13-09-2008 BWGHF Liège

Heart transplantation 2008

Evolution of life expectancy at birthin Belgium

source: NIS

number of procedures and donor shortage

current results cost remaining problems perspectives

NUMBER OF HEART TRANSPLANTS REPORTED BY YEAR

189 317665

1182

2158

2710

31373362

4001 4171 4197 4365 4439 4399 4263 41673833

3563 3410 3367 3269 3180 3026 3095

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Nu

mb

er

of

Tra

ns

pla

nts

ISHLT 2007

NOTE: This figure includes only the heart transplants that are reported to the ISHLT Transplant Registry. As such, this should not be construed as evidence that the number of hearts transplanted worldwide has declined in recent years.

J Heart Lung Transplant 2007;26: 769-781

U.S. Waiting List Registrations 1998-2007

0

1000

2000

3000

4000

5000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007Year of Snapshot

Nu

mb

er

of

Re

gis

tra

tio

ns

Heart Lung Heart-LungHeart - Active Lung - Active Heart-Lung - Active

Source: OPTN and UNOS

U.S. Wait List Death Rates 1998-2007

0

2

4

6

8

10

12

14

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Heart Lung

Pe

rce

nt

Source: OPTN and UNOS

heart transplantation in Belgium

heart transplantation in Belgium

28 4

19

37

8093

127

108

154

124130

115

98111116

96 9184 81 80

87

71 69 69 70

'82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06

1 3 4 5 6 7 N active centers

Eurotransplant region

1967

2007

2000

Donor and Transplant Statistics 2007

0

5

10

15

20

25

30

2001 2002 2003 2004 2005 2006 2007

Austria

B elg ium

G ermany

Netherlands

S lovenia

Eurotransplant annual donor rate pmp

ET waiting list for HTx

ET HTx waiting list mortality

0

50

100

150

200

250

300

350

1995 1997 1999 2001 2003 2005 2007

Mortality on the heart waiting list

263 241 225 244 187

82 83 6039 39

193 155 147 104 101

0%

20%

40%

60%

80%

100%

2003 2004 2005 2006 2007

inactive elective urgent

source: www.optn.org and Eurotransplant Annual Reports

61 75 61 93 76

109 112 118141 102

24 35 34 29 36

0%

20%

40%

60%

80%

100%

2003 2004 2005 2006 2007

USA

ET

538 479 432 387 327

194

222 213 263 214

0.92→0.47 pmp

~1.23pmp

the expert help of Jacqueline Smits is gratefully acknowledged

reporting of potential donors in Belgium

137 138 136 156 151 155 179208

175209

238 217 202 213242

271 292

366152 147 149

185 187152

163171

162

190158

148143

162149

167

209

175

0

50

100

150

200

250

300

350

400

450

500

550

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

n d

on

ors

Donor Hospitals Txp C enters

Donor and Transplant Statistics 2007 - 20/03/2008

national waiting list 31/12/2007: non-renal

78 80

102

159

184

243 249

185

166

34 33 35 40 33 34 32 29 2832 3042

5159

4660 56 52

18 16 1930 27

37 34 3037

0

50

100

150

200

250

300

1999 2000 2001 2002 2003 2004 2005 2006 2007

Y ear

n pa

tient

s

L iver

Heart

L ung

P ancreas

+219% -34%

patient and donor age

0

10

20

30

40

50

0- 10 11- 17 18- 34 35- 49 50- 59 60+

patients

donors

%

♀♂

patients donors

vrouw

18%man

82%

vrouw

29%man

71%

Congenital2%

ReTX2%

Myopathy45%

Misc.3%

Valvular3%

CAD45%

1/1982-6/2006

DIAGNOSIS IN ADULT HEART TRANSPLANTS

203040506070

% o

f Cas

es

Myopathy CAD

CAD38%

Valvular2%

Misc.10%

Myopathy45%

ReTX2%

Congenital3%

1/2003-6/2006

ISHLT 2007 J Heart Lung Transplant 2007;26: 769-781

reason for transplantation

CADCMPreHTxothercongenitalvalvular

‘87-’93 ‘94-’00

’01-’07

HEART TRANSPLANTATION Kaplan-Meier Survival (1/1982-6/2005)

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Years

Su

rviv

al

(%)

Half-life = 10.0 yearsConditional Half-life = 13.0 years

N=70,702

ISHLT 2007

N at risk at 22 years: 33

HEART TRANSPLANTATION Kaplan-Meier Survival (1/1982-6/2005)

J Heart Lung Transplant 2007;26: 769-781

01/01/08

survivalsurvival

%%

yearsyears

the expert help of A. Belmans and of H. Ector, MD, PhD is gratefully acknowledged

0

10

20

30

40

50

60

70

80

90

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

REMATCH

gen. pop.

ISHLT

HTx UZL

Overall graft survival rates by country,

corrected for local vs non-local donor, urgency status, CIT and VAD

5060708090

100

0 3 6 9 12

Adults, first heart only transplants in ET, in 1997 (N=665)

5060708090

100

0 3 6 9 12

Crude rates Corrected rates

P=0.0007 P=0.004

Post-transplant time (m) Post-transplant time (m)

ET meeting’99_JS.31

- Belgium- The Neth.- Austria- Germany

Mortality rates after heart transplantation.How to compare centre-specific outcome data ?

Crude centre effects, case-mix adjusted (with 95% CI). Centres sorted by transplant volume

-6

-4

-2

0

2

4

6

8

10

12

1 2 2 3 8 8 9 9 11 11 11 11 13 13 17 17 17 18 18 19 23 26 26 26 26 26 26 26 26 32 33 39 41 41 43 43 44 45 46 53 60 75 90 127

140

volume (24-months period)

GO

OD

B

AD

Ln(RR)

Smits JMA et al. Transplantation 2003;75:90-6.

cost/QALYcurrency amount source year

HTx - adults

- children

US $ 1992

US $ 2004

~45,000

~50,000

NL

US

2003

2006

dialysis US $ 2003

CAN $

€

84 – 108,000

71 – 125,000

54 – 60,000

US

CA

Greece

2000

2003

2007

LVAD US $

₤

36 – 86,000

40,000

UK

UK

2008

2005

ICD US $ 2005 34 – 70,000 US 2005

CRT-P

-D

₤

₤

~17,000

~24,000

UK

UK

2007

2007

statins - 2°

- 1°

₤

₤

10 – 17,000

20 – 48,000

UK

UK

2007

2007

01/01/08

acute rejection year 1acute rejection year 1

0

5

10

15

20

25

30

35

40

45

50

'87

'89

'91

'93

'95

'97

'99

'01

'03

'05

'07

% pts

17.4%

FREEDOM FROM CARDIAC ALLOGRAFT VASCULOPATHY AND FREEDOM FROM SEVERE RENAL DYSFUNCTION* For Adult Heart Recipients (Follow-ups: April 1994-June 2006)

0

10

20

30

40

50

60

70

80

90

100

0 1 2 3 4 5 6 7 8 9 10

Years

Freedom from CAV (N= 18,278)

Freedom from Severe Renal Dysfunction (N= 20,115)

* Severe renal dysfunction = Creatinine > 2.5 mg/dl, dialysis or renal transplant

% F

ree

do

m f

rom

CA

V o

r F

ree

do

m

fro

m S

ev

ere

Re

na

l D

ys

fuc

nti

on

ISHLT 2007 J Heart Lung Transplant 2007;26: 769-781

FREEDOM FROM MALIGNANCYFor Adult Heart Recipients (Follow-ups: April 1994 - June 2006)

50

60

70

80

90

100

0 1 2 3 4 5 6 7 8 9 10

Years

All malignancy Lymph Skin Other

% F

ree

fro

m M

ali

gn

an

cy

ISHLT 2007 J Heart Lung Transplant 2007;26: 769-781

perspectives

xenotransplantation

improved mechanical support systems(BTT, destination therapy, bridge to recovery ?)

new drugs PSI (sirolimus, everolimus)

monitoring through gene expression profiling rejection (acute and chronic)

tailored immunosuppression