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
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
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
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