Referral for Heart Transplantation - who and when?

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1 Transplant Referral for heart transplantation - who and when Sarah Fitzsimons Chairs: Kathy Ferrier & Richard Troughton Referral for Heart Transplantation - who and when? CSANZ June

2 Introduction Heart transplant effective treatment for advanced heart failure Prognosis without it is dismal Late referral World wide problem Increases risk of right HF, renal and liver dysfunction, cardiac cachexia => Increase risk of poor outcome post HT or inability to be listed due to advanced state Vital that the right patients are referred at the right time Relies on cardiologists and HF nurses identifying potential transplant candidates and understanding the assessment process Who to refer? The Journal of Heart and Lung Transplantation, Vol 36, No 5, May

3 Not sure if your patient would benefit? Risk assessment Seattle Heart Failure Score 1 year survival <80% Heart Failure Survival Score medium to high risk Qualitative test to consider TTE RV dysfunction & rising pulmonary pressures (aim PASP <50mmHg) Cardiopulmonary testing VO2 max<14 mls/min/kg Or decreasing 6min walk Cardiac index<1.8 L/min/m 2 Who we can t transplant HIV/AIDS Active or recent malignancy <5 years Active infection, acute PE, active peptic ulcer Systemic disease with multi-system involvement Irreversible neurological disorder Advanced RA Irreversible lung, liver or kidney disease FEV1 <40% predicted egfr <40 ml/min/1.73 m 2 Non-compliance Lack of social support 3

4 Who we shouldn t transplant Age >70 years >65 years need to have low co-morbid burden BMI >35 or <17 Diabetic end organ damage Vascular disease Active substance abuse Acute and no interaction previously with health services then can discuss IF likely to be able to abstain Recommended 6month abstinence Active mental health disorder Indications for urgent inpatient referral Requirement of continuous inotrope infusion (or/and intraaortic balloon pump (IABP)) to prevent multi-organ failure No scope for revascularisation in the setting of ongoing coronary ischaemia Persisting circulatory shock due to a primary cardiac disorder An absence of contraindications to transplantation 4

5 LVAD an option? Bridge to transplant for transplant eligible patients Usually use if deteriorating whilst on list and suitable Can be used to reverse problems secondary to HF Renal dysfunction Pulmonary HTN In emergency situations may be used as a bridge to decision to allow full assessment of the patient. What we d like in the referral History of cardiac condition (including investigations and treatments) and current symptomatic/functional status. Medical/surgical Problem List: Cardiac and non-cardiac diagnoses should be listed Medications (and medication intolerances if relevant) Examination findings including height, weight and BMI Current cardiac investigations (echocardiogram report, coronary angiogram report, cardiac MRI report if performed) Psychosocial history Tobacco/Alcohol/drug use Support network Heart failure self-management/adherence to medical therapy Employment history/status 5

6 What happens following referral Initial visit an overnight visit Assess current clinical status Full assessment a weeks visit Blood tests, TTE, USS, RHC, psychosocial assessment CPET Discussed at Transplant Selection Committee meeting Multi-disciplinary team Accepted => Active listed ~6/12 wait time SELECTION IS BASED BOTH ON THE PATIENT'S CLINICAL NEED AND THEIR CAPACITY TO BENEFIT 6

7 Case 43 year old Chemotherapy induced cardiomyopathy Presented with decompensated HF in July /52 of symptoms prior SOBOE, orthopnoea, PND Difficulty titrating meds secondary to hypotension Levosimendan Post discharge tolerating very slow up-titration of meds to medium doses Re-admitted 19/10 with symptomatic fluid overload -> Referred to transplant team Accepted for active listing 11/2017 Symptomatic decline 12/2017 Being worked up for LVAD Transplanted 12/2017 Case 64 year old STEMI 16/3/14 PCI to LAD Multiple admissions 03/14 07/14 Never >10/7 out of hospital Wheelchair for distance as SOBOE Renal and liver dysfunction, cardiac cachexia Referred after 3/52 admission Stabilised on dobutamine Deteriorated despite high dose Urosepsis Transferred home under palliative care 7

8 Case 56 year old man CAD 2004 NSTEMI PCI to LAD/D Delayed presentation MI ICM slow symptomatic decline, stabilized medical therapy, ICD 09/2017 VF secondary to HF decompensation Further VF and ICD lead failure - > CRT and ICD upgrade Angiography - PCI to LAD/D1 NHYA IV 09/ /2018 admissions with decompensation requiring inotropes ~ every 2/12 Other history Smoker quit 2009, re-started 2011 ( trauma), quit 09/2017 Chronic renal failure Cr 140 on inotropes Obesity BMI 33 Case continued Referred 09 th April Triages 14 th April Seen 15th May NYHA IV Gross fluid overload Admitted from clinic, iv diuretics & inotropes Admitted to CVICU 21 st May for more intensive support Transferred to home hospital by air ambulance 23 rd May for palliation 8

9 Case 60 year old man 2012 Anterior STEMI PCI to LAD, EF 32%, MRI non viable 2013 CRT-D 25/05/17 Cardiogenic shock secondary to Inferoposterior STEMI 25/05 10/17 3x admissions Difficult titration of medications Told no further medical options 31/10/17 Transplant assessment NYHA III-IV, cardiac cachexia, deconditioned 17/11/17 Decision -> LVAD due to deterioration 16/4/18 Heart transplant Currently making a good recovery Conclusion The primary cardiologist of the patient with advanced HF acts as gatekeeper Think I NEED HELP! Address any possible contra-indications early We need a window of time to assess and find a donor so refer early! If in doubt please call, or write we re always happy to discuss a patient with you 9