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1、Cardiac Transplantation and Mechanical Circulatory Support,Andrew Boyle,MDAssociate Professor of MedicineMedical Director of Heart Failure,Cardiac Transplantation,and Mechanical Circulatory SupportDivision of CardiologyUniversity of Minnesota,Metabolic Stress Testing,Mancini D et al.Circulation 1991
2、;83:778-786.,Group 1:peak VO2 14Group 3:rejected for OHTx,AGE DISTRIBUTION OF HEART RECIPIENTS(1/1982-6/2003),%of Transplants,J Heart Lung Transpl.2004;23:796-803.,DIAGNOSIS IN ADULT HEART TRANSPLANTS,HEART TRANSPLANTATION Kaplan-Meier Survival(1/1982-6/2006),J Heart Lung Transplant 2008;27:937-983.
3、,UMN Cardiac Transplant Survival,NUMBER OF HEART TRANSPLANTS REPORTED BY YEAR,J Heart Lung Transplant 2008;27:937-983,HEART TRANSPLANTS:Donor Age by Year of Transplant,J Heart Lung Transpl.2004;23:796-803.,Description of UNOS Status Levels,Status IARHC in place and:two or more inotropes regardless o
4、f doseIV milrinone at least 0.5 mcg/kg/min IV dobutamine at least 7.5 mcg/kg/min30 days following medical stabilization after VAD implantationStatus IBinotrope-dependentLVAD not meeting criteria for IA status No advantage for being hospitalizedStatus IINot inotrope-dependent and no VADPriority on UN
5、OS list based on status level and duration of time in that status levelNo credit given for time at a lower status level,Stevenson LW et al.Circulation 2003;108:492-7.,Inotropic Therapy for End-Stage Heart Failure,University of Minnesota VAD Implants,HeartMate II,Pulsatile vs Continuous Flow LVADs,Pu
6、lsatile/Volume Displacement,Continuous/Rotary,HeartMate II as BTT,Miller L,Boyle A,et al.NEJM 2007;357:893.,HeartMate II BTT Clinical TrialAdverse Event Rates,Events/Patient Year,1Frazier OH,et al.J Thor CV Surg 2001,Miller L,John R,Boyle A,et al.NEJM 2007;357:893.,HM II as BTT in Women,Outcomes at
7、one year,Pamboukian S,Boyle A,et al.Circulation.2008;118:S-1016,VentrAssist as Bridge to Transplant,VentrAssist Components,Implantable blood pump Powered via percutaneous lead Controller logs parameters&alarms Battery or AC power supply Laptop PC for clinician use,Blood pump,Outflow cannula,Controll
8、er and battery receptacle,Percutaneous lead,Inflow cannula,Worldwide VentrAssist Experience*,*As of 3/3/09,Study Outcomes:Interim Analysis Population(n=98),Boyle A et al.ACC Late Breaking Clinical Trial 2009.,Newest VAD:Heartware,VADs vs CRT for NYHA Class IV Heart Failure,2 Year Mortality with CRT/
9、CRT-D in NYHA Class IV Patients,Lindenfeld J et al.Circulation 2007;115:204-212.,COMPANION NYHA Class IV Patients,Lindenfeld J et al.Circulation 2007;115:204-212.,Improvement in Median Distance Walked in Six Minutes:HeartMate II vs CRT/CRT-D,Boyle A et al.Presented at ACC 2008.,Conclusions,Test to d
10、etermine candidacy for transplant is metabolic stress testMedian survival post-transplant is 10 yearsFrequency of transplantation is decliningLong term inotropic therapy not very successfulContinuous flow VADs show good long term survival with reduced adverse eventsVADs now approved for BSA as low as 1.2CRT for NYHA Class IV heart failure not terribly effective,
