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Humboldt Kolleg Limits and Interfaces in Science The Future of Heart Transplantation in Brazil Noedir A. G. Stolf

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Apresentação em tema: "Humboldt Kolleg Limits and Interfaces in Science The Future of Heart Transplantation in Brazil Noedir A. G. Stolf"— Transcrição da apresentação:

1 Humboldt Kolleg Limits and Interfaces in Science The Future of Heart Transplantation in Brazil Noedir A. G. Stolf

2 HISTORY OF HEART TRANSPLANTATION – LABORATORY WORK Carrel 1905

3 Carrel Demikhov HISTORY OF HEART TRANSPLANTATION – LABORATORY WORK

4 Carrel Demikhov Shumway HISTORY OF HEART TRANSPLANTATION – LABORATORY WORK

5 Carrel Demikhov Marques Shumway 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. 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. 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 mínimo de 2horas e um máximo de 26horas. São discutidos os fatores que Inflem no êxito do transplante. Os problemas a serem resolvidos em tal experimentação relacionam-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 via de 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 modelo experimental original da oficina Coração Pulmão-Artificial do Hospital das Clíni- 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 mínimo de 2horas e um máximo de 26horas. São discutidos os fatores que Inflem no êxito do transplante. Os problemas a serem resolvidos em tal experimentação relacionam-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 via de 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 modelo experimental original da oficina Coração Pulmão-Artificial do Hospital das Clíni- HISTORY OF HEART TRANSPLANTATION – LABORATORY WORK

6 23 de Janeiro de 1964 Carrel Demikhov Marques Shumway Hardy HISTORY OF HEART TRANSPLANTATION – CLINICAL APPLICATION

7 1964 Carrel Demikhov Hardy Marques Shumway Barnard HISTORY OF HEART TRANSPLANTATION – CLINICAL DEVELOPMENT

8 Carrel Demikhov Hardy Marques Shumway Barnard Zerbini HISTORY OF HEART TRANSPLANTATION – HISTORICAL TRANSP. PERIOD..

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12 Carrel Demikhov Hardy Marques Shumway Barnard Zerbini Nesralla Era pós-ciclosporina HISTORY OF HEART TRANSPLANTATION –

13 Carrel Demikhov Hardy Marques Shumway Barnard Zerbini Nesralla 1985.Incor HISTORY OF HEART TRANSPLANTATION

14 INTERNACIONAL REGITRY ISHLT INTERNACIONAL REGITRY ISHLT ISHLT Taylor DO. - J Heart Lung Transplant 2005;24: years

15 Heart Transplant Sources: SES/SP – CTX & ABTO Number of Transplants Number of Transplants ABTO Registry – Registered ( 25 Active ) 1,1 HTX / million Inhabitant 1,1 HTX / million Inhabitant ABTO Registry – Registered ( 25 Active ) 1,1 HTX / million Inhabitant 1,1 HTX / million Inhabitant

16 Heart Transplants Indication – Brazil Indication – Brazil From 1984 to 1999 – 835 Transplants Chagas 13% Idiopathic 56% Ischemic 22% Congenital 2% Valvar 3% Other 4% Ann Thorac Surg 2001; 71:1853

17 Heart Transplants Indication – Brazil Indication – Brazil From Jan 1995 to Dec 2004 – 482 Transplants Brazilian Registry of Transplants – ABTO (2007) ICM 24 % Chagas 23 % DCM 39 % Other 10 % Valvar 3 % Congenital 1 %

18 Heart Transplantation Heart Institute University of Sao Paulo Medical School Heart Transplantation Heart Institute University of Sao Paulo Medical School Year N° Transplants InCor – 1985 a Transplants InCor – 1985 a Transplants

19 Chagas Disease INDICATION – HEART INST -USP INDICATION – HEART INST -USP 472 Transplants (Adult-406) From 1985 to 2009 ICM 24,1% Chagas 16,9% DCM 44,8% Other 5,0% Valvar 4,7% Congenital 14,07% Heart Institute of the University of São Paulo- InCor

20 % Follow-up (years) Bocchi EA e Fiorelli AI -J Heart Lung Transplant Jun;20(6): HEART TRANSPLANTATION – SURVIVAL – COMPARATIVE ISHLT n = 835 Br*

21 Chagas-14,7% Idiopathic-51% Ischemic-24,6% Waitting List-Chagas Waitting List- Non Chagas Waitting List- Non Chagas I Guideline Brazilian Society of Cardiology Heart Transplantation (I GHT) I Guideline Brazilian Society of Cardiology Heart Transplantation (I GHT) p < 0,0277 Follow up (Years) Percentage (%) Survival after HTX Ann Thorac Surg 2001; 71:1853

22 Quality of Life % % Physical activity Physical activity Symptoms Sleep Food Sexual activity Sexual activity Pre-Op. 12 Months 6 Months HEART TRANSPLANTATION – RESULTS Borghetti-Maio et al. - J Heart Lung Transpl 1994; 13: 271-5

23 HEART TRANSPLANTATION – QUALITY OF LIFE

24 Contraindications Contraindications – Medical – Psychosocial Shortage of donors Shortage of donors – Mortality in waiting list Present Immunosuppression Present Immunosuppression –Lack of Specificity –Toxicity HEART TRANSPLANTATION – LIMITATIONS

25 HEART TRANSPLANTATION – CONTRAINDICATIONS Transplants 14,4% Transplants 14,4% Patient Refusal 2,6% Patient Refusal 2,6% Conventional Surgery 3,1% Psychological 6,0% Psychological 6,0% Heart- Institute 380 Cases referred 1991 a 1993 Heart- Institute 380 Cases referred 1991 a 1993 Freitas HFG et al. – Arq Bras Cardiol 62: , Social 11,3% Social 11,3% Improves Clinical 18,1% Improves Clinical 18,1% Cardiomyoplasty 2,3% Cardiomyoplasty 2,3% Medical 7,8% Medical 7,8% Age: a ( 43,5±11,4a ) Men: 79,7% Women: 20,3% Age: a ( 43,5±11,4a ) Men: 79,7% Women: 20,3%

26 Freitas HFG et al. – Arq Bras Cardiol 62: , HEART TRANSPLANTATION – CONTRAINDICATIONS Transplants 14,4% Transplants 14,4% Patient Refusal 2,6% Patient Refusal 2,6% Conventional Surgery 3,1% Psychological 6,0% Psychological 6,0% Heart- Institute 380 Cases 1991 a 1993 Heart- Institute 380 Cases 1991 a 1993 Social 11,3% Social 11,3% Improves Clinical 18,1% Improves Clinical 18,1% Cardiomyoplasty 2,3% Cardiomyoplasty 2,3% Medical 7,8% Medical 7,8% Age: a ( 43,5±11,4a ) Men: 79,7% Women: 20,3% Age: a ( 43,5±11,4a ) Men: 79,7% Women: 20,3%

27 Freitas HFG et al. – Arq Bras Cardiol 62: , % HEART TRANSPLANTATION – CONTRAINDICATIONS Transplants 14,4% Transplants 14,4% Patient Refusal 2,6% Patient Refusal 2,6% Conventional Surgery 3,1% Psychological 6,0% Psychological 6,0% Heart- Institute 380 Cases 1991 a 1993 Heart- Institute 380 Cases 1991 a 1993 Social 11,3% Social 11,3% Improves Clinical 18,1% Improves Clinical 18,1% Cardiomyoplasty 2,3% Cardiomyoplasty 2,3% Medical 7,8% Medical 7,8% Age: a ( 43,5±11,4a ) Men: 79,7% Women: 20,3% Age: a ( 43,5±11,4a ) Men: 79,7% Women: 20,3%

28 HEART INSTITUTE – WAITING LIST (INCOR) % Perspective of Tx Perspective of Tx Survival in list Months of follow - up Months of follow - up HEART TRANSPLANTATION – LIMITATIONS - DONORS

29 HEART TRANSPLANTATION 100 % Survival in list Natural history Natural history Months of follow - up Months of follow - up

30 MARGINAL DONORS 1. Donors with hemodynamic instability â Monitoring â Aggressive Treatment 2. Donors with localized infection â No systemic infection 3. Elder Donors 4. Donors with cardiopathy Takagaki et a. - J Heart Lung Transpl 1996;15:527. HEART TRANSPLANTATION – LIMITATIONS - DONORS

31 HEART TRANSPLANTATION – BRIDGE TO TRANSPLANTATION

32 Artificial ventricle (InCor) HEART TRANSPLANTATION – BRIDGE TO TRANSPLANTATION

33 Heart Transplantation in Brazil Present Status 1. Small number of transplants/year 2. Centers with small number of cases 3. Areas without Transplant Centers 4. Shortage of donors 5. Donors in worse condition 6. Recipients in worse condition 7. High mortality in waiting list 8. Higher early mortality of Tx 1. Small number of transplants/year 2. Centers with small number of cases 3. Areas without Transplant Centers 4. Shortage of donors 5. Donors in worse condition 6. Recipients in worse condition 7. High mortality in waiting list 8. Higher early mortality of Tx

34 Heart Transplantation in Brazil Strategies I. Increase the nr of transplants Improve the payment for the procedure Improve the payment for the procedure Support to present centers Support to present centers Encourage creation of new centers Encourage creation of new centers Payment for mechanical circulatory support Payment for mechanical circulatory support I. Increase the nr of transplants Improve the payment for the procedure Improve the payment for the procedure Support to present centers Support to present centers Encourage creation of new centers Encourage creation of new centers Payment for mechanical circulatory support Payment for mechanical circulatory support

35 Heart Transplantation in Brazil Strategies II. Increase the nr of donors Improve organ procurement system Improve organ procurement system Early communication of potential donors Early communication of potential donors Better treatment of donors Better treatment of donors Increase the use of marginal donors Increase the use of marginal donors II. Increase the nr of donors Improve organ procurement system Improve organ procurement system Early communication of potential donors Early communication of potential donors Better treatment of donors Better treatment of donors Increase the use of marginal donors Increase the use of marginal donors

36 Heart Transplantation in Brazil Strategies III. Improve nr and quality of recipients Early referral Early referral Clinics of Heart failure Clinics of Heart failure Payment / use of mechanical circulatory support Payment / use of mechanical circulatory support III. Improve nr and quality of recipients Early referral Early referral Clinics of Heart failure Clinics of Heart failure Payment / use of mechanical circulatory support Payment / use of mechanical circulatory support

37 Heart Transplantation in Brazil Strategies IV. Improve results All from I- III All from I- III Better donors Better donors Better recipients Better recipients IV. Improve results All from I- III All from I- III Better donors Better donors Better recipients Better recipients

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39 Thank you for your attention Thank you for your attention


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