Monica Colvin-Adams, MDAssistant Professor of Medicine

Advanced Heart Failure and TransplantationUniversity of Minnesota

Compassionate Allowances Outreach Hearing on Cardiovascular Diseases and

Multi-organ Transplantation

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

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

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

Persistent functional impairment related to longstanding heart failure, prior surgeries, steroids

Multiple clinic visits Delayed healing due to multiple

sternotomies, medications Infection Rejection

At least 14 clinic visits 12-14 biopsies Cardiac rehabilitation Early morbidity

Rejection 30% (ISHLT) Infection 60% (CTRD)

Re-hospitalizations

ISHLT

2009

Mild

Severe

Cardiac biopsy is used to monitor for rejection and guide usage of immunosuppressive drugs

Most US centers do 12-14 biopsies in year 1, 2-4 in years 2-5

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

MorbidityMorbidity 1 year1 year

(2000-(2000-2003)2003)

10 years 10 years (1994-(1994-2008)2008)

HypertensioHypertensionn

7676 98%98%

DiabetesDiabetes 2727 37%37%

Renal Renal DysfunctionDysfunction

2727 14%14%

Chronic Chronic DialysisDialysis

-------- 5%5%

Kidney Kidney TransplantTransplant

-------- 1%1%

Abnormal Abnormal LipidsLipids

7474 93%93%

Cardiac Cardiac Allograft Allograft VasculopatVasculopathyhy

52%52%

ISHLT 2009

Post Transplant Morbidity

ISHLT

2009

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 1991;12:359-379

Arbitrary Depends on type of job Exposure Functional limitations/Cardiac

rehabilitation Ability to maintain coverage Economic and social stability

ISHLT

2009

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

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