Life After Heart Transplantation

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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

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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
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Transition of Heart Failure
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Progression to Heart Failure
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Heart Failure Therapy
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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

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Status of Heart Transplantation
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Awaiting Transplantation

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

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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

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First Post-Transplant Year

• At least 14 clinic visits
• 12-14 biopsies
• Cardiac rehabilitation
• Early morbidity
• Rejection 30 (ISHLT)
• Infection 60 (CTRD)
• Re-hospitalizations

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


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Allomap A Blood Test to Diagnose Rejection

• 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

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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
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Most Common Causes of Late Death
Post Transplant Morbidity
Morbidity 1 year (2000-2003) 10 years (1994-2008)
Hypertension 76 98
Diabetes 27 37
Renal Dysfunction 27 14
Chronic Dialysis ---- 5
Kidney Transplant ---- 1
Abnormal Lipids 74 93
Cardiac Allograft Vasculopathy 52

• Malignancy
• Graft failure
• Cardiac allograft vasculopathy (coronary artery
  disease)

ISHLT 2009
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ADULT HEART RECIPIENTS Functional Status of
Surviving Recipients (Follow-ups 1995 - June
2008)
ISHLT
2009


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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
199112359-379
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Returning to Work

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

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


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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

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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