCTION

Heart failure remains a significant global health challenge, particularly in regions with constrained access to advanced medical technologies.[1,2] In Iraq, the burden of heart failure is compounded by infrastructural limitations and a lack of cutting-edge treatments. These circumstances underscore the necessity of innovative approaches that can bridge the gap in care and introduce advanced therapies such as heart transplantation.

The introduction of left ventricular assist devices (LVADs) has revolutionized treatment options for end-stage heart failure by offering both bridge-to-transplantation and destination therapy. Among these, the HeartMate 3 device – first implanted by Prof. Schmitto and his team at Hannover Medical School in 2014[3] – has demonstrated exceptional reliability and outcomes. Its magnetically levitated centrifugal flow pump minimizes shear stress, reduces thrombotic risks, and enhances patient survival.[4,5] In the context of Iraq, this device’s deployment signifies a monumental leap forward in cardiac care, facilitated by international collaboration.

This case report details the first implantation of the HeartMate 3 LVAD in Iraq, performed at Nasiriyah Heart Center. The procedure marks a significant milestone in the nation’s medical history and sets the foundation for advanced cardiac programs, including heart transplantation.

CASE PRESENTATION

Patient background

A 60-year-old male with a history of severe dilated cardiomyopathy presented with an LVEF of 20%. The patient had a previous history of multiple hospital admissions due to worsening heart failure symptoms despite receiving guideline-directed medical therapy. The patient was classified New York Heart Association (NYHA) IV as well as INTERMACS 3 according to the Interagency Registry for Mechanically Assisted Circulatory Support.

Preoperative evaluation

The patient’s mean arterial blood pressure was 60–70 mmHg, and the cardiac index was 1.8 L/min/m². Comprehensive preoperative evaluation included echocardiography, right heart catheterization, laboratory tests, clinical evaluation, and assessment of risk scores for the surgical procedure.

Procedure

The procedure, a testament to international collaboration, was jointly performed by Prof. Dr. J. D. Schmitto and Dr. Med. Ali Saad Merzah from Germany, in partnership with an Iraqi surgical team. Following detailed preoperative planning, the surgery began with a median sternotomy and a partial pericardial opening to stabilize right heart function. Once cardiopulmonary bypass was established, the pericardium was fully opened, and the left ventricular apex was identified.

The sewing cuff was meticulously secured approximately 1 cm from the apex using pledgeted 2-0 Ethibond sutures.[6] The myocardium was excised using a coring knife specifically designed for the HeartMate 3 device. The inflow conduit was then inserted and locked into position, whereas the outflow graft was trimmed and anastomosed to the ascending aorta. The driveline was externalized using a double-tunnel technique to enhance patient comfort and reduce infection risk. The cardiopulmonary bypass lasted 53 min, and the total operative time was 126 min.

Postoperative care

Postoperative management was tailored to the patient’s clinical status and local resource availability. Intravenous heparin was initiated as a bridge to oral anticoagulation, with a target INR of 2.0–3.0, complemented by daily aspirin at 100 mg.[7] The patient was extubated 7 h postsurgery and demonstrated excellent recovery with minimal blood loss and no complications. He was discharged after 19 days, with no readmissions required during the 1^st year.

RESULTS

Immediate postoperative outcome

The postoperative chest X-ray reveals the placement of the HeartMate 3 LVAD at the apex of the left ventricle, with the percutaneous driveline extending along the diaphragm toward the right upper quadrant of the abdomen [Figure 1]. No congestion of the lungs and no postoperative pleural effusion were seen.

Figure 1.

The postoperative chest X-ray reveals the placement of the HeartMate III left ventricular assist device at the apex of the left ventricle, with the percutaneous driveline extending along the diaphragm toward the right upper quadrant of the abdomen

At 1 year of follow-up, the patient was monitored closely, with vital signs, laboratory data, and echocardiogram results recorded from preimplant to 1-year postimplantation [Table 1]. A year after the implantation, the patient remained at home with NYHA I Functional Class I symptoms and exercised regularly.

Table 1.

Patient’s vital signs, echocardiogram, and laboratory data

Variables	Preimplant	Week 1	Discharge	Month 1	Month 6	1 year
Vital signs
Respiratory rate (breaths/min)	20	21	17	19	14	15
Heart rate (beats/min)	53	91	93	88	67	71
Blood pressure mean (mmHg)	62	106
Doppler blood pressure (mmHg)			78	90	93	72
Pump parameters
Pump flow (L/min)	NA	3.9	4.1	4.3	4.7	4.4
Pump speed (rpm)	NA	5300	5400	5400	5400	5300
Pulsatility index	NA	4.9	3.8	4.1	3.2	3.6
Power (W)	NA	3.6	4	4	3.8	4.2
Laboratory data
Lymphocytes (%)	22.4	22.9	22.3	21.4	27.9	31
Platelets (×1000/mL)	183	196	296	322	321	265
White blood cells (×1000/mL)	5.4	9.8	7.2	10.5	9.8	12.1
Hemoglobin (g/dL)	13.2	12.1	11.9	12.2	12.4	14.2
INR	1.01	1.3	2.31	2.7	2.5	2.41
Lactate dehydrogenase (U/L)	230	280	215	235	241	226
AST (U/L)	26	14	16	12	15	16
ALT (U/L)	27	8	12	9	12	9
Total bilirubin (μmol/L)	10	5	6	3	5	4.5
BUN	7.9	3.2	4.1	4.6	4.2	5
Creatinine (μmol/L)	136	79	82	88	75	78
Uric acid (μmol/L)	512	451	285	367	422	261
Sodium (mmol/L)	146	131	137	140	137	139
Potassium (mmol/L)	5.1	4.7	4.5	3.9	4.2	4.1
Total protein (g/L)	69	49	63	69	72	71
Echocardiogram: Left ventricular
Ejection fraction (%)	20	NA	21	27	32	26
Systolic dimension (mm)	82	NA	80	87	NA	83
Diastolic dimension (mm)	89	NA	79	72	76	71
Aortic valve open	NA	Yes	Yes	Yes	No	No
Mitral regurgitation	II	NA	II	I–II	None	None

ALT: Alanine aminotransferase, AST: Aspartate aminotransferase, BUN: Blood urea nitrogen, NA: Not applicable/available, INR: International normalized ratio

DISCUSSION

The successful implantation of the HeartMate 3 LVAD in Iraq highlights the feasibility of introducing advanced medical technologies in resource-limited settings. Key enablers included rigorous preoperative planning, comprehensive training for the local team, and the logistical support provided by international collaborators. Overcoming infrastructural challenges and fostering knowledge transfer were critical to the procedure’s success.

Compared to outcomes reported in established centers, this case’s results align closely with international benchmarks, demonstrating the device’s reliability across diverse settings. The patient’s improvement from NYHA Class IV to Class I underscores the transformative potential of such interventions, particularly in regions lacking robust cardiac care infrastructure.[7]

The lessons from this case extend beyond the technical aspects of the procedure. They emphasize the importance of sustained partnerships and investments in health care to ensure long-term program sustainability. Establishing comprehensive cardiac programs in Iraq, including heart transplantation, is now a tangible goal that builds upon this landmark achievement.

CONCLUSION

The first successful implantation of the HeartMate 3 LVAD in Iraq represents a pivotal advancement in the country’s medical history. Beyond its immediate impact on the patient’s quality of life, this case establishes a foundation for future cardiac care innovations, including heart transplantation programs. Continued international collaboration, alongside strategic investments in healthcare infrastructure, will be crucial for expanding these advancements and improving outcomes for patients with advanced heart failure.

Disclosure statement

Hannover Medical School receives grant funding from Abbott. JDS and MA are consultants for Abbott.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.