8/12/2016. HEART TRANSPLANTATION: Past, Present, and Future CARDIAC TRANSPLANTATION TOM ESTEP, MD HEART TRANSPLANT SURGEON

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1 HEART TRANSPLANTATION: Past, Present, and Future TOM ESTEP, MD HEART TRANSPLANT SURGEON CARDIAC TRANSPLANTATION 1

2 HISTORY 1900 S: CARREL AND GUTHRIE HETEROTOPIC TRANSPLANT 1951: FIRST ORTHOTOPIC CARDIAC TRANSPLANT (DOG) 1964: FIRST CARDIAC TX IN MAN XENOGRAPH 1967: FIRST HUMAN TO HUMAN CARDIAC TX CAPETOWN 18 DAY SURVIVAL INTERNATIONAL HEART TRANSPLANT REGISTRY (141 CENTERS 113 U.S.) INDICATIONS FOR HEART TRANSPLANTATION IN CHILDREN AND ADULTS 2

3 J OF HEART AND LUNG TRANSPLANTATION VOL 17, NO 7, JULY 1998 TOTAL HEART TRANSPLANT ACTUARIAL SURVIVAL CARDIAC TRANSPLANT SURVIVAL 1 YEAR 79% THEREAFTER 4% MORTALITY/YEAR 50% SURVIVE 8.8 YEARS THOSE SURVIVING 1 ST YEAR, 50% SURVIES 11.5 YEARS 3

4 RECIPIENT CRITERIA CLASS IV NON-SURGICALLY AND NON-MEDICALLY REVERSIBLE CARDIO STATUS, WITH LESS THAN 6 MONTHS PROGNOSIS. AGE <60 YRS. (60-65) OTHERWISE HEALTHY WITH NO END ORGAN FAILURE OR SYSTEMIC DISEASE PRECLUDING LONGTERM SURVIVAL. EXAMPLE: CONTRA- INDICATIONS: RECIPIENT CRITERIA (CON T) ACTIVE INFECTIONS OR EVIDENCE OF MALIGNANCY EXTENSIVE PERIPHERAL VASCULAR DISEASE INSULIN DEPENDENT DIABETES HEPATO-RENAL INSUFFICIENCY RECENT PULMONARY INFARCTION (2 MONTHS) PEPTIC ULCER DISEASE FIXED PULMONARY HYPERTENSION MARKED OBESITY CNS OR PSYCHIATRIC DISORDERS DEPRESSION, SUICIDE ATTEMPTS, ETC. ALCHOL, DRUG, OR RECENT TOBACCO USE. RECIPIENT CRITERIA (CON T) PREFORMED CYTOTOXIC REACTIVE ANTIBODIES <5% RECIPIENT WEIGHT <DONOR WEIGHT, (10-20%) PULMONARY VASCULAR RESISTANCE <4 WOOD UNITS. SEE NIPRIDE STUDY IF >4 WOOD UNITS 4

5 RECIPIENT CRITERIA (CONT D) ENDOCARDIAL BIOPSY: DOCUMENTING NO TREATABLE OR SYSTEMIC CONDITION INVOLVING THE HEART. EX. AMYLOID, SARCOID, ETC. MEDICALLY COMPLIANT: COMPLEX MEDICAL REGIMENS EMOTIONALLY STABLE WITH REALISTIC ATTITUDES STRONG COMMITMENT TO MAINTAIN HEALTH DONOR CRITERIA MEETS ESTABLISHED CRITERIA FOR BRAIN DEATH AGE <50 (50 55) NO HISTORY OF: CARDIAC DISEASE CHRONIC HTN DIABETES NO SYSTEMIC MALIGNANCY NO INFECTION NO SEVERE CHEST TRAUMA NO PROLONGED CARDIAC ARREST, INTRACARDIAC INJECTIONS, PROLONGED HYPOTENSION (<10MCG/KG/MIN DOPAMINE) ABO COMPATIBLE 5

6 UNOS STATUS 1A: ASSIST DEVICE <30 DAYS, ARTIFICIAL HEART, IABP, VENTILATOR, INOTROPE(S) + SWAN-GANZ 1B: ASSIST DEVICE > 30 DAYS OR CONTINUOUS INOTROPE INFUSION 2: ALL OTHER PATIENTS 7: INACTIVE 6

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13 CYCLOSPORINE (SANDIMMUNE) CYCLOSPORIN A, CICLOSPORIN DR. JOHN BOREL (1976) IMMUNOLOGIC PROPERTIES FROM METABOLITES OF SOIL FUNGUS TRICHODERMA POLYSPORUM RIFAI 13

14 MAINTENANCE IMMUNOSUPPRESSION GOAL AFTER 1-2 YEARS: LOWEST LEVEL OF IMMUNOSUPPRESSION TO PREVENT REJECTION CALCINEURIN INHIBITOR CYCLOSPORINE OR TACROLIMUS LEVELS IN LOW THERAPEUTIC RANGE ANTIPROLIFERATIVE AGENT AZATHIOPRINE 1-2MG/KG/DAY MMF 2000MG/DAY SIROLIMUS (RAPAMUNE) 1-2MG/DAY CORTICOSTEROID 0-0.1MG PREDNISONE/KG/DAY 14

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16 SEVERITY OF REJECTION EPISODE* PERCENT OF PATIENTS EXPERIENCING REJECTION EPISODE AT 1 YEAR POSTTRANSPLANT REJECTION RATE DURING THE FIRST YEAR POSTTRANSPLANT* 16

17 CORONARY ARTERY GRAFT VASCULOPATHY (CAGV) LEADING CAUSE OF DEATH > 1 YEAR AFTER TRANSPLANT PREVALENCE OF ANGIOGRAPHICALLY DETECTABLE DISEASE 1 YEAR: % 5 YEARS: % CAGV: DIAGNOSIS SUMPTOMAIC: ARRHYTHMIAS CHF ANGIA (RARE) ACUTE MYOCARDIAL INFECTION SUDDEN DEATH ASYMPTOMATIC CORONARY ANGIOGRAPHY NUCLEAR (THALLIUM) DOBUTAMINE STRESS ECHOCARDIOGRAPHY INTRAVASCULAR ULTRASOUND CAUSES OF DEATH POST TRANSPLANT 17

18 FIVE YEAR MORTALITY RISK OF INCREASED RECIPIENT AGE ONE YEAR MORTALITY RISK OF INCREASING DONOR AGE RISK FACTORS FOR 1 YEAR MORTALITY AFTER ADULT HEART TRANSPLANTATION 18

19 Are there any side effects to these pills apart from bankruptcy? SCIENTISTS WILL DECIDE WHAT CAN BE DONE. SOCIETY WILL DECIDE WHAT WILL BE DONE. 19

20 QUESTIONS FOR SOCIETY WHO SHOULD GET TRANSPLANT PROCEDURES? SEVERITY OF ILLNESS? AGE LIMIT? FINANCES? REPEAT TRANSPLANTS? ARE DONOR ORGANS A NATURAL RESOURCE? SHOULD FOREIGNERS BE TRANSPLANTED IN USA? ARE ARTIFICIAL HEART DEVICES HELPING OR HINDERING THE ALLOCATION OF DONATED HEARTS? 20

21 HEART FAILURE: YEAR 2000 UNITED STATES: 4,600,000 CASES NEW CASES PER YEAR: 550,000 TOTAL NUMBER OF HEART TRANSPLANTS: 1994: 4342 (PEAK YEAR) 2000:

22 ETHICAL BALANCE NEEDS OF MANY VS NEEDS OF FEW THEREFORE: IS THE QUESTION COST OR ALLOCATION OF COST DECISIONS FOR CARE MADE ON AN INIDIVIDUAL S NEEDS TO SERVE THE INDIVIDUAL JUSTLY WILL SERVE SOCIETY S NEEDS 22

23 AS ONE MOVES FROM THE STANDS INTO THE ARENA THE VIEW OF THE BULL CHANGES 23