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Humboldt Kolleg Limits and Interfaces in Science

Humboldt Kolleg Limits and Interfaces in Science. The Future of Heart Transplantation in Brazil. Noedir A. G. Stolf stolf@incor.usp.br. HISTORY OF HEART TRANSPLANTATION – LABORATORY WORK. Carrel. 1905. HISTORY OF HEART TRANSPLANTATION – LABORATORY WORK. Demikhov. Carrel. 1940. 1905.

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Humboldt Kolleg Limits and Interfaces in Science

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  1. Humboldt Kolleg Limits and Interfaces in Science The Future of Heart Transplantation in Brazil Noedir A. G. Stolfstolf@incor.usp.br

  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. 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- 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.

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

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

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

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

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

  11. 2005 INTERNACIONAL REGITRY ISHLT years ISHLT Taylor DO. - J Heart Lung Transplant 2005;24: 945-98

  12. Number of Transplants HeartTransplant • ABTO Registry – 2009 • 69 Registered ( 25 Active ) • 1,1 HTX / million Inhabitant Sources: SES/SP – CTX & ABTO

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

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

  15. Heart Transplantation Heart Institute University of Sao Paulo Medical School InCor – 1985 a 2009 472Transplants N° Transplants Year

  16. Chagas Disease INDICATION – HEART INST -USP 472 Transplants (Adult-406) From 1985 to 2009 Congenital 14,07% ICM 24,1% DCM 44,8% Chagas 16,9% Other 5,0% Valvar 4,7% Heart Institute of the University of São Paulo- InCor

  17. ISHLT n = 835 Br* HEART TRANSPLANTATION – SURVIVAL – COMPARATIVE % 100 80 60 40 20 0 0 1 2 3 4 5 6 7 8 9 10 11 12 Follow-up(years) Bocchi EA e Fiorelli AI -J Heart Lung Transplant. 2001 Jun;20(6):637-45.

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

  19. % 100 80 60 40 20 0 Physical activity Symptoms Sleep Food Sexual activity Pre-Op. 6 Months 12 Months Quality of Life HEART TRANSPLANTATION – RESULTS Borghetti-Maio et al. - J Heart Lung Transpl 1994; 13: 271-5

  20. HEART TRANSPLANTATION – QUALITY OF LIFE

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

  22. HEART TRANSPLANTATION – CONTRAINDICATIONS Heart- Institute 380 Cases referred 1991 a 1993 • Age: 16 - 68a (43,5±11,4a) • Men:79,7% • Women:20,3% Cardiomyoplasty 2,3% Improves Clinical 18,1% Transplants 14,4% Social 11,3% Patient Refusal 2,6% Medical 7,8% Psychological 6,0% Conventional Surgery3,1% Freitas HFG et al. – Arq Bras Cardiol 62:233-237, 1994.

  23. HEART TRANSPLANTATION – CONTRAINDICATIONS Heart- Institute 380 Cases 1991 a 1993 • Age: 16 - 68a (43,5±11,4a) • Men:79,7% • Women:20,3% Cardiomyoplasty 2,3% Improves Clinical 18,1% Transplants 14,4% Social 11,3% Patient Refusal 2,6% Medical 7,8% Psychological 6,0% Conventional Surgery3,1% Freitas HFG et al. – Arq Bras Cardiol 62:233-237, 1994.

  24. 5% HEART TRANSPLANTATION – CONTRAINDICATIONS Heart- Institute 380 Cases 1991 a 1993 • Age: 16 - 68a (43,5±11,4a) • Men:79,7% • Women:20,3% Cardiomyoplasty 2,3% Improves Clinical 18,1% Transplants 14,4% Social 11,3% Patient Refusal 2,6% Medical 7,8% Psychological 6,0% Conventional Surgery3,1% Freitas HFG et al. – Arq Bras Cardiol 62:233-237, 1994.

  25. HEART TRANSPLANTATION – LIMITATIONS - DONORS HEART INSTITUTE – WAITING LIST (INCOR) 100 % 80 60 40 20 0 0 6 12 18 24 30 36 Months of follow - up Perspective of Tx Survival in list

  26. 0 12 24 36 48 HEART TRANSPLANTATION % 100 80 60 40 20 0 Months of follow - up Survival in list Natural history

  27. 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.

  28. HEART TRANSPLANTATION – BRIDGE TO TRANSPLANTATION

  29. HEART TRANSPLANTATION – BRIDGE TO TRANSPLANTATION Artificial ventricle (InCor)

  30. Heart Transplantation in BrazilPresent 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

  31. Heart Transplantation in BrazilStrategies • 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

  32. Heart Transplantation in BrazilStrategies • Increase the nr of donors • Improve organ procurement system • Early communication of potential donors • Better treatment of donors • Increase the use of marginal donors

  33. Heart Transplantation in BrazilStrategies • Improve nr and quality of recipients • Early referral • Clinics of Heart failure • Payment / use of mechanical circulatory support

  34. Heart Transplantation in BrazilStrategies • Improve results • All from I- III • Better donors • Better recipients

  35. Thank you for your attention

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