SCOMPENSO CARDIACO AVANZATO Controversia: che fine sta facendo il trapianto cardiaco, è sempre la prima opzione?
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1 University of Pavia School of Medicine San Matteo Hospital, Division of Cardiac Surgery Pavia, Italy Prof. Andrea M. D Armini, M.D. SCOMPENSO CARDIACO AVANZATO Controversia: che fine sta facendo il trapianto cardiaco, è sempre la prima opzione?
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3 State of art
4 State of art Heart transplantation remains the gold standard The first decision should be, are they a candidate for heart transplantation?... The next decision should be, are they a candidate for a device?...
5 State of art 2015: 133 VAD (HeartWare 51% - HeartMate 28% - Jarvik %) 246 HTx Heart Transplantation Artificial Heart
6 State of art Patients listing at 31/12/2015: 9070 Kidney 6765** Liver 1072 Heart 731 Lung 383 Pancreas 248 Bowel 20 Heart Bowel Liver Pancreas Lung Kidney 0,2% 7,4% 11,2% 2,7% Kidney Inscription 8433** ** For kidney any patients could have more than one inscription 74,6% 4,0%
7 Heart Waiting List from 1/1/2015 to 31/12/2015 Enrolled patients at 1/1/ Registered patients from 1/1/2015 to 31/12/ Total patients number from 1/1/2015 to 31/12/ Median waiting time listed patients : 2,9 years Enrolled patients at 31/12/ Patients leaved waiting list from 1/1/2015 to 31/12/ TRANSPLANT: 246 Other causes: 6 Median time waiting transplants: 0,8 anni ISL: 36,1 % ISLT: 23,2 % *ISL: number TX/Number enrolled at the begin of the year ** ISLT: number TX/(Number enrolled at the begin of the year + the new entry) DEATH: 76 mortality in waiting lista: 7,2 %
8 Remarkable considerations: DONOR POOL Mortality rate during list is elevated Recipient number is increased ISTAT data: Italian population at the end of 2015: Donor/mln citizens REAL: Donor/mln citizens NEEDS: citizens 4 donors/mln citizens 17 donors/mln citizens DONORS NEEDS IS 4 TIMES DONORS REAL
9 Remarkable considerations: DONOR POOL
10 Remarkable considerations: MARGINAL DONORS Jan 2009 Jun 2014 JHLT Oct;34(10):
11 Remarkable considerations: MARGINAL DONORS Jan 1982 Jun 2013 JHLT Oct;34(10):
12 Remarkable considerations: MARGINAL DONORS % of Patients Bridged with Mechanical Circulatory Support Jan 2009 Jun 2014 JHLT Oct;34(10):
13 Remarkable considerations: MARGINAL DONORS Italian data (from 2000 to 2013) 19,5% donors > 50 aa 1/5 of all donors Italian survival heart transplantation: 83,1% at 1 year 73,6% at 5 years CNT font
14 Remarkable considerations: NATIONAL EMERGENCY PROGRAM The national emergency program for heart transplant has stole organs from ordinary listed patients (22%) 157 (78%) 61 (27%) 165 (73%) Urg Std CNT font
15 Heart transplantation: GOLD STANDARD FOR HF 1. VAD EXPEDIENT Gathering data below, not all listed patients could arrive at heart transplant. Into an ideal world of good donors, all heart trasnplants could be permormed and VAD could not be used. For these reasons, VAD is an EXPEDIENT.
16 Heart transplantation: GOLD STANDARD FOR HF 2. VAD SURVIVAL
17 Heart transplantation: GOLD STANDARD FOR HF 2. VAD SURVIVAL
18 Heart transplantation: GOLD STANDARD FOR HF 2. VAD SURVIVAL Kaplan-Meier Survival by VAD usage Jan 1999 Jun 2013 JHLT Oct;34(10):
19 : Heart transplantation: GOLD STANDARD FOR HF 3. COST-EFFECTIVENESS OF VAD
20 : Heart transplantation: GOLD STANDARD FOR HF 3. COST-EFFECTIVENESS OF VAD Data from 2006 to 2011 Toronto General Hospital
21 : Heart transplantation: GOLD STANDARD FOR HF 3. COST-EFFECTIVENESS OF VAD - Greater medical resource - Elevated cost of implantation - Hospitalization - Elevated cost for instrumentation needs at long-term - Important social support for VAD patients
22 : Heart transplantation: GOLD STANDARD FOR HF 4. COMPLICATIONS OF VAD - Infections, sepsi - Stroke - Thrombi formation and/or VAD thrombosis - Bleeding - Failure of VAD or Acute Heart Failure - VonWillembrand disease - Aortic Regurgitation
23 : Heart transplantation: GOLD STANDARD FOR HF 4. COMPLICATIONS OF VAD In 2015 in Italy VAD complicated was 26 % of 84 emergency heart transplant requests (61 emergency heart transplants real performed) CNT font
24 : Heart transplantation: GOLD STANDARD FOR HF 5. VAD CONTROINDICATIONS -Not treatable angina - VT not treatable - Restrective cardiomyopathy
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