1 / 28

Why are some organs used And others are not? Heart

Why are some organs used And others are not? Heart. Presented by David nelson, MD Chief, Heart Transplant medicine integris baptist medical center Nazih Zuhdi Transplant Institute oklahoma city, okLAHOMA.

rasul
Download Presentation

Why are some organs used And others are not? Heart

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Why are some organs used And others are not? Heart Presented byDavid nelson, MDChief, Heart Transplant medicineintegrisbaptist medical centerNazih Zuhdi Transplant Instituteoklahoma city, okLAHOMA

  2. Heart Transplantation Research in the Next Decade – A Goal to Achieving Evidence-Based Outcomes • National Heart, Lung and Blood Institute working group • Shah M. et. al. JACC 2012; 59:1263-9 • • “Currently, the definition for a ‘marginal donor’ varies considerably among institutions” • • 1 of 4 specific research directions recommended: • “donor-recipient optimization strategies”

  3. Turndown codes by % of Used hearts. UNOS Data

  4. Donor Predictors of Allograft Use and Recipient Outcomes After Heart Transplantation • Khush K. et. al. Circ Heart Fail. 2013;6:300-309 • • 1,872 Donors/CTDN/2001-2008 • • 45% Hearts Used • • 11 Donor Risk Factors Selected a priori • • Only Donor DM Predicted Recipient • Mortality • • Heart Use Decreased 4% per year • → speculate LVAD use causal

  5. ACCEPT/TURNDOWN DECISION Balance between recipient and donor factors

  6. RECIPIENT STABILITY • Time to death • Time to untransplantability • Amiodarone liver • VAD infection • Pulmonary Hypertension • VAD GI bleed • VAD thrombosis (SIRS)

  7. RECIPIENT OPTIONS

  8. RECIPIENT PRA

  9. RECIPIENT PHT

  10. DONOR SIZEISHLT Guidelines • Use of donor hearts whose weight is no greater than 30% below recipient is “uniformly safe” • A 70-kg male donor can be safely used for any recipient weight • Female donor whose weight is more than 20% less than male recipient should be “viewed with caution” Level of evidence: C Costanzo MR et. al. J Heart/Lung Transplant 2010:29;914

  11. PROBLEMSISHLT Size Guidelines • Fluid status • Body habitus • Oversized heart (male to female) • Ischemic time, PHT, age

  12. ISCHEMIC TIMEISHLT Guidelines Avoid ≥ 4 hours unless donor is young, normal function without inotrope

  13. DONOR CARDIAC FUNCTIONISHLT Guidelines: Negatives • • Intractable ventricular arrhythmias • • Dopamine ≥ 20 mcg/kg/min or comparable inotropes with optimal pre-load/after load • • Focal wall motion abnormality • • Ejection fraction <40% despite optimal hemodynamics and inotropes • • Major artery obstructive disease unless for alternate list and bypassed • • LVH with ECG evidence and wall thickness ≥ 14mm Costanzo MR et. al. J Heart/Lung Transplant 2010;29:914

  14. OTHER HEART function FACTORSNon-ISHLT

  15. Age dataUNOS 1/01/07 through 3/31/12

  16. Donor and Recipient Sex MiSmatch ISHLT registry analyzed 60,584, adult recipients • Male recipients of female hearts had 10% increase in adjusted mortality relative to male recipients of male hearts • Female recipients of female hearts had 10% decrease in mortality relative to female recipients of male hearts • Sex mismatching had no significant effect on acute rejection or allograft vasculopathy Khush K et. al., J Heart Lung Transplant 2012; 31:459-66

  17. Interactions Among Donor Characteristics Influence Post-transplant Survival: A Multi-institutional Analysis Stehlik J et. al. J Heart Lung Transplant 2010:29;291-298 The Cardiac Transplant Research Database group analyzed 7,322 patients from 32 centers between 1990 and 2006.

  18. Weight Difference • WD = weight difference • % WD = (Rwt – Dwt/Rwt) x 100 • Stehlik J et. al. J Heart Lung Transplant 2010:29;291-298

  19. Example • R = 180 lbs. • D = 140 lbs. • % WD = 22% Stehlik J et. al. J Heart Lung Transplant 2010:29;291-298

  20. Male Recipient Stehlik J et. al. J Heart Lung Transplant 2010:29;291-298

  21. Male Recipient Stehlik J et. al. J Heart Lung Transplant 2010:29;291-298

  22. Female Recipient • Donor donor ≤ to 40, %WD up to 30% without effect • Donor Age > 40, mortality increases as % WD increases Stehlik J et. al. J Heart Lung Transplant 2010:29;291-298

  23. Donor Risk Index Weiss ES et al from Columbia and Johns Hopkins analyzed UNOS data from 1987 to 2008 and developed a scoring system predictive of heart transplant, first year mortality based on 4 donor variables:

  24. From Weiss ES et. al. J Heart Lung Transplant 2012; 31:266

  25. KAPLAN-MEIER CURVE • From Weiss ES et. al. J Heart Lung Transplant 2012; 31:266

  26. Mechanical Circulatory Support and Heart Transplantation • Donor and Recipient Factors Influencing Survival • Maltais S., et. al., The Annals of Thoracic Surgery, available online July 31, 2013 (in press) • • SRTR 1997-2012: 2,674 bridged heart transplants (excluding BiVADs) • • HeartMate XVE 724; HeartMate II, 1, 882, HeartWare 68, TAH 111

  27. Findings • No heart transplant survival difference between VADs. • TAH one-year survival approx. 80% vs LVAD approx 90% • Mortality risk factors comparable to non-VAD • Independent variables affecting graft survival: • a. Donor age • b. Recipient pulmonary vascular resistance • c. Ischemic time • d. Gender match • e. Donor-to-recipient body mass index ratio

  28. Relationship Between Donor-to-Recipient BMI Ratio and Graft Survival

More Related