**5. Organ procurement**

For decades, the limited availability of heart donors has been an inherent hindrance to cardiac transplantation. As a matter of fact, establishment of a robust cardiac organ procurement system is the most complex task. Hearts procurement is considered a multi-stage process complimented by a series of different interrelated logistics that does not affect donors or recipients only but their families, friends, caregivers, morals, beliefs, and the whole society. Moreover, it's been years before agreeing on science and evidence became clear in setting guidelines to improve the donation numbers. The science of transplantation regarding the safety and availability of donors is evolving, and donors who have not been considered as donors in the past are now able to provide the flair of streaming life to others. Additionally, increasing the number of donors is necessary to increase the number of organs accepted for transplantation by carefully and safely taking into account people who were previously excluded from the process [15].

Current practice entitles two different procurement strategies: the classical strategy; donation after brain death (DBD) and recently; heart donation after circulatory death (DCD) [16].

Donation after brain death (DBD) has been the traditional pathway for years from which hearts have been obtained for transplantation. Unfortunately, most of the reasons resulting in brain death may directly affect the heart, in this regard; a very limited pool of donors has been considered suitable for transplantation. Moreover, the management of this pathway of donation after brain death is complex & it includes keeping cardiac and arterial pressures ensuring a protective ventilation strategy, and homeostasis. People with coronary artery disease (CAD) risk factors, such as age greater than 40, hypertension, a history of using cocaine, heroin, or amphetamines, previous or current smoking history, and dyslipidemia, should undergo coronary angiography; also for patients with a family history of premature CAD; or who have suspected wall motion abnormalities on echocardiography [17]. Each center should advocate a clear criterion to be met to facilitate the procurement decision after reviewing each donor using a specific flow diagram that entitles all information about donor history, all current diagnostic information, and previous and current hemodynamic parameters with continuous repeat assessment of ongoing management, diagnostics & vitals status parameters [18].

On the other hand, heart donation after circulatory death (DCD) is usually perceived as ethically more complex as it necessitates at some point fainting of support from the donor, which might be difficult to explain to the donor's families that a beloved one is kept alive only as a means to convey their hearts to the recipients. Such a concept of keeping and ending life touches on a very sincere tenet in the Middle East society, which values the courtesy of death as much as life. Contradicting misbeliefs and conflicts associated with DCD malefice its implementation in the Middle Eastern world [19].

*Establishing a Heart Transplantation Program in a Middle East Country: Requirements… DOI: http://dx.doi.org/10.5772/intechopen.113333*

	- a.In the Kingdom of Saudi Arabia, a person is deemed legally dead under two circumstances: (1) irreversible cessation of cardiac and respiratory function, and (2) irreversible cessation of all cerebral function, as per the Islamic jurisprudence resolution dated October 1986. DCD is therefore not in use in the Kingdom of Saudi Arabia or in the nations of the Gulf Cooperation Council (GCC) [20].
	- b.In Kuwait, only DBD has been in practice since the beginning of deceased donor transplantation in 1996.
	- c.The Lebanese law No 109/1983 legalizes "donation of human tissues and organs for medical and scientific purposes." DCD has not yet been attempted in Lebanon. Only corneas are retrieved from DCD donors [21, 22].
	- d.In Iran, in 1989, it was possible to obtain religious authorization from the Supreme Religious Leader that recognized brain death and permitted deceased-donor organ transplants. Currently, only 1% of donors come from circulatory death [23]. At the Iran University of Medical Sciences, uncontrolled donation after circulatory death (uDCD) was practiced for the first time as of November 2021 [24].
	- e.Iraq has been pioneering legislation on organ transplantation and donation in the Middle East. Iraq endorsed a precise legal definition of brain death in 1985; it was improved upon in 1989. Articles describing live and deceased donation, donor criteria, (nonpaid) donation, and consent are included in these laws. However, transplant activities are restricted to live donor transplants that are compatible with their blood group and are still only a live donor program.
	- f. According to the Jordanian Ministry of Health law, To be able to perform the necessary procedures, all hospitals with cases of brain death must inform the Jordanian Centre of Organ Transplantation (JCOTD) Directorate [25].
