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Life After Heart Transplantation

Life After Heart Transplantation. 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. Epidemiology of Heart Failure.

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Life After Heart Transplantation

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  1. Life After Heart Transplantation 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

  2. Epidemiology of Heart Failure • 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--2010 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. 1998 Dec

  3. Transition of Heart Failure

  4. Progression to Heart Failure

  5. Heart Failure Therapy

  6. When is Transplant Necessary? • 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

  7. Status of Heart Transplantation

  8. Awaiting Transplantation • Chronic Functional Impairment • Angina • Co-morbid conditions • Cachexia • Frequent/prolonged hospitalizations • Mechanical circulatory support

  9. Recovery from Transplantation • Persistent functional impairment related to longstanding heart failure, prior surgeries, steroids • Multiple clinic visits • Delayed healing due to multiple sternotomies, medications • Infection • Rejection

  10. First Post-Transplant Year • At least 14 clinic visits • 12-14 biopsies • Cardiac rehabilitation • Early morbidity • Rejection 30% (ISHLT) • Infection 60% (CTRD) • Re-hospitalizations

  11. ADULT HEART RECIPIENTSRehospitalization Post-transplant of Surviving Recipients (Follow-ups: 1995 - June 2008) ISHLT 2009

  12. Surveillance for Rejection in Heart Transplantation Cardiac biopsy is used to monitor for rejection and guide usage of immunosuppressive drugs Mild Severe Most US centers do 12-14 biopsies in year 1, 2-4 in years 2-5

  13. Post Transplant Morbidity Most Common Causes of Late Death Malignancy Graft failure Cardiac allograft vasculopathy (coronary artery disease) ISHLT 2009

  14. ADULT HEART RECIPIENTSFunctional Status of Surviving Recipients(Follow-ups: 1995 - June 2008) ISHLT 2009

  15. Functional Capacity • 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;12:359-379

  16. Returning to Work • Arbitrary • Depends on type of job • Exposure • Functional limitations/Cardiac rehabilitation • Ability to maintain coverage • Economic and social stability

  17. ADULT HEART RECIPIENTSEmployment Status of Surviving RecipientsAge at Follow-up: 25-55 Years(Follow-ups: 1995 - June 2008) ISHLT 2009

  18. Summary • 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

  19. Future Directions • 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

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