Amarelli SITO-SICCH Riunione Intersocietaria 2015

SOLO I PAZIENTI STABILI CON VAD
ANDREBBERO TRAPIANTATI
C. Amarelli

It doesn’t matter how well intentioned you are. If you can’t solve your problems effectively,
you may be doing more harm than good. Having a system to solve your problems will help
ensure you problem solve effectively.

• Define and Identify the Problem -
• If you don’t know what problem you are trying to solve or if you try to solve the
wrong problem you won’t be successful. Find out what the facts are and not only
develop a statement about what exactly the problem is you are trying to solve, but
what your goal is in solving it.

Figure 21
The Journal of Heart and Lung Transplantation 2014 33, 555-564DOI: (10.1016/j.healun.2014.04.010)

Figure 21
Copyright © 2014 International Society for Heart and Lung Transplantation Terms and Conditions
• Define and Identify the Problem -

Define and Identify the Problem -
Adult Heart Transplants
% of Patients Bridged with Mechanical Circulatory Support* (Transplants: January
2000 – December 2012)
0
10
20
30
40
50
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
% of patients
Year
* LVAD, RVAD, TAH, ECMO
2014
JHLT. 2014Oct; 33(10): 996-1008

Donor and Recipient Characteristics
1992-2000
(N = 37,538)
2001-2005
(N = 17,249)
2006-6/2013
(N = 26,294)
p-value
Pre-operative support (multiple items may be
reported)
Hospitalized at time of transplant 60.4% 47.9% 44.5% <0.0001
On IV inotropes 55.8%1 47.3% 42.2% <0.0001
Ventilator 3.4% 3.3% 2.7% 0.0005
IABP 6.5% 6.8% 6.6% 0.6612
Mechanical circulatory support 18.82 24.1 35.1 <0.0001
LVAD 11.9%2 16.9% 29.8% <0.0001
RVAD - 4.9%3 3.6% 0.0031
TAH 0.1%2 0.1% 1.0% <0.0001
ECMO 0.3%4 0.5% 1.1% <0.0001
1
Based on 4/1994-2000 transplants.
2
Based on 11/1999-2000 transplants.
3
Based on 2005 transplants.
4 Based on 5/1995-2000 transplants.
2014
JHLT. 2014Oct; 33(10): 996-1008

% of Patients Bridged with Mechanical Circulatory Support* by Year and
Device Type
0
10
20
30
40
50
2005 2006 2007 2008 2009 2010 2011 2012
% of patients
Year
ECMO VAD+ECMO
TAH LVAD+RVAD
RVAD LVAD
* LVAD, RVAD, TAH, ECMO2014
JHLT. 2014Oct; 33(10): 996-1008

Figure 6

Figure 7

Figure 7
Competing Outcomes Over Time by Initial Implant Strategy
(A) 6 months; (B) 12 months; and (C) 24 months. BTC = bridge to candidacy;
BTT = bridge to transplant.

Figure 7
Device Strategies Over Time
(A) BTT;
(B) BTC: likely;
(C) BTC: moderate;
(D) BTC: unlikely;
(E) DT.
Strategies have been grouped
according to original intent. BTC:
likely = BTC and likely to be
transplanted; BTC: moderate =
BTC and moderately likely to be
transplanted; BTC: unlikely = BTC
and unlikely to be transplanted;

• Analyze the Problem –
• Don’t assume you know what is causing the problem. Do your research and find out
if your assumptions are valid or not. This is what freethought, skepticism and
science is all about.

Figure 21
• Analyze the Problem –

Figure 21

• Identifying Possible Solutions -
• make a list of possible solutions. Don’t assume there are only a couple of solutions
available. Brainstorm, make a list, think outside the box, but don’t limit your
potential by liming your list of possible solutions. (the website lists several methods
to develop the list – and it is worth reading through!.

Figure 21
Complicationsafter VAD implantation:
• Pump Relatedà Pump Replacement
• AnticoagulationRelated à Appropriate medical treatment
• With possibilityof surgical conservative treatment
• Without possibilityof surgical conservative treatment

Figure 21
Current Situation for Heart Transplant:
• Lenghtening waiting list
• Decreasing quality of donor organs
• Considerablemortality on the waiting list
• Considerablepostoperative PGF/mortality

Figure 21
The 4 basic Ethical Principlesof Listing for Transplant:
• Beneficence – To do good.
• Non Malificence (primun non nocere) – to do no harm
• Autonomy- Patient’s right to make informed decisions
• Distributive Justice.

Figure 21
• Identifying Possible Solutions -

• Evaluating Solutions –
• what are the pros and cons of each proposed solution, will this really solve our problem, or
make it worse.

Kaplan-Meier Survival by VAD usage
(Transplants: January 1999 – June 2012)
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11 12
Survival (%)
Years
Pulsatile flow (N=3,497) Continuous flow (N=2,856)
ECMO (N=142) No LVAD / No Inotropes (N=10,271)
No LVAD / Inotropes (N=10,606)
All pair-wise comparisons with pulsatile flow and ECMO were
significant at p < 0.05. No other pair-wise comparisons were
significant at p < 0.05.
2014
JHLT. 2014Oct; 33(10): 996-1008

Kaplan-Meier Survival by VAD usage Conditional on Survival to 6 Months
(Transplants: January 1999 – June 2012)
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11 12
Survival (%)
Years
Pulsatile flow (N=2,941) Continuous flow (N=2,545)
ECMO (N=72) No LVAD / No Inotropes (N=8,939)
No LVAD / Inotropes (N=9,488)
No pair-wise comparisons were significant at p < 0.05.
2014
JHLT. 2014Oct; 33(10): 996-1008

• Selecting the Best Solution –
• After evaluating your possible solutions and ranking them as you need to choose
the one you think has the best chance of success that will help you accomplish the
goal you set in task 1. If none of the solutions will work, you need to re-evaluate
how you defined the problem and go back to step one taking into account what
you have learned through this process. No, this isn’t a pain, it is what is sometimes
required if you want to actually solve your problem.

• Developan Action Plan –
• what tasks need to be done, who will do them, when do they need to be done,
what could go wrong and how will you get around problems, who can help you, or
can you do it yourself?
• Implement the Solution –
• Now that you have a plan – get to it and start implementing it. If you need to
change it, do so, but if you don’t take action, the problem isn’t going to get
solved. There ain’t nothing to it but to do it.

Figure 21
Conclusioni
Il trapianto del paziente portatore di LVAD ha risultati sovrapponibili
se non superiori al trapianto su paziente senza LVAD quando il VAD
ha corretto la perfusione degli organi periferici e la congestione
venosa e polmonare e convertito un paziente ospedalizzato in un
paziente ambulatoriale.
Il VAD complicato si associa a una mortalità aumentata soprattutto
quando effettuato in condizioni di urgenza in precario compenso
clinicosenza poter allocare un organo “ideale”.

Figure 21
Conclusioni
Le complicanze del LVAD (soprattutto le
infettive) vanno trattate, nei limiti del
possibile, in maniera “conservativa” o con la
sostituzione del LVAD evitando di consumare
le poche risorse disponibili per terapie
rescue.
L’allocazione del donatore al VAD stabile (BTT
o BTC in cui il target è stato raggiunto) va
opportunamente regolata in maniera da
garantire al paziente portatore di LVAD un
donatore “ideale” prima che intervengano le
complicanze del LVAD.

Figure 21
Conclusioni
Il trapianto non può rappresentare la exit-strategy del fallimento della
VAD-therapy.

Amarelli SITO-SICCH Riunione Intersocietaria 2015

Recommended

Recommended

More Related Content

Similar to Amarelli SITO-SICCH Riunione Intersocietaria 2015

Similar to Amarelli SITO-SICCH Riunione Intersocietaria 2015 (20)

More from Cristiano Amarelli

More from Cristiano Amarelli (17)

Recently uploaded

Recently uploaded (20)

Amarelli SITO-SICCH Riunione Intersocietaria 2015