Transplantation pulmonaire et Hypertension pulmonaire

26/09/2012
Colloque SSPH 2012
Transplantation
pulmonaire et
Hypertension
pulmonaire
JD Aubert, Service de Pneumologie
Agenda
• Transplantation pulmonaire pour
l’h
l’hypertension
t
i artérielle
té i ll pulmonaire
l
i
• Transplantation pulmonaire pour des
pneumopathies chroniques compliquées
par une hypertension pulmonaire
• (Transplantation cardiaque en cas
d’hypertension pulmonaire post capillaire
« hors de proportion »)
1
26/09/2012
BREATHE-1: Analysis of survival
Event-free (%)
100
Treatment
125/250 mg bid
75
Placebo
50
25
p < 0.05 at weeks 16 and 28
0
0
4
8
144
69
142
68
141
63
12
16
20
24
28
138
62
103
48
31
10
25
7
Patients at risk
13 Bosentan
3 Placebo
Time (weeks)
Rubin LJ, et al. N Engl J Med 2002; 346:896-903.
2
26/09/2012
ISHLT
ISHLT
BREATHE-1: Analysis of survival
Event-free (%)
100
Treatment
125/250 mg bid
75
Placebo
50
25
p < 0.05 at weeks 16 and 28
0
0
4
8
144
69
142
68
141
63
12
16
20
24
28
138
62
103
48
31
10
25
7
Patients at risk
13 Bosentan
3 Placebo
Time (weeks)
Rubin LJ, et al. N Engl J Med 2002; 346:896-903.
3
26/09/2012
The impact of baseline FC
on patient outcomes
100
p = 0.0001
0 0001
Survival (%)
80
FC I/II (n = 139)
60
FC III (n = 268)
40
FC IV (n = 77)
(
)
20
0
0
1
2
3
Time (years)
4
5
Kane G, et al. Chest 2011; 139:1285-93.
4
26/09/2012
5
26/09/2012
Problèmes péri-opératoires
• Lésions d’ischémie-reperfusion du greffon
• Défaillance cardiaque droite à l’induction
• Défaillance cardiaque gauche après
l’implantation (dysfonction diastolique)
• Dysfonction d’autres organes: cirrhose
cardiaque/médicamenteuse,
di
/ édi
t
iinsuffisance
ffi
rénale….
6
26/09/2012
Transplantation: Current recommendations
(2008 consensus and 2009 ESC/ERS Guidelines)
• Medical treatment is mandatory, but should not delay
lung transplantation
• Appropriate patients in FC IV must be referred
• Appropriate patients with veno-occlusive disease or
pulmonary capillary haemangiomatosis should be
referred to a lung transplantation centre after diagnosis
• Timing for transplantation will be influenced by waiting
times, functional class, exercise capacity and treatment
response
Keogh AM, et al. J Am Coll Cardiol 2009; 54:S67-S77.
Galiè N, et al. Eur Heart J 2009; 30:2493-537.
7
26/09/2012
8
26/09/2012
Validation of the REVEAL risk score:
Long-term mortality in PAH
The REVEAL score* was calculated for 484 PAH patients at
baseline and was proportional to long-term mortality
Survival (%)
S
100
80
1 – 4 (n = 84)
60
5 – 6 (n = 140)
40
7 – 8 (n = 159)
20
0
(
)
9 (n = 48)
≥ 10 (n = 53)
p < 0.0001
0
1
2
3
4
Time (years)
5
Kane G, et al. Chest 2011; 139:1285-93.
*Benza RL, et al. Circulation 2010; 122:164-72.
9
26/09/2012
10
26/09/2012
Stratégie opératoire
• Un poumon ?
• Deux poumons ?
• Cœur-poumons ?
11
26/09/2012
12
26/09/2012
Centre Universitaire Romand de Transplantation
DONNÉES
É
LOCALES
13
26/09/2012
Répartition des diagnostics
2003-2012. N= 141
COPD
CF
IPF
PAH
Other
Centre Lausanne Genève de TX pulmonaire
Centre Lausanne Genève de TX pulmonaire
14
26/09/2012
The Toronto experience
15
26/09/2012
Hypertension pulmonaire de
catégorie 3 ou 5 et transplantation
COPD patients with PH have reduced
survival compared to those without PH
1
0.9
Survival rate
0.8
0.7
0.6
0.5
0.4
p < 0.001
0.3
02
0.2
No PH
PH
0.1
0
24
48 72 96 120 144 168
Time (months)
Minai O, et al. Chest 2010; 137:39S-51S.
16
26/09/2012
A1
fbalse
20
abstract
stractt(text)
Cystic Fibrosis and PH
J Cardiovasc Surg (Torino). 2012 May 28. [Epub
ahead of print]
p ]
Pulmonary hypertension is
associated with higher
mortality in cystic fibrosis
patients awaiting lung
transplantation.
Venuta F, Tonelli
F Tonelli AR, Anile M, Diso
AR Anile M Diso D, De D De
Giacomo T, Ruberto F, Russo E, Rolla M, Quattrucci S, Rendina EA, Li Phd N, Coloni GF.
Source
Department of Thoracic Surgery, La Sapienza
University of Rome, Rome, Italy ‐
[email protected].
Sarcoidosis and PH
Presse Med. 2012 Jun;41(6 Pt 2):e303‐16. Epub 2012 May 18.
Pulmonary hypertension complicating sarcoidosis.
Pulmonary hypertension complicating
sarcoidosis
Nunes H, Uzunhan Y, Freynet O, Humbert M, Brillet PY, Kambouchner M, Valeyre D.
Source
University Paris 13, UPRES EA 2363, Assistance publique‐Hôpitaux de Paris, Avicenne Hospital, Department of Pneumology, 93009 Bobigny, France. [email protected]
“PH
PH carries a poor prognosis in sarcoidosis
carries a poor prognosis in sarcoidosis
patients, with a significantly increased morbidity and mortality”
17
26/09/2012
Sarcoidosis and PH: data from the
Swiss Registry
N= 22
G. Verdi, 2012 SSPH International meeting, 27.09.12
Evaluation of pulmonary arterial pressure in lung transplant candidates:
transthoracic echocardiography versus right heart catheterization
Jesica Mazza Stalder, Fréderic Lador, Paola M. Soccal, John‐David Aubert
Lausanne‐Geneva Lung Transplantation Centre, Switzerland
Table 1. Patients characteristics
Characteristics
Mean age (years)
Sex ( female/male)
N=47
50.4 (22-66)
27/ 20
COPD
29
Cystic fibrosis
8
Pulmonary hypertension
4
¾ Idiopathic
2
¾ Thromboembolic
1
¾ Sarcoidosis
1
Others
8
Single lung transplant
9
Double lung transplant
38
18
26/09/2012
Table 2. Mortality in absence vs presence PHT
Right heart
catheter n=20
< or = 25 mmHg
Right heart
catheter n=25
>25 mmHg
Mortality
at 30 days
1/20
1/25
NS
Mortality
at 1 year
1/20
2/25
NS
600
6-MWT metres
sPAP - RHC mmHg
60
40
20
0
400
200
0
No tricuspid jet evaluable
0
25
50
75
100
125
sPAP - RHC
19
26/09/2012
IMPACT DE L’HYPERTENSION
PULMONAIRE SUR
L’ALLOCATION DES ORGANES
ABM
SOAS
LAS
3.6
7.01
4.5
TTemps moyen en 135
liste (j)
2082
148
% décès en liste
10.3
10.02
14
% poumons acceptés
17
422
36
HTAP cat 1
À la discrétion
du transplanteur
Priorité de niveau 3
+3.6 points *
HTP cat 3/5
idem
Priorité de niveau 3 si
NYHA > III sous ttt
+ 0.55 points *
Nb LTX/10E6
Comparé à BPCO sans HTAP
20
26/09/2012
Pour conclure
• La transplantation pulmonaire est une
option
ti pour les
l patients
ti t avec HTAP ne
répondant pas au traitement médical
• L’HTP compliquant une pneumopathie
chronique en aggrave le pronostic
• Ces patients doivent être référés
suffisamment tôt à un centre de transplantation
21