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Dr Emily Granger Cardiothoracic and Heart Lung Transplant Surgeon St Vincent’s Hospital Darlinghurst NSW Heart Transplant Controversies: New frontiers, new hope?

Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

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Page 1: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Dr Emily Granger

Cardiothoracic and Heart Lung Transplant Surgeon

St Vincent’s Hospital Darlinghurst

NSW

Heart Transplant Controversies:

New frontiers, new hope?

Page 2: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Overview:

Background

Cardiac Surgery on transplanted hearts

Ex-vivo perfusion of donor hearts

Day/Month/Year Footnote to go here Page 2

Page 3: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

St Vincent’s Hospital first heart transplant 1984

Currently 950

~ 40/year in NSW

3

Page 4: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Day/Month/Year Footnote to go here Page 4

Page 5: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Organ donation rates in Australia

• Australia has a relatively low organ donation rate in the developed world

• Although this rate is climbing, it still lags behind many parts of America

and Europe

Page 6: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo
Page 7: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Number of all transplant types by year

1984 - 2015

0

50

100

150

200

250

84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

HEARTS HEART-LUNG SINGLE LUNG B-L LUNG

ANZCOTR 2015

Page 8: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Mean Waiting Time to Transplant

Hearts 1984 – 2015: >150 days

0

50

100

150

200

250

84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Mean Waiting Time in days

DAYS

YEAR

ANZCOTR 2015

Page 9: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Pre transplant patient status1996 -

2015: Sicker patients, more VADS

ANZCOTR 2015

Page 10: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

0

5

10

15

20

25

30

35

40

84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Year

Age in

years

ANZCOTR 2015

Hearts Mean Donor Age ~ 35

Older donors!

Page 11: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

HEARTS - Mean Ischaemic Time ~4 hours

Donor heart has to travel further!

Year

ANZCOTR 2013

0

50

100

150

200

250

300

84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Page 12: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Are we getting desperate?

Do we need to push the boundaries?

Is cardiac surgery on a transplanted heart possible?

Does it convey benefit?

Who, what pathology, how?

Day/Month/Year Footnote to go here Page 12

Page 13: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Review of redo cardiac surgery on

transplanted hearts:

Single center, retrospective review

940 patients who underwent HTx February 1984 - June 2016

28 patients with subsequent cardiac surgery

Average age 49 (29-64)

86% male

Average time to surgery 7.2 years (1.4-10.8)

Average follow-up 4.6 years

Day/Month/Year Footnote to go here Page 13

Page 14: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Table 1 Characteristics of Patient Population

N 28

Age (y)

49 SD=11 (Range: 29-

64)

Sex

Male

Female

21

7

Interval (y) 7.2 (1.4-10.8)

Pre-op creatinine clearance

(ml/min) 70 (59-105)

Pre-op creatinine (umol/l) 119 (SD=32)

Bypass (min) 97 (88-144)

X-clamp (min) 59 (44-111)

Follow-up (y) 4.6 (1.7-10.2)

Day/Month/Year Footnote to go here Page 14

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Day/Month/Year Footnote to go here Page 15

Table 1 Characteristics of Patient Population

Revascularisations

CABG 10

Valve Surgery

TV Repair

TV Replacement

2

6

MV Replacement 1

MV + TV Repair 1

Other Operations

Pericardiectomy 2

Other (sternotomy) 1

Replacement ascending aorta

1

Bentalls operation

4

Page 16: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Day/Month/Year Footnote to go here Page 16

Table 2 Post-Operative Details

15.0 (5.5-29.3)Ventilated hrs

LOS ICU (hrs) 45 (24-101)

LOS (days) 10 (8-20)

Returns to theatre 4 (18%)

Early mortality 1 (5%)

Post op Dialysis 3 (14%)

Re-intubation / respiratory failure 2 (10%)

Tracheostomy 2 (10%)

Sternal wound infections 2

Pneumonia 1

Stroke 0

Page 17: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

CABG

Day/Month/Year Footnote to go here Page 17

Table 3 Pre-operative Characteristics of Patients undergoing CABG Surgery

Patient Age Sex Interv

al (y)

Urgency Euroscore Pre-op

Creatinine

Grafts Conduit

Bypass

(min)

X-

clamp

(min)

1 49 M 8.4 Elec 2.3 160 3 LIMA+ vein 88 54

2a 36 M 7.1 Elec 2.3 150 3 LIMA+ vein 144 49

3 48 M 5.4 Elec 7.2 80 3 LIMA+ radial 135 102

4 22 M 7.5 Emerg 7.6 94 2 Vein 67 36

5 52 M 1.6 Elec 9.2 120 3 LIMA+ vein 89 45

6 41 M 14 Elec 23.3 120 2 LIMA +

radial

95 64

7 54 M 2.4 Elec 1.5 83 2 LIMA +vein 90 43

8 52 M 7.1 Elec 2.3 148 4 vein 107 49

9 34 M 9.8 Elec 3.7 126 5 LIMA + vein 128 69

Page 18: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

CABG Results:

2 peri-operative deaths

Day/Month/Year Footnote to go here Page 18

Table 4 Outcomes After CABG Surgery

Patient Ventilated

Hrs

LOS-ICU

(hrs)

LOS

(d)

RTT DSWI Follow-Up

(y)

Mortality

1 42 97 23 1 1 7.0 Died

2 - - - - - 0.0 Died

3 40 40 8 0 0 16.6 Alive

4 4 12 7 0 0 9.8 Died

5 706 706 61 1 1 0.4 Died

6 4 18 10 0 0 8.3 Alive

7 4 17 7 1 0 12.9 Alive

8 3.5 24 8 0 0 11.3 Alive

9 15 36 15 0 0 17.2 Alive

Med

(n=8)a

9.5 30 9 N=3 N=2 9.8 5/9 alive

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Valve Surgery:

Tricuspid regurgitation

Day/Month/Year Footnote to go here Page 19

Table 5 Pre-operative Characteristics of Patients Undergoing Valve Surgery

Pt IndicationUnderlying

PathologyProcedure Age Sex

Interval

(y)Urgency

Pre-op Cr

(uml/L)

1 TR Iatrogenic TV Repair 32 M 3.6 Elec 141

2 TR TechnicalTV Replacement

(b)32 F 0.4 Elec 86

3 TR IatrogenicTV replacement

(m)37 F 9.2 Elec 190

4 TR IatrogenicTV Replacement

(b)34 M 14.9 Elec 114

5 TR Technical TV replacement 42 f 0.5 Elec 115

6 TR Donor TV replacement 44 f 0.4 Elec 90

7 TR Iatrogenic TV replacement 34 f 6.0 Elec 105

Page 20: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Valve surgery:

Aortic, mitral

Day/Month/Year Footnote to go here Page 20

Pre-operative Characteristics of Patients Undergoing Valve Surgery

Pt IndicationUnderlying

PathologyProcedure Age Sex

Interval

(y)Urgency

Pre-op Cr

(uml/L)

1 MR+ TR FunctionalMV Repair +

TV Repair 57 M 13.1 Urg 136

2 MR Endocarditis

MV

Replacement

(b)

58 M 1.0 Urg 119

3 AR Endocarditis Bentalls 42 M 0.3 Urg 58

4 AR Endocarditis Bentalls 54 M 0.8 Urg 103

5 AA/ARAortic

aneurysm, ARBentalls 57 M 14.0 Elec 130

6 AAMycotic

aneurysm

Replacement

ascending

aorta

35 m 0.2 urg 190

7 AA

Aortic stenosis

and calcified

aortic root

Bentalls 57 M 17.5 Elec 140

Page 21: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Constrictive

pericarditis

Day/Month/Year Footnote to go here Page 21

Table 7 Patients Undergoing Other Operations

Variable Patient

1 2

Pre-Operative

Characteristics

Age 40 64

Sex M F

Procedure Pericardiectomy Pericardiectomy

Indication Constrictive

pericarditis

Constrictive

pericarditis

Interval 1 5

Urgency Elec Elec

Euroscore 2.4 7.4

Pre-Op Cr (umol/L) 64 126

Post-Operative

Outcomes

Ventilated Hrs 17 6

LOS-ICU (hrs) 20 165

LOS (d) 6 30

RTT 0 0

DSWI 0 0

Follow-Up (y) 1.3 1.8

Mortality Alive Died

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Day/Month/Year Footnote to go here Page 22

Page 23: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Summary

Highly select cases –

Few patients are suitable for CABG

Most others result from infection (endocarditis), iatrogenic (tricuspid)

Very few from donor acquired disease (Marfans, mitral prolapse)

Operation has a :

High take back rate (~20%) for bleeding

14% dialysis rate

Poor pre-op renal function showed a trend to poorer outcome

Day/Month/Year Footnote to go here Page 23

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Operative strategy

Careful pre-operative planning:

1. CT Chest

2. Previous operation report – past cannulation strategy /

bicaval vs biatrial / previous pathology (?congenital)

3. Optimise renal function

4. Transition to Cyclosporin (rather than sirolimus)

5. Cease anti-platelet agents

Day/Month/Year Footnote to go here Page 24

Page 25: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Other options?

Percutaneous interventions – Mitraclip / TAVI

Coronary / valve surgery at time of transplant?

Day/Month/Year Footnote to go here Page 25

Page 26: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

But what about native coronary

disease in the donor?

Day/Month/Year Footnote to go here Page 26

Page 27: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Should we graft a donor coronary?

Day/Month/Year Footnote to go here Page 27

Page 28: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

14 hearts retrieved so far

2 rejected

• severe angiographic CAD

• Unfavourable lactate profile

12 transplanted with excellent early graft function

Retrieval of ‘Marginal’Hearts from Brain

Dead Donors with Transmedics OCS –

SVH experience

Page 29: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

St Vincent’s DCD heart donation timeline

20

13

20

14

20

15

20

16

Research

DCD

human

donors

N12

DCD HTx

First

Clinical

DCD HTx

20

12

20

11

Porcine

DCD

Ex-vivo

perfusion

Porcine

DCD Tx

Page 30: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

16/04/2015 Page 30

Clinical DCD Donor Selection Criteria

• Maastricht Category III controlled DCD donors

• Age <40 years

– To reduce risk of acquired cardiovascular disease

– Older hearts less tolerant of prolonged ischaemia

• Echocardiography not mandatory

• Warm ischaemic time (time from withdrawal to cardioplegia) <30mins

– Animal model evidence for poorer outcomes when WIT further

prolonged

Page 31: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo
Page 32: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

DCD Heart Transplant Pathway

16/04/2015 Page 32

Withdrawal

Sternotomy and

cardioplegia

Declaration of Death

Heart excised

Ex-vivo perfusion

Transplant

Page 33: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Donor locations of the transplanted DCD hearts

Sydney

Melbourne

Darwin

Gold Coast

Page 34: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Perioperative DCD Heart Results

No. Post operative

mechanical support

ICU stay Postoperative

length of stay

Cardiac

Function at

1 week

1 ECMO (4 days) 7 days 26 days Normal

2 nil 8 days 28 daysNormal

3 IABP (2 days) 6 days 21 daysNormal

4 nil 4 days 23 daysNormal

5 nil 9 days 32 daysNormal

6 nil 2 days 7 daysNormal

7 ECMO (5 days) 10 days 38 daysNormal

8 nil 4 days 16 daysNormal

9 nil 7 days 7 daysNormal

• No recipient mortality

Page 35: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Other options – Coronary angiogram on

Transmedics Organ Care System?

Day/Month/Year Footnote to go here Page 35

Page 36: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Donor coronary artery disease

Day/Month/Year Footnote to go here Page 36

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Day/Month/Year Footnote to go here Page 37

Page 38: Heart Transplant Controversies: New frontiers, new …...Heart Transplant Controversies: New frontiers, new hope? Overview: Background Cardiac Surgery on transplanted hearts Ex-vivo

Conclusion

Cardiac transplantation is evolving

Boundaries are being redrawn – ex-vivo perfusion

Donation after circulatory death

Taking on more challenging redo cardiac surgery

Ageing heart transplant population – more redo cardiac surgery on

select population, or re-list for redo heart transplant.

Day/Month/Year Footnote to go here Page 38