humboldt kolleg limits and interfaces in science the future of heart transplantation in brazil...

Humboldt Kolleg Humboldt Kolleg

Limits and Interfaces in ScienceLimits and Interfaces in ScienceHumboldt Kolleg Humboldt Kolleg

Limits and Interfaces in ScienceLimits and Interfaces in Science

The Future of Heart The Future of Heart

Transplantation in BrazilTransplantation in BrazilThe Future of Heart The Future of Heart

Transplantation in BrazilTransplantation in Brazil

Noedir A. G. StolfNoedir A. G. Stolf

[email protected]@incor.usp.br

http://upload.wikimedia.org/wikipedia/commons/f/f3/AvHumboldt.jpg

HISTORY OF HEART TRANSPLANTATION –HISTORY OF HEART TRANSPLANTATION – LABORATORY LABORATORY

WORKWORKHISTORY OF HEART TRANSPLANTATION –HISTORY OF HEART TRANSPLANTATION – LABORATORY LABORATORY

WORKWORKC

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1905

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WORKWORK

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WORKWORK

Car

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Dem

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Mar

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1940

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1962

III Congresso Sul Americano de Cardiologia XXIII Congresso Brasileiro de Cardiologia

TRANSPLANTE ISOTÓPICO DO CORAÇÃO DE CÃES

Euclydes F. Marques, Noedir A.G. Stolf, Seigo Tsuzuki, Samuel R.Marek, Irimar P. Posso, Pedro C. Piantino e Euriclides J. Zerbini.







Os autores relatam os ensinamentos resultantes de 30 transplantes isotó-picos de coração em cães, obtendo-se 20casos de sobrevivência de um mínimode 2horas e um máximo de 26horas. São discutidos os fatores que Inflem noêxito do transplante. Os problemas a serem resolvidos em tal experimentaçãorelacionam-se à técnica cirúrgica, preservação do hospedeiro durante o trans-Plante, preservação do coração durante o transplante e recuperação do coração.Assim são discutidos as diferentes técnicas de transplante, no que tange a viade acesso, tipo de suturas, prevenção de embolia gasosa, problemas de drena-gem de veias cavas. Apresentam-se as diferentes maneiras com que se conser-vou vivo o hospedeiro durante a troca do coração. Foi utilizada sempre a circu-lação extracorpóreacom oxigenadores de Zuhdi, Kay-Cross e ainda um modeloexperimental original da oficina “Coração Pulmão-Artificial” do Hospital das Clíni-




Os autores relatam os ensinamentos resultantes de 30 transplantes isotó-picos de coração em cães, obtendo-se 20casos de sobrevivência de um mínimode 2horas e um máximo de 26horas. São discutidos os fatores que Inflem noêxito do transplante. Os problemas a serem resolvidos em tal experimentaçãorelacionam-se à técnica cirúrgica, preservação do hospedeiro durante o trans-Plante, preservação do coração durante o transplante e recuperação do coração.Assim são discutidos as diferentes técnicas de transplante, no que tange a viade acesso, tipo de suturas, prevenção de embolia gasosa, problemas de drena-gem de veias cavas. Apresentam-se as diferentes maneiras com que se conser-vou vivo o hospedeiro durante a troca do coração. Foi utilizada sempre a circu-lação extracorpóreacom oxigenadores de Zuhdi, Kay-Cross e ainda um modeloexperimental original da oficina “Coração Pulmão-Artificial” do Hospital das Clíni-



WORKWORK

23 de Janeiro de 196423 de Janeiro de 1964

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1964

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HISTORY OF HEART TRANSPLANTATION –HISTORY OF HEART TRANSPLANTATION – CLINICAL CLINICAL

APPLICATIONAPPLICATIONHISTORY OF HEART TRANSPLANTATION –HISTORY OF HEART TRANSPLANTATION – CLINICAL CLINICAL

APPLICATIONAPPLICATION

1964

1964

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HISTORY OF HEART TRANSPLANTATION –HISTORY OF HEART TRANSPLANTATION – CLINICAL CLINICAL

DEVELOPMENTDEVELOPMENT HISTORY OF HEART TRANSPLANTATION –HISTORY OF HEART TRANSPLANTATION – CLINICAL CLINICAL

DEVELOPMENTDEVELOPMENT

1964

1964

1967

1967

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Har

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1940

1940

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1905

1968

1968

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ini

Zerb

ini

1960

1960

1962

1962

HISTORY OF HEART TRANSPLANTATION –HISTORY OF HEART TRANSPLANTATION – HISTORICAL TRANSP. HISTORICAL TRANSP.

PERIOD..PERIOD..HISTORY OF HEART TRANSPLANTATION –HISTORY OF HEART TRANSPLANTATION – HISTORICAL TRANSP. HISTORICAL TRANSP.

PERIOD..PERIOD..

1964

1964

1967

1967

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1940

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1960

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1962

1984

1984

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ralla

Nes

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Era pós-ciclosporinaEra pós-ciclosporinaHISTORY OF HEART TRANSPLANTATION –HISTORY OF HEART TRANSPLANTATION – HISTORY OF HEART TRANSPLANTATION –HISTORY OF HEART TRANSPLANTATION –

1964

1964

1967

1967

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1940

1940

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1968

1968

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1960

1960

1962

1962

1984

1984

Nes

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Nes

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1985

1985

.Inco

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.Inco

r

HISTORY OF HEART TRANSPLANTATIONHISTORY OF HEART TRANSPLANTATIONHISTORY OF HEART TRANSPLANTATIONHISTORY OF HEART TRANSPLANTATION

INTERNACIONAL REGITRY ISHLTINTERNACIONAL REGITRY ISHLT INTERNACIONAL REGITRY ISHLTINTERNACIONAL REGITRY ISHLT

ISHLT Taylor DO. - J Heart Lung Transplant 2005;24: 945-98Taylor DO. - J Heart Lung Transplant 2005;24: 945-98

189 317669

1185

2160

2718

31573383

40314196 4219 4389 4435 4358 4251 4157

38183547 3402 3340 3252 3135

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Nº

Tra

ns

pla

nts

189 317669

1185

2160

2718

31573383

40314196 4219 4389 4435 4358 4251 4157

38183547 3402 3340 3252 3135

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Nº

Tra

ns

pla

nts

20052005

years

110

64

19

119

61

16

128

64

9

147

71

14

175

93

24

206

105

19

196

92

30

139

60

16

136

46

15

200

74

29

100

75

23

0

50

100

150

200

250

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Brasil São Paulo InCor

Heart TransplantHeart TransplantHeart TransplantHeart Transplant

Sources: SES/SP – CTX & ABTOSources: SES/SP – CTX & ABTOSources: SES/SP – CTX & ABTOSources: SES/SP – CTX & ABTO

Number of Transplants Number of Transplants

ABTO RegistryABTO Registry – – 20092009

69 Registered ( 25 69 Registered ( 25 Active )Active )

• 1,1 HTX / million 1,1 HTX / million InhabitantInhabitant

ABTO RegistryABTO Registry – – 20092009

69 Registered ( 25 69 Registered ( 25 Active )Active )

• 1,1 HTX / million 1,1 HTX / million InhabitantInhabitant

Heart Transplants Heart Transplants Heart Transplants Heart Transplants

Indication – Brazil Indication – Brazil

From 1984 to 1999 – 835 Transplants From 1984 to 1999 – 835 Transplants

Chagas 13%Chagas 13%Chagas 13%Chagas 13%

Idiopathic 56%Idiopathic 56%Idiopathic 56%Idiopathic 56%

Ischemic 22%Ischemic 22%Ischemic 22%Ischemic 22%

Congenital 2%Congenital 2%Congenital 2%Congenital 2%

Valvar 3%Valvar 3%Valvar 3%Valvar 3%

Other 4%Other 4%Other 4%Other 4%

Ann Thorac Surg 2001; 71:1853Ann Thorac Surg 2001; 71:1853Ann Thorac Surg 2001; 71:1853Ann Thorac Surg 2001; 71:1853

Heart Transplants Heart Transplants Heart Transplants Heart Transplants

Indication – Brazil Indication – Brazil

From Jan 1995 to Dec 2004 – 482 From Jan 1995 to Dec 2004 – 482 Transplants Transplants

Brazilian Registry of Transplants – ABTO (2007)Brazilian Registry of Transplants – ABTO (2007)Brazilian Registry of Transplants – ABTO (2007)Brazilian Registry of Transplants – ABTO (2007)

ICM 24 %

Chagas 23 %

DCM 39 %

Other10 %

Valvar 3 %

Congenital 1 %

Heart Transplantation Heart Transplantation

Heart Institute University of Sao Paulo Medical SchoolHeart Institute University of Sao Paulo Medical School

Heart Transplantation Heart Transplantation

Heart Institute University of Sao Paulo Medical SchoolHeart Institute University of Sao Paulo Medical School

3

9

13

17

910

12

2018

22

17

14

21

1816

24

19

15

20

31

27

35

22

19

36

24

0

5

10

15

20

25

30

35

40

3

9

13

17

910

12

2018

22

17

14

21

1816

24

19

15

20

31

27

35

22

19

36

24

0

5

10

15

20

25

30

35

40

Year

N°

Tra

nspl

ants

N°

Tra

nspl

ants

InCor – 1985 a 2009InCor – 1985 a 2009

472472 TransplantsTransplants

InCor – 1985 a 2009InCor – 1985 a 2009

472472 TransplantsTransplants

Chagas Disease Chagas Disease Chagas Disease Chagas Disease

INDICATION – HEART INST -USP INDICATION – HEART INST -USP INDICATION – HEART INST -USP INDICATION – HEART INST -USP

472 Transplants (Adult-406) 472 Transplants (Adult-406) From 1985 to 2009 From 1985 to 2009

ICM 24,1%

Chagas 16,9%

DCM 44,8%

Other5,0%

Valvar 4,7%

Congenital 14,07%

Heart Institute of the University of São Paulo- InCorHeart Institute of the University of São Paulo- InCor

%%

Follow-up (years)Follow-up (years)

00

2020

4040

6060

8080

100100

00 11 22 33 44 55 66 77 88 99 1010 1111 1212

Bocchi EA e Fiorelli AI -J Heart Lung Transplant. 2001 Jun;20(6):637-45.Bocchi EA e Fiorelli AI -J Heart Lung Transplant. 2001 Jun;20(6):637-45.

HEART TRANSPLANTATION – SURVIVAL – COMPARATIVEHEART TRANSPLANTATION – SURVIVAL – COMPARATIVE

ISHLTISHLTn = 835n = 835

Br*Br*

Chagas’-14,7%Chagas’-14,7%

Idiopathic-51%Idiopathic-51%

Ischemic-24,6%Ischemic-24,6%Waitting List-ChagasWaitting List-Chagas

Waitting List- Non ChagasWaitting List- Non Chagas’

I Guideline Brazilian Society of CardiologyI Guideline Brazilian Society of CardiologyHeart Transplantation (I GHT)Heart Transplantation (I GHT)

I Guideline Brazilian Society of CardiologyI Guideline Brazilian Society of CardiologyHeart Transplantation (I GHT)Heart Transplantation (I GHT)

p < 0,0277p < 0,0277p < 0,0277p < 0,0277

Follow up (Years)Follow up (Years)Follow up (Years)Follow up (Years)

Perc

en

tag

e (

%)

Perc

en

tag

e (

%)

Perc

en

tag

e (

%)

Perc

en

tag

e (

%)

Survival after HTXSurvival after HTX

Ann Thorac Surg 2001; 71:1853Ann Thorac Surg 2001; 71:1853Ann Thorac Surg 2001; 71:1853Ann Thorac Surg 2001; 71:1853

Quality of Life Quality of Life

%%

00

2020

4040

6060

8080

100100

Physical activity Physical activity

Symptoms Symptoms Sleep Sleep Food Food Sexual activity Sexual

activity

Pre-Op.Pre-Op. 12 Months12 Months6 Months6 Months

HEART TRANSPLANTATION –HEART TRANSPLANTATION – RESULTS RESULTSHEART TRANSPLANTATION –HEART TRANSPLANTATION – RESULTS RESULTS

Borghetti-Maio et al. - J Heart Lung Transpl 1994; 13: 271-5Borghetti-Maio et al. - J Heart Lung Transpl 1994; 13: 271-5

HEART TRANSPLANTATION – HEART TRANSPLANTATION – QUALITY OF LIFEQUALITY OF LIFE HEART TRANSPLANTATION – HEART TRANSPLANTATION – QUALITY OF LIFEQUALITY OF LIFE

Contraindications Contraindications – MedicalMedical

– Psychosocial Psychosocial

Shortage of donorsShortage of donors– Mortality in waiting listMortality in waiting list

Present ImmunosuppressionPresent Immunosuppression– Lack of Specificity Lack of Specificity

– Toxicity Toxicity

Contraindications Contraindications – MedicalMedical

– Psychosocial Psychosocial

Shortage of donorsShortage of donors– Mortality in waiting listMortality in waiting list

Present ImmunosuppressionPresent Immunosuppression– Lack of Specificity Lack of Specificity

– Toxicity Toxicity

HEART TRANSPLANTATION – HEART TRANSPLANTATION – LIMITATIONSLIMITATIONS HEART TRANSPLANTATION – HEART TRANSPLANTATION – LIMITATIONSLIMITATIONS

HEART TRANSPLANTATION – HEART TRANSPLANTATION – CONTRAINDICATIONSCONTRAINDICATIONS HEART TRANSPLANTATION – HEART TRANSPLANTATION – CONTRAINDICATIONSCONTRAINDICATIONS

Transplants14,4%

Transplants14,4%

Patient Refusal 2,6%


Conventional Surgery 3,1%Conventional Surgery 3,1%Psychological

6,0%Psychological

6,0%

Heart- Institute Heart- Institute 380 Cases referred380 Cases referred

1991 a 19931991 a 1993

Heart- Institute Heart- Institute 380 Cases referred380 Cases referred

1991 a 19931991 a 1993

Freitas HFG et al. – Arq Bras Cardiol 62:233-237, 1994.Freitas HFG et al. – Arq Bras Cardiol 62:233-237, 1994.

Social11,3%Social11,3%

Improves Clinical 18,1%


Cardiomyoplasty 2,3%


Medical7,8%

Medical7,8%

• Age: 16 - 68a (43,5±11,4a)• Men: 79,7%• Women: 20,3%

• Age: 16 - 68a (43,5±11,4a)• Men: 79,7%• Women: 20,3%



Transplants14,4%

Transplants14,4%




6,0%Psychological

6,0%

Heart- Institute Heart- Institute 380 Cases 380 Cases 1991 a 19931991 a 1993







Medical7,8%

Medical7,8%

• Age: 16 - 68a (43,5±11,4a)• Men: 79,7%• Women: 20,3%

• Age: 16 - 68a (43,5±11,4a)• Men: 79,7%• Women: 20,3%


5%5%


Transplants14,4%

Transplants14,4%




6,0%Psychological

6,0%








Medical7,8%

Medical7,8%

• Age: 16 - 68a (43,5±11,4a)• Men: 79,7%• Women: 20,3%

• Age: 16 - 68a (43,5±11,4a)• Men: 79,7%• Women: 20,3%

HEART INSTITUTE – WAITING LIST (INCOR)HEART INSTITUTE – WAITING LIST (INCOR)

%%

00

2020

4040

6060

8080

100100

0000 6666 12121212 18181818 24242424 30303030 36363636

Perspective of TxPerspective of Tx Survival in listSurvival in list

Months of follow - upMonths of follow - up

HEART TRANSPLANTATION – HEART TRANSPLANTATION – LIMITATIONS - DONORSLIMITATIONS - DONORS HEART TRANSPLANTATION – HEART TRANSPLANTATION – LIMITATIONS - DONORSLIMITATIONS - DONORS

HEART TRANSPLANTATIONHEART TRANSPLANTATION

100100%%

00

2020

4040

6060

8080

Survival in listSurvival in list Natural historyNatural history

Months of follow - upMonths of follow - up00 1212 2424 3636 4848

MARGINAL DONORSMARGINAL DONORS

1. Donors with hemodynamic instability

Monitoring Aggressive Treatment

2. Donors with localized infection

No systemic infection

3. Elder Donors

4. Donors with cardiopathy

Takagaki et a. - J Heart Lung Transpl 1996;15:527.

1. Donors with hemodynamic instability

Monitoring Aggressive Treatment

2. Donors with localized infection

No systemic infection

3. Elder Donors

4. Donors with cardiopathy

Takagaki et a. - J Heart Lung Transpl 1996;15:527.

HEART TRANSPLANTATION – HEART TRANSPLANTATION – LIMITATIONS - DONORSLIMITATIONS - DONORS HEART TRANSPLANTATION – HEART TRANSPLANTATION – LIMITATIONS - DONORSLIMITATIONS - DONORS

HEART TRANSPLANTATION – HEART TRANSPLANTATION – BRIDGE TO TRANSPLANTATIONBRIDGE TO TRANSPLANTATION HEART TRANSPLANTATION – HEART TRANSPLANTATION – BRIDGE TO TRANSPLANTATIONBRIDGE TO TRANSPLANTATION

Artificial ventricle (InCor) Artificial ventricle (InCor) Artificial ventricle (InCor) Artificial ventricle (InCor)

HEART TRANSPLANTATION – HEART TRANSPLANTATION – BRIDGE TO TRANSPLANTATIONBRIDGE TO TRANSPLANTATION HEART TRANSPLANTATION – HEART TRANSPLANTATION – BRIDGE TO TRANSPLANTATIONBRIDGE TO TRANSPLANTATION

Heart Transplantation in BrazilHeart Transplantation in Brazil

Present StatusPresent Status Heart Transplantation in BrazilHeart Transplantation in Brazil

Present StatusPresent Status

1.1. Small number of Small number of

transplants/yeartransplants/year

2.2. Centers with small number of Centers with small number of

casescases

3.3. Areas without Transplant Areas without Transplant

CentersCenters

4.4. Shortage of donorsShortage of donors

5.5. Donors in worse conditionDonors in worse condition

6.6. Recipients in worse conditionRecipients in worse condition

7.7. High mortality in waiting listHigh mortality in waiting list

8.8. Higher early mortality of TxHigher early mortality of Tx

1.1. Small number of Small number of

transplants/yeartransplants/year

2.2. Centers with small number of Centers with small number of

casescases

3.3. Areas without Transplant Areas without Transplant

CentersCenters

4.4. Shortage of donorsShortage of donors

5.5. Donors in worse conditionDonors in worse condition

6.6. Recipients in worse conditionRecipients in worse condition

7.7. High mortality in waiting listHigh mortality in waiting list

8.8. Higher early mortality of TxHigher early mortality of Tx


Strategies Strategies Heart Transplantation in BrazilHeart Transplantation in Brazil

Strategies Strategies

I.I. Increase the nr of transplants Increase the nr of transplants

Improve the payment for the procedureImprove the payment for the procedure

Support to present centers Support to present centers

Encourage creation of new centersEncourage creation of new centers

Payment for mechanical circulatory Payment for mechanical circulatory

supportsupport

I.I. Increase the nr of transplants Increase the nr of transplants

Improve the payment for the procedureImprove the payment for the procedure

Support to present centers Support to present centers

Encourage creation of new centersEncourage creation of new centers

Payment for mechanical circulatory Payment for mechanical circulatory

supportsupport




II.II. Increase the nr of donors Increase the nr of donors

Improve organ procurement systemImprove organ procurement system

Early communication of potential Early communication of potential

donorsdonors

Better treatment of donorsBetter treatment of donors

Increase the use of marginal donorsIncrease the use of marginal donors

II.II. Increase the nr of donors Increase the nr of donors

Improve organ procurement systemImprove organ procurement system

Early communication of potential Early communication of potential

donorsdonors

Better treatment of donorsBetter treatment of donors

Increase the use of marginal donorsIncrease the use of marginal donors




III.III. Improve nr and quality of recipients Improve nr and quality of recipients

Early referral Early referral

Clinics of Heart failureClinics of Heart failure

Payment / use of mechanical circulatory Payment / use of mechanical circulatory

supportsupport

III.III. Improve nr and quality of recipients Improve nr and quality of recipients

Early referral Early referral

Clinics of Heart failureClinics of Heart failure

Payment / use of mechanical circulatory Payment / use of mechanical circulatory

supportsupport




IV.IV. Improve results Improve results

All from I- IIIAll from I- III

Better donorsBetter donors

Better recipientsBetter recipients

IV.IV. Improve results Improve results

All from I- IIIAll from I- III

Better donorsBetter donors

Better recipientsBetter recipients

Thank you for your attention Thank you for your attention Thank you for your attention Thank you for your attention

humboldt kolleg limits and interfaces in science the future of heart transplantation in brazil...

Documents

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