Monica Colvin-Adams, MD Assistant Professor of Medicine Advanced Heart Failure and Transplantation University of Minnesota Compassionate Allowances Outreach Hearing on Cardiovascular Diseases and Multi-organ Transplantation
5.8 million people in US in 2006 23 million worldwide One year mortality up to 50% in advanced heart failure At 40 years old, life-time risk is 1/5 Aging population Improved treatment of cardiovascular disease Lloyd-Jones, D, Adams, RJ, Brown, TM, et al. Heart disease and stroke statistics update: a report from the American Heart Association. Circulation 2010; Clinical epidemiology of heart failure: public and private health burden.AUMcMurray JJ; Petrie MC; Murdoch DR; Davie APSOEur Heart J Dec
When symptoms become excessive despite optimal medical therapy Class III/IV heart failure Symptoms with minimal activity or at rest Frequent hospitalizations Hemodynamic instability Low cardiac output Fluid retention Arrhythmias Intractable angina
Chronic Functional Impairment Angina Co-morbid conditions Cachexia Frequent/prolonged hospitalizations Mechanical circulatory support
Persistent functional impairment related to longstanding heart failure, prior surgeries, steroids Multiple clinic visits Delayed healing due to multiple sternotomies, medications Infection Rejection
At least 14 clinic visits biopsies Cardiac rehabilitation Early morbidity Rejection 30% (ISHLT) Infection 60% (CTRD) Re-hospitalizations
ISHLT 2009
Analyzes gene expression data Identifies gene expression patterns in peripheral blood assoc. with acute cellular rejection Translates complex signals into a score 2 months post-transplant
Mild Severe Cardiac biopsy is used to monitor for rejection and guide usage of immunosuppressive drugs Most US centers do biopsies in year 1, 2-4 in years 2-5
Most Common Causes of Late Death Malignancy Graft failure Cardiac allograft vasculopathy (coronary artery disease) Morbidity 1 year ( ) 10 years ( ) Hypertension7698% Diabetes2737% Renal Dysfunction 2714% Chronic Dialysis ----5% Kidney Transplant ----1% Abnormal Lipids 7493% Cardiac Allograft Vasculopathy 52% ISHLT 2009 Post Transplant Morbidity
ISHLT 2009
Reduced and does not return to “normal” after transplant 57% of patients still at NYHA class II-IV Altered physiologic response of denervated heart to exercise Glucocorticoids (steroids) Deconditioning prior to transplant Effect of heart failure on skeletal muscle Niset G, Hermans L, Depelcin P. Exercise and Heart Transplantation: a review. Sports Med 1991;12:
Arbitrary Depends on type of job Exposure Functional limitations/Cardiac rehabilitation Ability to maintain coverage Economic and social stability
ISHLT 2009
Advanced heart failure is associated with severe functional and even cognitive limitations Heart transplantation is a “cure” for heart failure which offers a significant improvement in functional status and return to near-normal levels of functioning in most people Heart transplantation represents a new medical condition Due to associated co-morbidities, baseline functional impairment, and complications of transplant, transient and chronic disabilities can ensue at any time during transplant
Modulation of donor/recipient interaction Improved therapy for rejection Earlier detection of rejection and coronary disease Earlier implantation of LVADs/smaller devices Less reliance on transplantation Mechanical Circulatory Support