Heart Transplant in NZ Challenges and Triumphs

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1 Transplant Update on New Zealand heart transplant programme: challenges and triumphs Cara Wasywich Chairs: Kathy Ferrier & Richard Troughton Heart Transplant in NZ Challenges and Triumphs Cara Wasywich, Cardiologist 15 June

2 Disclosures No conflicts of interest Outline Snapshot to 2018 Referral and assessment Mechanical Circulatory Support Donor utilisation 2

3 Excellent sources of information TSANZ Clinical Guidelines for Organ Transplantation from Deceased Donors ANZCOR Australia and NZ Cardiothoracic Organ Transplant Registry ISHLT International Society for Heart and Lung Transplantation guidelines/slides State of the Nation in 2018 Four transplant cardiologists, expanded coordinator team Maturation of the service Tensions between increasing donation rates and transplant activity and hospital resource Appointment of a Clinical Lead for the NZ Heart and Lung Transplant service Fellow position established 3

4 Outcomes Annual activity

5 Quality improvement Vaccination protocol Commenced at the time of referral/first clinic visit (facilitated by GP s) Part of our processes since late 2016 Pathogen Vaccine Influenza Influenza Vaccine (if/when available) HPV, males and females under 45 Gardasil (0, 2, 6 months- may be completed post transplant) Tetanus, Diptheria, Pertussis (Tdap) Boostrix Pneumococcus (1) Prevenar 13 (conjugated) Pneumococcus (2) Pneumovax 23 (polysaccharide, non conjugated) Meningococcus (2) Menactra (MCV4-D)2 doses 8 weeks apart Haemophilus influenzae Act-HibB/hiberix MMR, check serology, if any of M,M or R negative then give MMR (3) MMR vaccine Hepatitis A, check serology, if negativehavrix (0 and 6 months-may be completed post transplant) Month 0 Month 1 Month 2 Month 3 Month 5 Month 6 Hepatitis B (4) Check serology, if non immune: HBvaxPRO 10 microgram (0,1,5 months) VZV (Chickenpox) (3)( 5) Check serology, if negative Varilrix (0 and 2 months) VZV (shingles) (3) Check serology, if positive and recipient over 50 years Zostavax Challenges/Opportunities Equity of assessment Geographic variability across NZ Signals potential unmet need Congenital heart disease Increasing survivorship into adulthood, increasingly referred to transplant team 5

6 Timing of referral Not too early/not too late Sick enough but not so sick that transplant is prohibitively high risk Pay attention to potential contraindications to transplant in heart failure patients Get them sorted at an early stage so in the event of disease progression transplant is an option Many tools to assist (SF talk) Timeliness of assessment Measure and report back No data currently on times from referral to assessment Quality of referral makes a big difference Allows prioritization of sicker patients If delays are identified processes can be put in place to fix 6

7 Durable ventricular support Allows safe bridging to transplant in those suitable for therapy Highly invasive therapy MCS VAD-indications/contraindications Indications for MCS Deterioration while waiting Need for escalation of HF therapy Recurrent HF admissions Adequate supports Contraindications to MCS Right heart failure Multiple tools used to assess this Echo Cardiac catheterization Blood tests Valvular abnormalities Aortic regurgitation Mechanical prostheses 7

8 Improved outcomes with MCS Rematch Study Rematch Study, 2001 DT Rose, EA., REMATCH Study Group, et al. N Engl J Med 2001;345: HVAD DT Endurance Study Rogers, JG., Endurance Study, et al. N Engl J Med 2017;376: Endurance Study Heartmate 3, 2018 Mehra, M.R., MOMENTUM 3 Investigators, et al. N Engl J Med 2018;378: Adult and Paediatric Heart Transplants: Green Lane vs International (2-year follow-up) MOMENTUM 3, Heartmate 3 Donor utilization-waiting List Donor recipient matching Blood group Body size/pvr Acuity Waiting list needs to be big enough to allow utilization of every suitable donor organ Those who wait longest are heavy O recipients 8

9 Donor utilization-donor issues Changing demographics of organ donors Road trauma vs intracerebral trauma Older, more comorbid donors Increased likelihood of needing angiography (please help us) Recognition that LV dysfunction post brain death may be transient DCD donors Donor utilization-increased risk Measurable increase in organ donation in US/Canada related to the opioid epidemic Younger, less morbid, increased infectious risk N Engl J Med 2018; 378:

10 Changing landscape of Hep C New antiviral drugs have rendered Hep C a curable disease NAT testing has reduced the potentially infectious window and therefore the risk of donor derived infections Recognition that the risk of transmission in a Hep C Ab+, NAT- donor to a Hep C recipient is essentially zero Some programs will use a NAT+ donor and treat Hep C post transplant Virus Serology NAT HIV 22 days 5-9 days HBV 44 days 22 days HCV 66 days 5-7 days We are desperate for organ donors We will consider (almost) anything So long as a careful donor assessment has been undertaken and an informed risk benefit calculation has been made 10

11 Transplant is an option for your advanced HF patients We are not magicians Have a low threshold for calling to discuss patients Address HF self management and potential contraindications early Closing messages 11