CHAPTER 3 HEART AND LUNG TRANSPLANTATION. Editors: Mr Mohamed Ezani Md. Taib Dato Dr David Chew Soon Ping Dr Ashari Yunus

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1 CHAPTER 3 HEART AND LUNG TRANSPLANTATION Editors: Mr Mohamed Ezani Md. Taib Dato Dr David Chew Soon Ping Dr Ashari Yunus Expert Panel: Mr Mohamed Ezani Md. Taib (Chairperson) Dr Abdul Rais Sanusi Datuk Dr Aizai Azan Abdul Rahim Dr Ashari Yunus Dato Dr David Chew Soon Ping Contents 3.0 Introduction 3.1 Stock and Flow of Heart Transplantation 3.2 Recipients Characteristics Demographics and Clinical Status Primary Diagnosis 3.3 Transplant Practices Type of Transplant Immunosuppressive Therapy and Other Medications Duration of Waiting Time on the Waiting List 3.4 Transplant Outcomes Post Transplant Complications Patient Survival Causes of Death

2 HEART AND LUNG TRANSPLANTATION National Transplant Registry 2014 List of Tables Table 3.1.1a: Stock and Flow of Heart Transplantation, Table 3.2.1a: Distribution of Patients by Gender, Table 3.2.2a: Distribution of Patients by Ethnic Group, Table 3.2.3a: Distribution of Patients by Age, Table 3.2.4a: Distribution of Patients by Primary Diagnosis, Table 3.3.1a: Distribution of Patients by Heart Procedure, Table 3.3.2a: Distribution of Patients by Immunosuppressive Used, Table 3.3.3a: Immunosuppressive Used at Time of Last Follow-up up to Table 3.4.1: Post Transplant Events at Last Follow-up up to Table 3.4.2: Post Transplant Malignancies at Follow-up up to Table 3.4.3: Non-compliance at Follow-up up to Table 3.4.4: Patient Treated for Rejection at Follow-up up to Table 3.4.5a: Distribution of Patients by Time of Deaths, Table 3.4.6: Patient Survival, Table 3.4.7: Cause of Death at Discharge, Table 3.4.8: Cause of Death at Follow-up, Table 3.1.1b: Stock and Flow of Lung Transplantation, Table 3.2.1b: Distribution of Patients by Gender, Table 3.2.2b: Distribution of Patients by Ethnic Group, Table 3.2.3b: Distribution of Patients by Age, Table 3.2.4b: Distribution of Patients by Primary Diagnosis, Table 3.3.1b: Distribution of Patients by Heart Procedure, Table 3.3.3b: Immunosuppressive Used at Time of Last Follow-up up to Table 3.4.5b: Distribution of Patients by Time of Deaths, List of Figures Figure 3.1.1a: Stock and Flow of Heart Transplantation, Figure 3.4.6: Patient Survival, Figure 3.1.1b Stock and Flow of Lung Transplant and Heart Lung Transplant

3 National Transplant Registry 2014 HEART AND LUNG TRANSPLANTATION 3.0 INTRODUCTION The first heart transplant in Malaysia was in 1997, and the first lung transplant was in Since then the numbers of thoracic transplants have remained few and far between. For end stage heart failure patients, the use of left ventricular assist device (LVAD) as a bridge to heart transplant has been employed, to keep patients alive when their condition deteriorated while on the heart transplant waiting list. In 2014, there was only one thoracic organ transplant (heart transplant) performed. After 16 years since heart transplantation started in Malaysia, this option for the treatment of patients with end stage heart failure remains limited in availability. The Kaplan Meier survival curve is 54% at 1 year and 44% at 5 years. Most patients succumb early post heart transplant. The rest of the report that follows review the results of heart and lung transplantation in Malaysia till end of

4 HEART AND LUNG TRANSPLANTATION National Transplant Registry 2014 HEART TRANSPLANTATION 3.1 STOCK AND FLOW Table 3.1.1a: Stock and Flow of Heart Transplantation, New transplant patients Deaths Retransplanted Alive at 31 st December Note: The same patient was re-transplanted in the year 2007, thus only counted as one Figure 3.1.1a: Stock and Flow of Heart Transplant,

5 National Transplant Registry 2014 HEART AND LUNG TRANSPLANTATION 3.2 RECIPIENTS CHARACTERISTICS Table 3.2.1a: Distribution of Patients by Gender, TOTAL Gender n n n n n n n n n n n n n n n n n n n Male Female TOTAL Note: The same patient was re-transplanted in the year 2007, thus only counted as one Table 3.2.2a: Distribution of Patients by Ethnic Group, TOTAL Ethnic group n n n n n n n n n n n n n n n n n n n Malay Chinese Indian TOTAL Note: The same patient was re-transplanted in the year 2007, thus only counted as one Table 3.2.3a: Distribution of Patients by Age, TOTAL Age, years n n n n n n n n n n n n n n n n n n n TOTAL Mean SD Median Minimum Maximum Age=date of transplant-date of birth Note: The same patient was re-transplanted in the year 2007, thus only counted as one Age for 2007 patient was same for 1 st and 2 nd transplant Table 3.2.4a: Distribution of Patients by Primary Diagnosis, TOTAL Primary diagnosis n n n n n n n n n n n n n n n n n n n Ischaemic Cardiomyopathy Idiopathic Dilated Cardiomyopathy Restrictive Cardiomyopathy End Stage Valvular Heart Disease Hypertrophic Cardiomyopathy Others * 4 TOTAL *Non ischemic dilated cardiomyopathy Note: The same patient was re-transplanted in the year 2007, thus only counted as one 5

6 HEART AND LUNG TRANSPLANTATION National Transplant Registry TRANSPLANT PRACTICES Table 3.3.1a: Distribution of Patients by Heart Procedure, TOTAL Heart Procedure n n n n n n n n n n n n n n n n n n n Orthotopic Bicaval Orthotopic Traditional TOTAL Table 3.3.2a: Distribution of Patients by Immunosuppressive Used, Total Type of immunosuppressive n n n n n n n n n n n n n n n n n n n Steroids Prednisolone Methylprednisolone Calcineurin Inhibitors Neoral Tacrolimus (FK506) Antimetabolites Azathioprine (AZA) Mycophenolate Mofetil (MMF) Anti-lymphocyte Receptor Antibodies Anti-thymocyte globulin (ATG) Simulect TOTAL patients at notification Table 3.3.3a: Immunosuppressive Used at Time of Last Follow-up up to 2014 of follow up* Type of immunosuppressive n n n n n n n n n n n Steroids Prednisolone Methylprednisolone Everolimus Calcineurin Inhibitors Neoral FK Antimetabolites Azathioprine (AZA) Mycophenolate Mofetil (MMF) Everolimus TOTAL patients at follow-up *Data according to year of follow up of transplanted patients 6

7 National Transplant Registry 2014 HEART AND LUNG TRANSPLANTATION Table 3.3.4a: Duration of Waiting Time on Waiting List, TOTAL Duration (months)* n n n n n n n n n n n n n n n n n n n < TOTAL Mean SD Median Minimum Maximum *Duration=date of transplant-date added to wait list 3.4 TRANPLANT OUTCOMES Table 3.4.1: Post Transplant Events at Last Follow-up up to 2014 of transplant* Type of post transplant events Drug Treated Hypertension Bone Disease (Symptomatic) TOTAL n n n n n n n n n n n n n n n n n n n Chronic Liver Disease Cataracts Diabetes Renal Dysfunction Stroke Drug-Treated Hyperlipidaemia TOTAL patients at follow-up *Data according to year of transplant of patient 7

8 HEART AND LUNG TRANSPLANTATION National Transplant Registry 2014 Table 3.4.2: Post Transplant Malignancies at Follow-up up to 2014 of transplant* TOTAL Type of post transplant n n n n n n n n n n n n n n n n n n n malignancies Donor related Recurrence of pretransplant tumor De novo solid tumor De novo lymphoproliferative Skin Total patients at follow up *Data according to year of transplant of patient Table 3.4.3: Non-compliance at Follow-up up to 2014 of transplant* TOTAL Non-compliance during follow-up n n n n n n n n n n n n n n n n n n n Yes No TOTAL patients at follow-up *Data according to year of transplant of patient Table 3.4.4: Patient Treated for Rejection at Follow-up up to 2014 of transplant* TOTAL Patient treated for rejection n n n n n n n n n n n n n n n n n n n Yes No TOTAL patients at follow-up *Data according to year of transplant of patient Table 3.4.5a: Distribution of Patients by Time of Deaths, of discharge TOTAL Time of deaths* n n n n n n n n n n n n n n n n n n n <3 months (at discharge) <6 months months-1 year >1 year TOTAL patients who died *Time=Date of death date of transplant 8

9 National Transplant Registry 2014 HEART AND LUNG TRANSPLANTATION Table 3.4.6: Patient Survival, of Transplant Interval % Survival SE 1 year year year year Figure 3.4.6: Patient Survival,

10 HEART AND LUNG TRANSPLANTATION National Transplant Registry 2014 Table 3.4.7: Cause of Death at Discharge, TOTAL Cause of death n n n n n n n n n n n n n n n n n n n Hyperacute rejection Multi organ failure Respiratory failure secondary to septicaemia Respiratory failure, renal function and liver failure, ARDS, septicaemia Septicaemia, multiorgan failure Graft failure Severe Pneumonia TOTAL patients who died at discharge

11 National Transplant Registry 2014 HEART AND LUNG TRANSPLANTATION Table 3.4.8: Cause of Death at Follow-up, TOTAL Cause of death n n n n n n n n n n n n n n n n n n n Severe bleeding Lung cancer, small cell type bronchopneumonia Rejection due to non compliance Sudden death due most likely to graft CAD Unknown TOTAL patients who died at follow up

12 HEART AND LUNG TRANSPLANTATION National Transplant Registry 2014 LUNG TRANSPLANTATION Table 3.1.1b: Stock and Flow of Lung Transplantation, New Heart and Lung Transplant Patients New Lung Transplant Patients Deaths Alive at 31 st December Figure 3.1.1b Stock and Flow of Lung Transplant and Heart Lung Transplant 12

13 National Transplant Registry 2014 HEART AND LUNG TRANSPLANTATION 3.2 RECIPIENTS CHARACTERISTICS Table 3.2.1b: Distribution of Patients by Gender, TOTAL Gender n n n n n n n n n n n Male Female TOTAL Table 3.2.2b: Distribution of Patients by Ethnic Group, TOTAL Ethnic group n n n n n n n n n n n Malay Chinese Indian Bumiputra Sarawak TOTAL Table 3.2.3b: Distribution of Patients by Age, TOTAL Age, n n n n n n n n n n n years TOTAL Age=date of transplant-date of birth Table 3.2.4b: Distribution of Patients by Primary Diagnosis, TOTAL Primary diagnosis n n n n n n n n n n n Idiopathic pulmonary fibrosis Idiopathic pulmonary arterial hypertension Chronic obstructive pulmonary disease Bronchiectasis Others * TOTAL * ventricular septal defect (VSD) and Eisenmenger s syndrome 13

14 HEART AND LUNG TRANSPLANTATION National Transplant Registry TRANSPLANT PRACTICES Table 3.3.1b: Distribution of Patients by Thoracic Transplant Procedure, TOTAL Heart Procedure n n n n n n n n n n n Single lung transplant Double lung transplant Heart-Lung tranplant TOTAL Table 3.3.3b: Immunosuppressive Used at Time of Last Follow-up up to 2014 of follow up* Type of immunosuppressive n n n n n n n n n n Steroids: Prednisolone Methylprednisolone Calcineurin Inhibitors: Neoral FK506 (Tacrolimus) Antimetabolites: Mycophenolate Mofetil (MMF) TOTAL patients at followup *Data according to year of follow up of transplanted patients 3.4 TRANSPLANT OUTCOMES Table 3.4.5b: Distribution of Patients by Time of Deaths, of discharge TOTAL Time of deaths* n n n n n n n n n n n <3 months (at discharge) <6 months months-1 year >1 year TOTAL patients who died *Time=Date of death date of transplant 14