The Future of Heart Transplantation in Brazil

Apresentação em tema: "The Future of Heart Transplantation in Brazil"— Transcrição da apresentação:

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

2 HISTORY OF HEART TRANSPLANTATION – LABORATORY WORK
Carrel 1905

3 HISTORY OF HEART TRANSPLANTATION – LABORATORY WORK
Demikhov Carrel 1940 1905

4 HISTORY OF HEART TRANSPLANTATION – LABORATORY WORK
Shumway Demikhov Carrel 1960 1905 1940

5 HISTORY OF HEART TRANSPLANTATION – LABORATORY WORK
Marques Demikhov Shumway Carrel 1962 1905 1940 1960 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.

6 HISTORY OF HEART TRANSPLANTATION – CLINICAL APPLICATION
1964 Hardy Demikhov Shumway Marques Carrel 1905 1940 1960 1962 23 de Janeiro de 1964

7 HISTORY OF HEART TRANSPLANTATION – CLINICAL DEVELOPMENT
1967 Barnard Demikhov Shumway Marques Carrel Hardy 1905 1940 1960 1962 1964

8 HISTORY OF HEART TRANSPLANTATION – HISTORICAL TRANSP. PERIOD..
1968 Zerbini Demikhov Shumway Marques Barnard Carrel Hardy 1905 1940 1960 1962 1964 1967

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12 Nesralla HISTORY OF HEART TRANSPLANTATION – Demikhov Shumway Marques
Era pós-ciclosporina Nesralla Demikhov Shumway Marques Barnard Carrel Hardy Zerbini 1984 1905 1940 1960 1962 1964 1967 1968

13 HISTORY OF HEART TRANSPLANTATION
Demikhov Shumway .Incor Marques Barnard Nesralla Carrel Hardy Zerbini 1985 1905 1940 1960 1962 1964 1967 1968 1984

14 INTERNACIONAL REGITRY ISHLT
2005 This figure includes only the heart transplants that are reported to the ISHLT Transplant Registry. As such, this should not be construed as evidence that the number of hearts transplanted worldwide has declined in recent years. years ISHLT Taylor DO. - J Heart Lung Transplant 2005;24:

15 1,1 HTX / million Inhabitant
Number of Transplants Heart Transplant ABTO Registry – 2009 69 Registered ( 25 Active ) 1,1 HTX / million Inhabitant 15 Sources: SES/SP – CTX & ABTO

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

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

18 Heart Transplantation
Heart Institute University of Sao Paulo Medical School InCor – 1985 a 2009 472 Transplants N° Transplants n° de Tx de 2006, pegar na ABTO Year 18

19 Heart Institute of the University of São Paulo- InCor
INDICATION – HEART INST -USP Chagas Disease 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 19

20 HEART TRANSPLANTATION – SURVIVAL – COMPARATIVE
% 100 ISHLT n = 835 Br* 80 60 40 20 1 2 3 4 5 6 7 8 9 10 11 12 Follow-up (years) Bocchi EA e Fiorelli AI -J Heart Lung Transplant Jun;20(6):

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

22 Quality of Life HEART TRANSPLANTATION – RESULTS 20 40 60 80 100
% 20 40 60 80 100 Physical activity Symptoms Sleep Food Sexual Pre-Op. 12 Months 6 Months Borghetti-Maio et al. - J Heart Lung Transpl 1994; 13: 271-5

23 HEART TRANSPLANTATION – QUALITY OF LIFE

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

25 HEART TRANSPLANTATION – CONTRAINDICATIONS
Age: a (43,5±11,4a) Men: 79,7% Women: 20,3% Heart- Institute 380 Cases referred 1991 a 1993 Cardiomyoplasty 2,3% Improves Clinical 18,1% Transplants 14,4% Social 11,3% Patient Refusal 2,6% Medical 7,8% Psychological 6,0% Conventional Surgery 3,1% Freitas HFG et al. – Arq Bras Cardiol 62: , 1994.

26 HEART TRANSPLANTATION – CONTRAINDICATIONS
Age: a (43,5±11,4a) Men: 79,7% Women: 20,3% Heart- Institute 380 Cases 1991 a 1993 Cardiomyoplasty 2,3% Improves Clinical 18,1% Transplants 14,4% Social 11,3% Patient Refusal 2,6% Medical 7,8% Psychological 6,0% Conventional Surgery 3,1% Freitas HFG et al. – Arq Bras Cardiol 62: , 1994.

27 HEART TRANSPLANTATION – CONTRAINDICATIONS
Age: a (43,5±11,4a) Men: 79,7% Women: 20,3% Heart- Institute 380 Cases 1991 a 1993 Cardiomyoplasty 2,3% 5% Improves Clinical 18,1% Transplants 14,4% Social 11,3% Patient Refusal 2,6% Medical 7,8% Psychological 6,0% Conventional Surgery 3,1% Freitas HFG et al. – Arq Bras Cardiol 62: , 1994.

28 HEART INSTITUTE – WAITING LIST (INCOR)
HEART TRANSPLANTATION – LIMITATIONS - DONORS HEART INSTITUTE – WAITING LIST (INCOR) 100 % 80 60 40 20 6 12 18 24 30 36 Months of follow - up Perspective of Tx Survival in list

29 HEART TRANSPLANTATION
% 100 80 60 40 20 12 24 36 48 Months of follow - up Survival in list Natural history

30 HEART TRANSPLANTATION – LIMITATIONS - DONORS
MARGINAL 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.

31 HEART TRANSPLANTATION – BRIDGE TO TRANSPLANTATION

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

33 Heart Transplantation in Brazil Present Status
Small number of transplants/year Centers with small number of cases Areas without Transplant Centers Shortage of donors Donors in worse condition Recipients in worse condition High mortality in waiting list Higher early mortality of Tx

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

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

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

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

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39 Thank you for your attention