Heart Transplantation in Seniors European View

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1 Heart Transplantation in Seniors European View Hynek RIHA Department of Anesthesiology and Intensive Care Institute for Clinical and Experimental Medicine Prague, Czech Republic 3 rd Int l Symposium: Perioperative Care for Seniors no financial interests to disclose

2 What is it Europe? Europe as geographic entity? European Union (EU)? Schengen area? free travel among countries without the borders The countries using the currency Euro ( )?

The history of heart transplantation 1960 1964 first successful orthotopic heart transplantation (OHT) in dogs Lower and Shumway first chimpanzee-to-human OHT (cardiogenic shock after MI) Hardy (not

3 The history of heart transplantation first successful orthotopic heart transplantation (OHT) in dogs Lower and Shumway first chimpanzee-to-human OHT (cardiogenic shock after MI) Hardy (not successful because new heart couldn t bear the load) first human-to-human OHT recipient lived for 18 days Christiaan Barnard s team in Cape Town 101 OHTs by 54 teams in 22 countries rarely survival >1 year early 1980s change in immunosuppression (CyA)

4 The first 25 OHTs in the world December 3, 1967 July 9, 1968 in 9 countries on 4 continents Post-OHT survival: 3 hours 592 days Age of recipients mean±sd maximum minimum 47.2±17.2 yr 66 yr 18 days Silvay G, Mazzeffi M. J Cardiothorac Vasc Anesth 2008;22:644-6

5 Current status of OHT OHT numbers ~ 2200 OHT/year in USA ~ 3500 OHT/year worldwide ~ 2000 OHT/year not reported to ISHLT ISHLT registry ~ 2/3 of OHTs worldwide Lund LH, et al. JHLT 2013;32: survival rate after OHT 1 year survival ~ 90% 5 years survival ~ 70% >50% OHT recipients >11 yr survival

OHT challenges for anesthesia/critical care recipient hemodynamic instability (inotropes, IABP, VADs, ) redo surgery (VADs, surgery for congenital heart disease, ) pulmonary hypertension

6 OHT challenges for anesthesia/critical care recipient hemodynamic instability (inotropes, IABP, VADs, ) redo surgery (VADs, surgery for congenital heart disease, ) pulmonary hypertension anticoagulation before OHT donor graft dysfx (intrinsic dysfx, period of cold ischemia) operating room graft dysfx during CPB separation (RV dysfx, LV dysfx, biventricular dysfx) coagulopathy ICU RV dysfx renal dysfx (baseline dysfx, CPB, blood products, bleeding, ) immunosuppression with risk of infection Lund LH, et al. JHLT 2013;32:951-64

Perioperative monitoring in OHT patients continuous ECG monitoring continuous measurement of S p O 2 invasive BP measurement direct measurement of

7 Perioperative monitoring in OHT patients continuous ECG monitoring continuous measurement of S p O 2 invasive BP measurement direct measurement of RAP/CVP measurement of LAP/PAWP intermitent measurement of CO intraoperative TEE continuous assessment of urine output Constanzo MR, et al. JHLT 2010;29:914-56

8 Donor management the rate of organ donation vs. increasing demand for donors goals of donor management for OHT euvolemia adjust vasoconstrictors/dilators to maintain sufficient perfusion pressure optimize CO without relying on high doses of inotropes (MVO 2 ) serial echocardiography; coronary angiography (depending on the risk factors)

9 Cardiac surgery in seniors in USA Castillo JG, et al. HSR Proc Intensive Care Cardiovasc Anesth 2009;1:6-19

10 Cardiac surgery in seniors in USA Filsoufi F, et al. J Cardiothorac Vasc Anesth 2007;21:784-92

11 Recipient criteria Mancini D, et al. Circulation 2010;122:

12 Characteristics of patients listed on WL end-stage heart failure as indication for OHT ischemic cardiomyopathy 45% other cardiomyopathies (dilated, ) 45% valvular and congenital heart disease 10% Mancini D, et al. Circulation 2010;122:

13 Age in the ISHLT registry Lund LH, et al. JHLT 2013;32:951-64

14 Adult Heart Transplants Recipient Age Distribution by Location (Transplants: January 2006 June 2012) 2013 JHLT Oct; 32(10): Mean/median recipient age: Europe = 50.2/53.0 North America = 52.2/55.0 Other = 47.2/50.0

Cardiac surgery in seniors in Europe EuroSCORE(European System for Cardiac Operative Risk Evaluation) EuroSCORE II published in 2011 Over 20,000 patients in the EuroSCORE database Only 21 patients

15 Cardiac surgery in seniors in Europe EuroSCORE(European System for Cardiac Operative Risk Evaluation) EuroSCORE II published in 2011 Over 20,000 patients in the EuroSCORE database Only 21 patients were aged over 90 The risk model may not be accurate in these patients The oldest patient in the EuroSCORE database was 95 EuroSCORE II is not validated in patients over this age Nashef SA, et al. EuroSCORE II. Eur J Cardiothorac Surg 2012;41:734-44

16 Eurotransplant Founded in 1967 Responsible for the allocation of donor organs in 8 countries Austria, Belgium, Croatia, Germany, Hungary, Luxembourg, the Netherlands and Slovenia The countries outside Eurotransplant manage Tx programs on their own

17 OHT in the Czech Republic Population ~ 10.6 millions Two centers for adult patients (IKEM in Prague, CKTCH in Brno) One center for pediatric patients (Motol University Hospital in Prague) Total number of OHTs in adults ~ 70 80/year Hoskova L, et al. Vnitr Lek 2014;60:275-81

18 OHT in the Czech Republic End-stage heart failure (diagnoses) listed for OHT Hoskova L, et al. Vnitr Lek 2014;60: The age > 65 yr is relative contraindication for OHT

19 Long-term LVADs as BTT/BTC in IKEM Bridge-to-transplantation (BTT) indication Bridge-to-candidacy (BTC) indication Riha H, et al. Vnitr Lek 2010;56:30-6 Kettner J, et al. Physiol Res 2011;60:769-75

20 Alternatives for OHT in seniors Destination therapy with long-term LVADs Improvement in comorbidities Possible listing on WL for OHT Complications of LVADs Stroke (contraindication for OHT) Kirklin JK, et al. J Heart Lung Transplant 2011;30:115-23

21 Summary Age alone is rarely absolute contraindication for OHT Detailed preoperative assessment balancing perioperative risks and longterm benefits with the aim of maximizing post-oht survival Team approach is necessary (cardiologists, cardiac surgeons, anesthesiologists) The choice between OHT and destination therapy with long-term LVADs in seniors with end-stage heart failure should be carefully evaluated Ethical issues (shortage of donors vs number of patients on WL)

Bridge to Heart Transplantation

Bridge to Heart Transplantation Ulf Kjellman MD, PhD Senior Consultant Surgeon Heart Centre KFSH&RC 1 Disclosure Appointed for Proctorship by Thoratec/St.Jude/Abbott 2 To run a full overall covering transplant