Indicaciones límites en el trasplante para el trasplante cardiaco

Indicaciones límites en el
trasplante para el
trasplante cardiaco
¿Donde ponemos el límite?
Gregorio Rábago
Servicio de Cirugía Cardíaca

jueves 24 de febrero de 2011

¿Que es una indicación
limite?
Edad > 70 años

Afectación sistémica

Diabetes mellitus, Amiloidosis, Miopatías....

Arteriopatía periférica severa

Infecciones crónicas


Supervivencia del trasplante cardiaco
en España

Almenar L et al. Registro Español de Trasplante Cardiaco. XXI Informe Oﬁcial (1984-2009)


ISHLT 2010
Tx by age group
100
18-29 (N=4,957) 30-39 (N= 6,968)
40-49 (N=15,772) 50-59 (N=27,900)
80 60-69 (N=15,269) 70+ (N=453)
Survival (%)

60

All pair-wise comparisons are
40 statistically significant at p < 0.04
except for 18-29 vs 30-39 p=0.1856

20
HALF-LIFE 18-29: 11.5 years; 30-39: 11.5 years; 40-49: 10.8 years; 50-59: 9.7 years;
60-69: 8.8 years; 70+: 7.1 years
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Years


Situación mundial

Trasplantes cardiacos en el mundo (pmp)


Situación Actual
400 349336353 341
318 310
287292278282 290294287 292
300 274 274
232 245 241 243

200 164

97
100 73
45 52
10 22
0
1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Trasplantes cardiacos en España 1984-2010


¿Por que disminuyen los
trasplantes Cardiacos?
Menos
donantes

Menos
Receptores


La lista de espera/donantes

Registro Español de Trasplante Cardiaco. XXI Informe Oﬁcial
de la Sección de Insuﬁciencia Cardiaca y Trasplante Cardiaco
de la Sociedad Española de Cardiología (1984-2009)

Impact of donor quality on outcome
of heart transplantation.

G1: (young recipients/optimal donors)
G2: (young recipients/marginal donors)
G3 (older recipients/marginal donors)
G4 (older recipients/optimal donors)

G1 G2 G3 G4 p
Donor age 14-41 39-64 10-68 16-39 0,4
Donor CAD 0 19% 48% 0 0,008
Donor Inotropic 25% 58% 55% 36% 0,006
Recipient MCS 17% 36% 24% 45% 0,006
Mean Survival 8,3 y 6,3 y 7,1 y 7,8 0,07

Forni A et al. Eur J Cardiothorac Surg. 2010 Dec;38(6):788-94


Donor Age Is Associated With Chronic Allograft
Vasculopathy After Adult Heart Transplantation:
Implications for Donor Allocation

Alykhan S. Nagji, et al. Ann Thorac Surg. 2010;90(1):168-175.

Marginal Cardiac Allografts Do Not Have Increased Primary
Graft Dysfunction in Alternate List Transplantation

B. Lima Circulation. 2006;114:I-27 – I-32.

Marginal Cardiac Allografts Do Not Have Increased Primary
Graft Dysfunction in Alternate List Transplantation

Patients who have end stage heart failure and fail to
qualify for standard heart transplant listing, have
limited options. Most commonly, intravenous inotropic
support is utilized to alleviate symptoms, but this
treatment carries up to a 90 one year mortality.
Another option for these patients is destination LVAD
therapy; LVAD results are improving but one year
mortality is still greater than 30%. Relative to these
treatment options, the Alternative List heart
transplant strategy appears to provide substantially
better results for patients with end state heart
failure and does not appear to be limited by early
graft dysfunction.

B. Lima Circulation. 2006;114:I-27 – I-32.

Donor mitral valve repair in
cardiac transplantation
We subjected 4 donor hearts to bench repair of the mitral valve. The first heart was from a 35-year-
old woman whose echocardiogram showed mild to moderate sclerotic leaflets. We performed a
posteromedial commissurotomy and posterior annuloplasty. Transthoracic echocardiography at 57
months after transplantation demonstrated mild mitral regurgitation and no enlargement of VE. The
second organ was from a 17-year-old woman with no history of heart disease and an echocardiogram
that showed evidence of slightly sclerotic leaflets and mild mitral regurgitation. We performed a
posterior annuloplasty. Echocardiography at 12 months demonstrated minimal mitral regurgitation. The
third heart was from a 28-year-old woman with a normal echocardiogram. After harvesting, we
found a torn head of the posterior papillary muscle, which was reimplanted. Two weeks later, the
echocardiogram showed no mitral regurgitation. The fourth was from a 47-year-old woman with no
history of heart disease and a normal echocardiogram. Examination before implantation showed central
insufficiency, for which we performed posterior annuloplasty. Echocardiography at 12 months showed
no mitral regurgitation.
CONCLUSION: An aggressive approach to use hearts from marginal donors expands the pool and
decreases waiting time for patients who desire heart transplantation.

Prieto D, Antunes MJ. Transplant Proc. 2009 Apr;41(3):932-4.


Homeless donors and heart
transplantation outcomes

In conclusion, this small study (n=10 from 295 donors) has shown that heart
transplant patients who receive their organs from homeless donors have a
signiﬁcantly increased early mortality due to infection and rejection

D. Lockhart et al. Journal of Heart and Lung Transplantation, Vol 30, No 3, March 2011


Conclusiones
Expandir el pool de donantes es posible

Similares resultados postoperatorios

Mayor EVI

Menor supervivencia a largo plazo

Seria aconsejable un correcto
emparejamiento donante receptor si se
expanden las indicaciones, para evitar
aumento de mortalidad en lista de espera en
pacientes electivos.


Indicaciones límites en el trasplante para el trasplante cardiaco

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Indicaciones límites en el trasplante para el trasplante cardiaco