ΠΕΤΡΟΣ Δ. ΣΦΥΡΑΚΗΣ ΚΑΡΔΙΟΧΕΙΡΟΥΡΓΟΣ … · 0 25 50 75 100 0 1 2 3 4...

ΠΕΤΡΟΣ Δ. ΣΦΥΡΑΚΗΣ

ΚΑΡΔΙΟΧΕΙΡΟΥΡΓΟΣ

METROPOLITAN HOSPITAL ΑΘΗΝΑ

29/06/2018 SFIRAKIS D. PETROS 1

Adult and Pediatric Heart Transplants

Number of Transplants by Year and Location

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

5500

Nu

mb

er

of

tra

nsp

lan

ts

Other

North America

Europe

NOTE: This figure includes only the heart transplants that are

reported to the ISHLT Transplant Registry. As such, the

presented data may not mirror the changes in the number of

heart transplants performed worldwide.

2017JHLT. 2017 Oct; 36(10): 1037-1079


HEART TRANSPLANTS 137 pts + 2 Retransplant

LONG-TERM ASSIST DEVICES 115 pts (BTT-BTC-DT)

LUNG TRANSPLANTS 12 pts + 1 Retransplant

ONASSIS CARDIAC SURGERY CENTER 04/1995-09/2015

0

2

4

6

8

10

12

14

16

18

20

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

20

13

20

14

HEART TRANSPLANTS 137 pts (45,25% VAD pts)

LONG-TERM ASSIST DEVICES 115 pts DEVICES 123

LUNG TRANSPLANTS 12

SFIRAKIS D. PETROS 429/06/2018

0

25

50

75

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

Su

rviv

al

(%)

Years

2017JHLT. 2017 Oct; 36(10): 1037-1079

Adult and Pediatric Heart TransplantsKaplan-Meier Survival

Median survival = 10.9 years;Median survival conditional on surviving to 1 year = 13.5 years

N = 127,097

(Transplants: January 1982 – June 2015)

HEART TRANSPLANTS - DEATHS

4/1995-09/2015 (137 +2 Retransplant)

0

20

40

60

80

100

120

140

160

HEART TRANSPLANTS 137 + 2

RETRANSPLANTS

DEATHS 31 (22,62%), ( 14 pts on DEVICE

45,16%)


0

10

20

30

40

50

0-30 Days(N=6,774)

31 Days - 1Year (N=5,842)

>1-3 Years(N=4,129)

>3-5 Years(N=3,579)

>5-10 Years(N=9,122)

>10-15 Years(N=6,468)

>15 years(N=4,664)

% o

f D

ea

ths

CAV Acute Rejection

Malignancy (non-Lymph/PTLD) Infection (non-CMV)

Graft Failure Multiple Organ Failure

Renal Failure

Since only leading causes of death are shown, the sum

of percentages for each time period is less than 100%.

2017JHLT. 2017 Oct; 36(10): 1037-1079

Adult Heart Transplants Relative Incidence of Leading Causes of Death

(Deaths: January 1994 – June 2016)

EVENTS OF TRANSPLANTED PATIENTS

0

5

10

15

20

25

30 REJECTION 28

CAV 18

PTCA 11

CMV 14

PACER 9

AICD 2

GF 6

CND 3

PE 2

Renal F. 4

Malignacies 5

TR 3

G. Surgery 7

Aspergilus 1

Retrans 2


Adult and Pediatric Heart TransplantsDonor Age by Year of Transplant

0

5

10

15

20

25

30

35

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Me

dia

n d

on

or

ag

e (

ye

ars

)

% o

f tr

an

sp

lan

ts

0-9 10-17 18-39 40-59 60-69 70+ Median Age

2017JHLT. 2017 Oct; 36(10): 1037-1079

THE MEAN AGE OF DONORS

AND RECIPIENTS

0

10

20

30

40

50

60

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

20

13

20

14

20

15

MEAN AGE OFDONORS

MEAN AGE OFRECIPIENTS


Changes and the Future ofHeart Transplantation

-Recipient and Donor Demographics

-Survival after Heart Transplantation

-Technological and pharmaceutical

-Patient and Donor selection

-Medical management

-Operative care

-Long-term follow-up


Immunosuppression-Calcineurin inhibitors (CNI) in 1980

-Steroid weaning

-CNI monotherapy

-CNI –free immunosuppression

-Mammalian Target of Rapamycin (mTOR)

(Sirolimus, Everolimus)

-Inhibitors of CD28/B7

-Customized immunosuppression

-Therapeutic antibodies (rituximab-antiCD20,

basiliximad-anti-IL2,alemtuzumab antiCD52,

bortezomib 26S proteasome inhibitor, Belatacept

CD 28/B7 inhibitor, eculizumab anti-C5 )


Regection

-Achilles heel of organ transplantation

-Cellular mediated rejection (CMR)

-Antibody mediated rejection (AMR)

-HLA class I ,class II, non-HLA antigen

-Donor-Specific Antibodies (DSA)

-AlloMap test (CMR)

-Donor derived cell-free DNA, microRNA

and messenger RNA


Cardiac allograft vasculopathy (CAV)

-Late post-transplant mortality 50% at 10y.

-Diffuse coronary process

-Form of chronic rejection

-Cardiovascular risk factors

-Chronic inflammation

-Donor specific antigens (DSA)

-Ischemia-reperfusion injury


Mechanical Circulatory Support (MCS)

-MCS as a Bridge to Transplantation (BTT)

-Complications

-Status priority

-Short and Long-term Device

-Bridge to Recovery

-Destination Therapy


Figure 1

The Journal of Heart and Lung Transplantation 2018 37, 685-691DOI: (10.1016/j.healun.2018.01.1294)

Copyright © 2018 International Society for the Heart and Lung Transplantation Terms and Conditions

Figure 2



Figure 3



From: The European Registry for Patients with Mechanical Circulatory Support (EUROMACS) of the European Association for Cardio-Thoracic Surgery (EACTS): second reportEur J Cardiothorac Surg. 2017;53(2):309-316. doi:10.1093/ejcts/ezx320

Eur J Cardiothorac Surg | © The Author 2017. Published by Oxford University Press on behalf of the European Association for

Cardio-Thoracic Surgery. All rights reserved.29/06/2018 SFIRAKIS D. PETROS 20

Ex vivo Preservation

-OCS (Organ Care System)

-PROCEED II clinical trial

(130 patients)

-DCD (Donation after Cardiac Death)


Xenotransplantation

-Size and anatomy

-Immunological risks

-Infection risks

-Primary graft dysfunction

-Ethical problems


Biomaterial for Cardiopumonary System

-Embryonic stem cells, cardiac stem cells,

endothelial progenitor cells, skeletal myoblasts,

bone marrow mononuclear cells

-Extracellular Matrix of the Heart

-Natural Biomaterials

-Synthetic Biomaterials

-Nanotechnology in Cardiomyogenesis

-Tissue Engineering in Regeneration


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