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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?
Overview:
Background
Cardiac Surgery on transplanted hearts
Ex-vivo perfusion of donor hearts
Day/Month/Year Footnote to go here Page 2
St Vincent’s Hospital first heart transplant 1984
Currently 950
~ 40/year in NSW
3
Day/Month/Year Footnote to go here Page 4
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
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
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
Pre transplant patient status1996 -
2015: Sicker patients, more VADS
ANZCOTR 2015
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!
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
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
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
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
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
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
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
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
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
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
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
Day/Month/Year Footnote to go here Page 22
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
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
Other options?
Percutaneous interventions – Mitraclip / TAVI
Coronary / valve surgery at time of transplant?
Day/Month/Year Footnote to go here Page 25
But what about native coronary
disease in the donor?
Day/Month/Year Footnote to go here Page 26
Should we graft a donor coronary?
Day/Month/Year Footnote to go here Page 27
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
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
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
DCD Heart Transplant Pathway
16/04/2015 Page 32
Withdrawal
Sternotomy and
cardioplegia
Declaration of Death
Heart excised
Ex-vivo perfusion
Transplant
Donor locations of the transplanted DCD hearts
Sydney
Melbourne
Darwin
Gold Coast
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
Other options – Coronary angiogram on
Transmedics Organ Care System?
Day/Month/Year Footnote to go here Page 35
Donor coronary artery disease
Day/Month/Year Footnote to go here Page 36
Day/Month/Year Footnote to go here Page 37
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