Download Heart and Lung Transplantation

Advanced Therapy
for
Heart and Lung Failure
June 8, 2012
Alan Simeone, M.D.
Johns Hopkins Cardiac Surgery
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Today’s Discussion
• End-Stage Heart Failure
– Heart Transplantation
– Mechanical Circulatory Support
• End-Stage Lung disease
– Lung Transplantation
Common Causes of Heart Failure
• Ischemic Cardiomyopathy (60%)
• Non-Ischemic Cardiomyopathy
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Idiopathic
Hypertensive
Valvular
Toxin-induced
Infectious/Inflammatory
Result of Congenital Disease
Classification
New York Heart Association
(NYHA) Heart Failure
Symptom Classification
System
American College of
Cardiology-American Heart
Association Classification of
Chronic Heart Failure
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I: No symptom limitation with
ordinary physical activity
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II: Ordinary physical activity
somewhat limited by dyspnea
(e.g., long-distance walking,
climbing two flights of stairs)
A: High risk for developing
heart failure: Hypertension,
diabetes mellitus, CAD, family
history of cardiomyopathy
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B: Asymptomatic heart failure:
Previous MI, LV dysfunction,
valvular heart disease
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C: Symptomatic heart failure:
Structural heart disease,
dyspnea and fatigue, impaired
exercise tolerance
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D: Refractory end-stage heart
failure: Marked symptoms at
rest despite maximal medical
therapy
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III: Exercise limited by
dyspnea with moderate
workload (e.g., short-distance
walking, climbing one flight of
stairs)
IV: Dyspnea at rest or with
very little exertion
Low Ejection Fraction Heart Failure
400,000 Americans Hospitalized yearly despite best
medical therapy
When Hospitalization Required
• 30 to 50% re-admitted within the first 6 months
One Year Mortality
Class II:
10 - 15%
Class III:
15 – 25%
Class IV:
30 – 50%
The Survival numbers are even worse
with more advanced Heart Failure
Clearly, better treatment options are
needed
Heart Transplantation
Mechanical Circulatory Support
History – Heart Transplantation
• First success 1967
in South Africa
• 54 year old man
with Ischemic
Cardiomyopathy
• Donor a 24 year old
woman
• Lived 18 days pneumonia
• Initial Enthusiasm
• Poor results
• Most gave up
• Norman Shumway
at Stanford
persisted with an
organized research
program
• Cyclosporine, first used in 1980, helped improve
long-term results
• This rekindled interest in Heart Transplantation
• Over 44,000 have been performed in the U.S.
Current Results
• One-year survival about 90 percent
• Three-year survival 80 percent
• Ten-year survival 50 percent
Dilated, End-Stage Cardiomyopathy
Transplant for End-Stage Heart Failure
• Transplant Evaluation
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Medical
Psychological
Social
Financial
• Goal is to ensure that
transplant is the right
treatment for the patient and
maximize chance of a
successful outcome
Contraindications to Cardiac
Transplantation
Pulmonary Hypertension
Diabetes with End-Organ
Dysfunction
Immunologic Sensitization
Severe Lung or Liver Disease
Active Malignancy
Psychosocial Deficiencies
Substance Dependence
Documented Medical Noncompliance
Kidney Disease with GFR<40
Tobacco Use in previous 6
Months
Advanced Age
Symptomatic Vascular Disease
Obesity, BMI>30
History of Malignancy
Donor Heart Allocation
• Status (How sick are you?)
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1A, 1B, 2
Age (pediatric or adult)
Blood Type
Distance from Donor Hospital
Time accrued on the waitlist
Other factors, such as size, weight, sex, HLA typing
The Surgery
• Early Risks
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Death
Stroke
Bleeding/Transfusion/Return to Operating Room
Infection
Other Organ Dysfunction
Primary Graft Dysfunction
Rejection
Right Ventricular Failure
Respiratory Failure
• Late Risks and Important Issues
• Rejection
• Infection
• Graft Coronary Disease
Immunosuppressive Drugs
Steroids, FK 506, CellCept
Commitment to close Follow up and Monitoring
The Process
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Donor organ offered to a specific recipient
Organ accepted for a specific recipient
You get the call to head to JHU
Procurement team heads off to donor hospital
Once heart quality is confirmed and timing settled a
“Go Call” is made
• The recipient moves to the operating room
• In the Operating Room
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Sedation
Arterial catheter
General anesthesia, breathing tube
Large neck IV catheter, Pulmonary Artery Catheter
Sterile Surgical Prep and Drape
Median Sternotomy Incision
Heart/Lung Bypass Circuit
Sick Heart removed when new heart “on the ground”
New Heart implanted, allowed to beat and recover
Hardware removed
Heart/Lung Bypass weaned off
Median Sternotomy Incision
Heart-Lung Bypass
Relevant Anatomy
The Empty Chest
The Diseased Heart
The Donor Heart on Ice
The Left Atrial Anastomosis
• In CVSICU
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Sedated, on the ventilator, with a breathing tube, Nitric Oxide
Multiple chest drains
Catheter in bladder for urine
IV drugs to support heart function and blood pressure
Possibly a Balloon Pump or other advanced support device
Milestones to achieve
• Stability (blood pressure, heart and lung function)
• No Bleeding
• Normal Brain Function
Post-Transplant, in the ICU
• When those Goals have been reached
• Wean from Ventilator, remove breathing tube
(Extubation)
• Wean off any other Advanced Support Device
• Remove Pulmonary Artery Catheter
• Out of Bed!
• Deep Breathe and Cough to prevent pneumonia
and respiratory failure
• When Stable, move out to Step Down Unit
• On Step Down Unit
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Breath, Cough, Walk
Eat
Move bowels
Pee (diurese)
Wean off Oxygen
Remove tubes, drains, etc.
First Right Heart Catheterization and Biopsy at 7 days
Remove temporary pacing wires
Get medications adjusted correctly
Discharge
Post-transplant, ready to go home
The Bad News
2322 hearts were transplanted in the U.S. in
2011
3202 people are on the national waitlist
Listing Issues
• Median Times on the Waitlist by Blood Type
O
327 days
A
111 days
B
102 days
AB
31 days
• The “High-Risk” Donor
Mechanical Circulatory Support
An Interesting History
&
Current Devices
Concepts
• Bridge to Recovery
• Bridge to Transplant
• Bridge to Decision
• Destination Therapy
First LVAD (Left Ventricular Assist Device)
1963 Liotta and Crawford
1966 DeBakey and Liotta
Current Devices
Heartmate II
HeartWare
Current Devices
Heartmate II
HeartWare
Current Devices
Heartmate II
HeartWare
First Total Artificial Heart (TAH)
• Cooley, DeBakey
and Liotta
• 1969
• First Bridge to
Transplant
• Pneumatic Device
• Dacron and Silastic
First TAH
Other Support Devices
Thoratec PVAD
Heartmate II
Lung Transplantation
Dr. James Hardy
Dr. Joel Cooper
NUMBER OF LUNG TRANSPLANTS REPORTED
BY YEAR AND PROCEDURE TYPE
2196
2200
2000
Bilateral/Double Lung
Single Lung
1600
1366
1229
1400
1200
1924
1789 1788
1615
1574
1461 14571481
1375
1087
923
1000
707
800
600
418
400
189
200
45 83
15
14
ISHLT
2008
J Heart Lung Transplant 2008;27: 937-983
06
20
05
20
04
20
03
20
02
20
01
20
00
20
99
19
98
19
97
19
96
19
95
19
94
19
93
19
92
19
91
19
90
19
89
19
88
19
87
19
86
19
85
0
19
Number of Transplants
1800
2168
NOTE: This figure includes only the lung transplants that are
reported to the ISHLT Transplant Registry. As such, this
should not be construed as representing changes in the
number of lung transplants performed worldwide.
Lung Transplant 2011
Wait list
1655
Transplants
1822
How are Lung Offers Allocated
• Patients are matched by blood type and size
• Patients are listed by Lung Allocation Score (LAS)
– Based on the chance of Dying while waiting
• Time on the list doesn’t matter anymore
Adult Lung Transplant Diagnoses
50%
45%
COPD
40%
37%
Percent of total
35%
30%
31%
IPF
25%
Other
20%
19%
CF
15%
13%
10%
LAS implemented May 2005
5%
0%
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Total Cases
789
827
893
995
975
1006
1298
1090
1343
1283
Contraindications to Lung
Transplantation
Diabetes with End-Organ Dysfunction
Immunologic Sensitization
Severe Heart or Liver Disease
Active Malignancy
Psychosocial Deficiencies
Substance Dependence
Documented Medical Non-compliance
Kidney Disease with GFR<40
Tobacco Use in previous 6 Months
Advanced Age
Symptomatic Vascular Disease
Obesity
History of Malignancy
ADULT LUNG TRANSPLANTATION
Kaplan-Meier Survival
(Transplants: January 1994 - June 2006)
100
Double lung: 1/2-life = 6.2 Years; Conditional 1/2-life = 8.8 Years
Single lung: 1/2-life = 4.5 Years; Conditional 1/2-life = 6.4 Years
All lungs: 1/2-life = 5.2 Years; Conditional 1/2-life = 7.3 Years
.
80
P < 0.0001
Survival (%)
60
40
Bilateral/Double Lung (N=10,064)
Single Lung
(N=9,384)
All Lungs
(N=19,448)
20
0
0
1
2
3
4
5
Years
ISHLT
2008
J Heart Lung Transplant 2008;27: 937-983
6
7
8
9
10
Healthy vs. Diseased
After Lung Transplant
After Lung Transplant
• ICU with Breathing Tube, sedated
• When stable with good lung function
Epidural Pain Control
Wean Ventilator
Bronchoscopy
Deep Breathing and Coughing
AMBULATION
BREATHE / COUGH
BRONCHOSCOPY
I hope I haven’t put anyone to sleep!
QUESTIONS?