From Devices to Donors: What’s New in HF From the 2016 International Society of Heart and Lung Transplantation Meeting
August 25, 2016 | Nisha Gilotra, MD
The home of the ACC in the nation’s capital was buzzing this spring with nearly 4000 attendees from all over the world for the 36th Annual International Society of Heart and Lung Transplantation (ISHLT) Scientific Sessions.
Many FITs attended and presented their work via oral or poster presentations. Below are highlights from the meeting addressing the current hot topics of next generation left ventricular assist device (LVAD) therapy and methods of increasing the heart transplant donor pool:
Coverage of mechanical circulatory support hasgained momentum over the last few years at the ISHLT meetings. This year, an update on results from the Heartmate 3 CE mark trial were presented. The Hearmate 3 is the latest LVAD from Thoratec, now St. Jude. Like HeartWare’s HVAD, the Heartmate 3 is a centrifugal pump with a fully levitated magnetic impeller. What’s new about it is that it incorporates an artificial pulse for intermittent pulsatility in an attempt to enhance hemocompatibility. Data presented from the CE Mark trial described results of 50 European patients (54 percent bridge to transplant and 46 percent destination therapy). There were no incidents of hemolysis, pump thrombosis or pump malfunction during the first year. Notably, there was an 18 percent stroke rate. Both six minute walk test distance and quality of life improved post-implant. The new pump is currently under investigation in the U.S. in the MOMENTUM trial.
Heart failure (HF) cardiologists and cardiothoracic surgeons strive to pick the perfect time for LVAD placement: too early and a patient may not gain the potential benefits, too late and a patient may not fare well with the surgery. It is understood that patients who are critically ill or close to it do not have good outcomes, and therefore there is a push to identify patients that may need LVAD therapy earlier. The Risk Assessment and Comparative Effectiveness of LVAD and Medical Management in Ambulatory HF Patients (ROADMAP) study demonstrated better survival with improved functional class in ambulatory patients undergoing LVAD who were not inotrope-dependent. At the ISHLT meeting, the two-year endpoints of this 200 patient randomized observational study were presented. The primary endpoint was the percent alive on original therapy with improvement in six minute walk distance of at least 75 meters. Patients undergoing LVAD reached this endpoint at statistically significantly higher frequency (30 vs. 12 percent at two years). The ROADMAP trial provides evidence for providers to discuss the potential benefits of LVAD therapy with patients earlier in their disease course, when still stable but with known poor long-term prognosis due to HF.
Donation After Cardiac Death Hearts: An Approach to Increasing the Donor Pool
Heart transplantation is limited by the supply of suitable organs. Despite a growing HF population, the number of heart transplants has remained relatively stagnant in the U.S. over the last several years. There was much focus at this year’s ISHLT meeting on how to broaden the donor pool. One of the sessions, co-chaired by Jon A. Kobashigawa, MD, FACC, chair of ACC’s HF and Transplant Member Section Leadership Council, and Maria Crespo-Leiro, PhD, was dedicated to strategies to improve organ utilization. Kiran Khush, MD, reviewed discussions from the recent U.S. (Philadelphia, PA, May 2015) and European (Brussels, September 2015) Donor Management Consensus Conferences, pointing out that sometimes regulatory issues limit suitability of donors (i.e., concern for effect on program outcomes in setting of current standards). There was also much discussion on the use of hearts from donors after circulatory death, and Kumud Dhital, PhD, described the Australian experience using this approach. Though the first ever heart transplants were performed using donation after cardiac death (DCD) hearts, with the formalization of brain death in the 1970s, this has not been the case for several decades. The first contemporary DCD hearts were performed in October 2014 at St. Vincent’s Hospital in Sydney. The organ assessment and procurement strategy is of utmost importance as these organs suffer warm ischemic time prior to organ harvest, in contrast to donors after brain death. Researchers across the world, including the U.S., are examining how to improve and potentially employ this strategy in a more widespread fashion in the future.
This article was authored by Nisha A. Gilotra, MD, a fellow in training (FIT) at Johns Hopkins School of Medicine.