A Heart Transplant Patient’s Outline: Journey › ei › images › CSNZ19_Presentations... ·...

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Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, NZ

A Heart Transplant Patient’s

Journey......


Outline:

• A Transplant Patient's Journey. Tom Pasley

• Referral for Transplant: Who and when? Sarah Fitzsimons

• Psychosocial Assessment: Why is it Important?

Iris S. Fontanilla and Michael Stubbs

• Follow up and Outcomes. Cara Wasywich

• Questions and Panel Discussion


The Journey Begins…


• 2006: Female, age 26. Diagnosed with DCM, LVEF 42%. BMI 40. Heavy ETOH consumption

• 2010 Jan: First admission, NYHA III/IV. LVEF 10-15% (severe MR/TR). BMI 42 (120kg). Liaised with Transplant team. May: Gastric Banding. Dec: Weight 99kg, LVEF 33%

• 2011-2013: Stable. Exercising, decreased ETOH. LVEF 35%. NYHA I/II. Transplant assessment deferred

• 2014: 140kg, BMI 50. Admitted with decompensated HF. NYHA IV, LVEF 10-15%. Palliative care considered, but improved


2015: First Transplant Review

• Poor adherence to HF meds, with uncontrolled DM • Loose/no fluid restriction, 6 beers per day• Weight 111kg (BMI 39) • Stopped seeing local HF nurse specialist

• Not for further assessment. Multiple contra-indications for Transplant.

• Who and when should patients be referred for Transplant?


Referral for Heart Transplantation -who and when?

Sarah Fitzsimons Cardiologist

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Introduction

• Heart transplant effective treatment for advanced heart failure• Prognosis without it is dismal • Late referral

– World wide problem– Increases risk of right HF, renal and liver dysfunction, cardiac

cachexia• => Increase risk of poor outcome post HT or inability to be listed due to

advanced state

• Vital that the right patients are referred at the right time– Relies on cardiologists and HF nurses identifying potential

transplant candidates and understanding the assessment process


Who to refer?

The Journal of Heart and Lung Transplantation, Vol 36, No 5, May 2017


Not sure if your patient would benefit?

• Risk assessment–Seattle Heart Failure Score – 1 year survival <80%–Heart Failure Survival Score – medium to high risk

• Qualitative test to consider–TTE – RV dysfunction & rising pulmonary pressures (aim PASP <50mmHg)–Cardiopulmonary testing VO2 max<14 mls/min/kg

• Or decreasing 6min walk

–Cardiac index<1.8 L/min/m2


Who we can’t transplant• HIV/AIDS• Active or recent malignancy

– <5 years

• Active infection, acute PE, active peptic ulcer• Systemic disease with multi-system involvement

– Irreversible neurological disorder– Advanced RA

• Irreversible lung, liver or kidney disease– FEV1 <40% predicted– eGFR <40 ml/min/1.73 m2

• Non-compliance• Lack of social support


Who we shouldn’t transplant• Age >70 years

– >65 years need to have low co-morbid burden

• BMI >35 or <17• Diabetic end organ damage• Vascular disease• Active substance abuse

– Acute and no interaction previously with health services then can discuss IF likely to be able to abstain

– Recommended 6month abstinence

• Active mental health disorder


Indications for urgent inpatient referral

• Requirement of continuous inotrope infusion (or/and intra-aortic balloon pump (IABP)) to prevent multi-organ failure

• No scope for revascularisation in the setting of ongoing coronary ischaemia

• Persisting circulatory shock due to a primary cardiac disorder

• An absence of contraindications to transplantation

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LVAD an option?

• Bridge to transplant for transplant eligible patients

• Usually use if deteriorating whilst on list and suitable

• Can be used to reverse problems secondary to HF

– Renal dysfunction

– Pulmonary HTN

• In emergency situations may be used as a ‘bridge to decision’ to allow full assessment of the patient.


What we’d like in the referral• History of cardiac condition (including investigations and treatments) and current

symptomatic/functional status.• Medical/surgical Problem List: Cardiac and non-cardiac diagnoses should be listed• Medications (and medication intolerances if relevant)• Examination findings including height, weight and BMI• Current cardiac investigations (echocardiogram report, coronary angiogram

report, cardiac MRI report if performed)• Psychosocial history

– Tobacco/Alcohol/drug use– Support network– Heart failure self-management/adherence to medical therapy– Employment history/status


What happens following referral• Initial visit – an overnight visit

– Assess current clinical status

• Full assessment – a weeks visit– Blood tests, TTE, USS, RHC, psychosocial assessment– CPET

• Discussed at Transplant Selection Committee meeting– Multi-disciplinary team

• Accepted => Active listed – ~6/12 wait time


The Journey Continues…..


• 2016: Weight back to 118kg. Intermittent adherence. Significant social stressors: solo mum, unemployed, depressed.

• 2016-2017: Sleeve Gastrectomy with weight reduction to 90kg. Increased support (medical/social), improved adherence, NYHA II.

• 2017: 3 x ICD shocks (implanted 2015)


• 2017: Referred and Accepted for Full Transplant Assessment as BMI 32, adherence improved

• RHC: RA 6mmHg, MPA 14, PCWP 8, TPG 6, CO 4.74 L/min, PVR 1.26 WU• CPET: VO2 max 16.7 ml/kg/min. NYHA II.

• Psychosocial Assessment: A number of concerns raised• Transplant Selection: “Inactively listed”

• Advice to referring team: “Address psychosocial concerns”

• What does this mean and is it important??

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Psychosocial Assessmentof potential Heart Transplant

Recipients

Iris Fontanilla, Health Psychologist

Michael Stubbs Cardiology FellowGreen Lane Cardiovascular Service, Auckland City Hospital, Auckland, NZ


• PRE -Transplant: – Selection of patients for suitability for Transplant

– Maintaining psychological resilience/ distress

• POST – Transplant: – Maintaining psychological resilience/ distress

– Maintaining Adherence

• Medications

• Lifestyle changes

Psychosocial contribution: To Improve Outcomes in Heart Transplant


Selection : Assessment of Psychological Suitability


Selection : Assessment of Psychological Suitability

Who does well?

Those who are able to follow complex medical regimes

Those who are “Psychologically Resilient”

Best use of scarce resource

Best predictor of future behaviour is past behaviour


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Psychosocial factors that contribute to successful transplant outcomes.

What makes a “good” candidate

✓Ability to adhere/behave

✓Active participation & understanding

✓Manageable levels of psychological distress

✓Support – available & stable

✓Resilient, flexible, and adaptive



Use of SIPAT

• Patient’s readiness

• Social support system

• Psychological stability and

psychopathology

• Lifestyle and effect of substance

abuse

Scores•0 - 6 Excellent

•7 - 20 Good

•21 - 39 Minimally Acceptable

•40 - 68 High risk

•> 69 Poor

Maldonado et al., (2012, 2015) Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, NZ


Psychosocial declines


Substance use history

• ISHLT guidelines 2018– Active alcohol or drug abuse is a contraindication to

cardiothoracic transplantation and MCS– Active tobacco smoking is a contraindication to

cardiothoracic transplantation– Smoking cessation prior to MCS is recommended, but

not always possible due to patient acuity – abstinence is required post implant to be considered for transplantation

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TSANZ GUIDELINES

• Active substance abuse:

– If history of substance abuse, 6 months abstinence is mandated (with confirmatory blood testing if considered appropriate) before active listing is considered

– This includes smoking, excessive alcohol consumption, and illicit drug use


Smoking

• Smoking tobacco increases risk of:– Mortality (post Tx survival 16 years reduced to 12

years)– Allograft vasculopathy 21.2% vs. 12.3%– Malignancy 16.3% vs. 5.8%– HTN– Acute kidney injury– Pump thrombosis, GI bleeding and mortality with MCS


Impact of Smoking on Mortality


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25

50

75

100

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Surv

ival

(%

)

Years

Cigarette history (N=11,822) No cigarette history (N=13,319)

Adult Heart TransplantsKaplan-Meier Survival by Recipient Cigarette History

p<0.0001

(Transplants: July 2004 – June 2016)

2018JHLT. 2018 Oct; 37(10): 1155-1206


Alcohol

• Alcohol abuse and drug abuse increases risk of:– Mortality

– Medication non-adherence

– Mental health disturbance

– Driveline infections and hospital readmissions in MCS


Alcohol cardiomyopathy outcomes

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Cannabis• Evolving field (some new challenges with medicinal

cannabis)– Any substance abuse is associated with poorer outcomes– Inhaled marijuana increases risk of post transplant

infection, may be the source of fungal lung infections, psychosis

– Cannabis may alter metabolism of immune suppressants– Currently active cannabis use is a contraindication to

transplant


Abstinence

• Shorter duration of pre-transplant abstinence → higher risk of relapse, hence 6 months rule

• Alcohol and drug abuse run in families, and increase relapse risk


Social Supports

• Social isolation is not compatible with good outcome post transplantation

– Higher risk of treatment non-adherence, substance use and psychological disturbance

• Support needs to be reliable, capable and available for medium to long term


Perceived Social Isolation and Outcomes in Patients With Heart Failure, Volume: 7, Issue: 11, DOI: (10.1161/JAHA.117.008069)

Social isolation and heart failure


Obesity

• BMI >30 is not a contraindication, but is associated with poorer outcomes

• BMI >35 is an absolute contraindication


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1.0

1.5

2.0

2.5

20 25 30 35

Haza

rd Ra

tio of

20 Ye

ar M

orta

lity

Recipient BMI (kg/m2)

p < 0.0001

(N = 22,481)

Recipient BMIRisk Factors For 20 Year Mortality with 95% Confidence Limits

Adult Heart Transplants (1992-6/1997)

2018JHLT. 2018 Oct; 37(10): 1155-1206

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• PRE -Transplant: – Selection of patients for suitability for Transplant

– Maintaining psychological resilience/ distress

• POST – Transplant: – Maintaining psychological resilience/ distress

– Maintaining Adherence

• Medications

• Lifestyle changes

Psychosocial contribution: To Improve Outcomes in Heart Transplant


• Medication & Lifestyle

adherence

Post-Transplant


• Mood - depressed

• Cognitive functioning - memory

• How they feel “today” (maintenance medications)

Psychological Barriers to Adherence


Contrasts with “as needed” meds

“No symptoms, no problem”“I’m better now I don’t need it”

Maintenance medications – MT

Taking MT does not

necessarily make you

“feel better”

Missing MT does not

make you

(immediately) feel

worse

Potentially reinforces belief that MT don’t

matter/make a difference


Treatment/

medicationsIllness

Unintentional (30%) vs. Intentional non-adherence (70%)

Goodness of Fit

“FORGET?”


Doubts about

NECESSITYTREATMENT DOESN’T

MAKE SENSE

CONCERNS/

WORRIES about potential side/

adverse effects

Patients know what to do & how to do it

BUT are reluctant to adhere because either :-

Necessity v Concerns

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No difference - TX organ, ethnicity and time since TX

Best adherers

Older, male with good support, less educated

Moderate/Poor adherers

• More negative beliefs about medication concerns/side effects/harm

• More beliefs IS medication would not prevent rejection

• More reported Sx distress associated with TX

• Younger, female, poor support Kung et al., (2012)

Medication Adherence with Heart, Lung and Liver Transplant Recipients


• "My medication is part of my life and sometimes I do forget a dose but never want to stop. Otherwise life would stop. Life is too precious."

• I have experimented taking less or 1/2 the prescribed dose without doctors consent and had no problems".

• "…I believe I don't need the medication but continue to take it in respect of the doctor's advice...“

• “I had no problems at all with taking medication. Always have taken this very seriously…”

• “Just take pills as I think I need"

• "I sometimes self-dosed based on my knowledge.”

• "I have never followed the drug instructions precisely because it's impractical; I've always just been close to doing it properly”

Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, NZ Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, NZ

• 2017 - Oct 2018. Reviewed regularly at ADHB/Home DHB, ”Very stable”. Remained on inactive list

• October 2018: Three admissions over 6 weeks, with decompensated HF/LRTI. Discussed with Tx team during 3rd admission after minimal improvement on Dopamine/Levosimendan. Euvolaemic with weight 84kg

• Acutely transferred to ADHB:

- On arrival: Unwell… Very unwell. Milrinone trialed, but ongoing deterioration with end-organ dysfunction (INTERMACS 2)


• Updated Investigations. Echo: LVEF 15%. LVEDD 8.5cm. Mod RV dysfunction, severe TR.

• RHC: RA 23, M)PA 42, PCWP 34, TPG 8, CO 2.8 L/min, CI 1.15 L/min/m2 (On Inotropes)

• CCU: 3 x polymorphic VT arrests over 24 hours. Ongoing renal/liver dysfunction.

• Urgently discussed and accepted on “Active” Transplant list. However obvious concerns re imminent death: INTERMACS 2/Deteriorating End-Organ function/Refractory VT.

• “Urgent Listing” vs Mechanical Support (LVAD/ECMO) as bridge to Transplant.


LVAD

• OT: RA 28mmHg, Torrential MR/TR, Severe Biventricular failure.

Complications:• Early Tamponade • Slow Respiratory wean • 32 day ICU stay

• D/C hearty Towers. Severely deconditioned (62kg)

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• Stood down from Active list while recovering• Aggressive: PT/OT/Nutrition• Returned home

• Repeat RHC: RA 5, RV 26/7, PCWP 6, PA 26/10 (17). TPG 11. CO 5.75 L/min, PVR 1.74 WU

• February 2019: Re-presented and accepted for Tx

• Transplanted March. 2 day ICU stay. No complications. 9 day hospital stay


Post Transplant: • Now 3 months post Transplant

• Three episodes of 2R rejection. All treated with IV methylprednisolone and augmented immunosuppression. Current immunosuppression: Tacrolimus, Sirolimus, Mycophenolate and Prednisone

• Mild renal impairment, normal liver function. Weight 70kg

• Echo: Normal left/right ventricular size and systolic function

• The Future: Management and Prognosis post Transplant??


Heart TransplantFollow Up and Outcomes

Cara Wasywich, Cardiologist


Immediate Post Op Period• Establishment of immunosuppression

– Induction therapy– CNI, Mycophenolate mofetil, prednisone

• Recovery from surgery• Establishment of other supportive medications

– Aspirin, statin, antimicrobial prophylaxis

• In hospital education and physiotherapy• First biopsy and echocardiogram


Hearty Towers Rehabilitation• Daily exercise rehabilitation• Frequent clinic review

– At the time of biopsies– Additionally as required

• Management of early post transplant issues– Medication issues– Rejection– Surgical complications

• Gradual loosening of the apron strings


Requirements for discharge home• Adequate physical rehabilitation

– Should be able to walk to the top of One Tree Hill

• Stable medications• Absence of rejection and post operative complications

requiring on-going management• Usually occurs between 6 weeks and three months

post transplant• Support person required in Auckland for all of this time

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Long term follow up

• Shared care between Transplant Team and local cardiologist

• All post transplant follow up in Auckland for first year post transplant (aligned to biopsies)

• Four monthly follow in year two

• Six monthly or annual follow up thereafter (depending on local cardiology services)


Post transplant outcomes

To end 2017


Living well

• Most patients return to full functional capacity

– Education/work/sport

– Family life (including parenthood)

• Moderate treatment burden



Early mortality• Perioperative complications

– Primary graft dysfunction– Multi-organ failure– Sepsis– Early aggressive rejection

• Patient selection – Sick enough but not too sick

• Donor recipient matching– Blood group, body size, acuity

Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, NZSince only leading causes of death are shown, the sum

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

Adult Heart Transplants Relative Incidence of Leading Causes of Death

(Deaths: January 1994 – June 2017)

2018JHLT. 2018 Oct; 37(10): 1155-1206

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Medium term mortality

• Chronic rejection/allograft vasculopathy/graft failure

• Cancer

– Post transplant lymphoproliferative disease

– Skin cancer

– Solid tumours


Longer term mortality

• Diseases of ageing

– Renal failure

– Hypertension

– Diabetes

– Cerebrovascular disease


Aims of transplant medicine

• Improved patient survival

• Improved quality of life

• Full use of all donor organs

• Tension between adequate immunosuppression (prevention of rejection) and over immunosuppression (infections/cancers)



Summary of Case• Complicated patient, with a turbulent history, not unusual for patients with advanced

HF

• Emphasises the importance of medication adherence, weight loss, addressing psychosocial concerns early

• Significant contraindications initially, which were addressed with help of excellent local Cardiology service.

• ”Rescue” LVAD worked (just) and is an option as a bridge to transplant in the right patient. INTERMACS 2 not ideal situation, best to refer and implant early

• Was this a “success”?


Key Points• Ring us anytime. Patients on active/inactive list, unsure re timing of referral/suitability

• If in doubt, refer early or consider CPET or Survival scores to guide

• First presentation: Address/discuss medical contraindications for Transplant and review psychosocial factors

• Good social support is vital for patients pre and post Transplant

• LVAD is an option in NZ if suitable and once Transplanted, outcomes generally “good”!

• Post Transplant: Any concerns please ring us

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A Heart Transplant Patient’s Outline: Journey › ei › images › CSNZ19_Presentations... ·...

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