Cardiovascular surgical care is undergoing important transformations resulting from technological advances in the form of minimally invasive, robotic surgery, circulatory support, and approaches to end-stage heart failure. Destination left ventricular assist device (LVAD) placement is increasing around the globe as a result of donor shortages and changing patient and caregiver attitudes, whether for personal, cultural, religious, or other reasons [1]. In the USA alone, over five million people live with heart failure (HF) and over half a million are diagnosed every year [2, 3]. For advanced cases (NYHA stage IV), 1-year mortality has been reported to be as high as 75% [4]. Despite the success and standard of transplantation, up to 14.3% of patients die while on the waiting list [5]. By 2030, the cost of heart failure is expected to reach 70 billion dollars [2, 3]. In island states, there is an increased need for this technology due to the even lower rates of transplantation. The population of island states is approximately 65 million people across 58 islands regions [6, 7]. Of these, it is estimated that 540,150 people have or will soon be suffering from HF [2, 6,7,8]. Island states and regions such as the Caribbean have an upper-middle- or high-income profile (with the exception of islands such as the Dominican Republic and Haiti). However, population differences and healthcare policy disparities lead to consequences of limited access to quality and immediate cardiac surgical care [6,7,8]. The remote distances of island states from specialized mainland transplant centers make destination LVAD therapy an attractive solution [6,7,8]. In 2019, a record number of 3198 continuous flow LVADs were placed worldwide according to the INTERMACS database [1]. During the last decade (2010–2019), a total of 25,551 LVADs have been placed. Additionally, over 5000 heart transplants are being performed annually worldwide. As organ shortages become critical, patients keep dying waiting for a heart; LVADs have emerged as the only other viable option for many patients [1]. Here, we provide a look into the current state and availability of LVAD programs in island states across the world and insights into future care.

Heart failure in island states

In low- and middle-income countries (LMICs) with similar demographic profiles such as those found in island regions, hospital admission rates due to heart failure have been reported to be 2.2% [3]. Global prevalence of HF remains high (831 per 100,000) and over 64 million people worldwide ail from HF [2]. The prevalence of HF in LMICs and high-income countries are 830 per 100,000 and 871 per 100,000 people, respectively [2]. The Caribbean region as a whole has a HF prevalence of 814 per 100,000 and Oceania 667 per 100,000 people [2]. In some countries, low organ donation rates of approximately 7 per million population are insufficient to meet the demands of the rise in HF care. Applying the ratio of heart transplant candidacy-to-population as seen in the USA to island states across the world (exclusively using population ratio), we estimate that over 3000 people in island states worldwide need either a heart transplant or an LVAD [5]. The income profile disparities between islands along with the healthcare burden of HF in island states remain a serious public health issue. In island states, special challenges exist. Aside from being remote distances from centralized and specialized mainland centers, emergency air-bridging may not always be a safe solution to patients with HF [8,9,10]. Despite the difficulties of being long distances from specialized centers many islands have managed to develop high-quality cardiac institutions overcoming the distance factor. These centers include but are not limited to Health City Cayman Islands, ADK hospital Male Maldives, Eric Williams heart center in Trinidad and Tobago, and Martinique University Hospital Fort-de-France Martinique. However, only Grand Cayman and Singapore have established LVAD programs. These centers have successfully developed quality cardiovascular care for especially underserved regions of the world [6,7,8]. Despite these endeavors, the burden of HF makes ventricular assistance an underused and necessary solution to many of these islands.

Procedures such as aortic valve replacements or coronary artery bypass grafting are simpler than aspiring to develop heart failure programs including LVAD programs which require a more complex team and institutional infrastructure. Alongside the decreasing availability of cardiac transplant donors and recipients rejecting transplantation worldwide, the need to find alternative solutions to HF treatment is becoming critical. In centralized institutions in middle- to high-income countries, many programs have developed programs to answer to this shift from transplantation to destination LVAD. In LMICs and island states, however, these programs have faced a more challenging process. Technological advances regarding medical and surgical developments in island states reflect those of lower-middle-income countries.

Cardiac surgery in island states

Of the 58 island states across the globe, over 40 cardiac surgical centers are spread across these islands, most of which are located in the Caribbean region [6,7,8]. Cardiac surgical care on islands is accomplished through three main systems: (1) local cardiac surgery, (2) visiting cardiac surgery teams, and (3) air-bridging patients to other neighboring institutions [6,7,8,9,10,11]. Despite these three systems, there is still a need for additional centers in both the Caribbean region and other island regions across the globe to answer to the cardiovascular surgical disease burden [6,7,8,9,10,11].

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