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IN THE SPOTLIGHT: ISHLT 2015 Recapitulation: Summary of the Plenary Sessions at ISHLT 2015

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Vincent Valentine, MD
University of Texas Medical Branch
Galveston, TX, USA

The inimitable Andreas Zuckermann opened the 35th Annual ISHLT Meeting Plenary Sessions in the South of France by assuring that everyone will be famous for 15 minutes - Andy Warhol. Andreas pointed out that the meaning of Zuckermann in English, Sugarman, now who are you calling "sucker?" In his Program Chair Report, 2900 attendees represents the largest gathering of any ISHLT meeting outside North America. An all-time record of 1706 abstracts were submitted with 61% accepted. There is continued expansion of emerging nations from the Middle East, Asia, Eastern Europe and South America up another 3.5%. With that, two Emergent Regions Concurrent oral sessions and one Emergent Regions Poster session have been added to the slate. A shout out was made to having more abstracts submitted from Latin American countries and the Middle East and, overall, 59% of the abstracts were from the United States and 21% from western Europe. He went on to describe his year as Program Chair as being as difficult as traversing a huge mountain in Austria. With a good team, he managed to ascend the steepest cliffs and celebrate at the top, but he warned us of the treacherous descent resulting in surgery, a cast and confinement. The silver lining of this mishap was that it allowed him to dedicate more time to the ISHLT and the meeting. Amanda Rowe recognized that Andreas has set a precedence for future Program Chairs to dedicate more time to the ISHLT and the upcoming meeting. Among the highlights of his summary was how he chose the program committee. Picture three overlapping rings: 1) Dream big, 2) Get shit done and 3) Know how to have fun - Andreas pointed out that the people he preferred were those who possessed elements from all three rings. He concluded his summary with a demand - Go to the Sessions and not to the Beach!!!

After the Program Chair's report, the Thoracic Registry and MCSD Reports were delivered by Drs Josef Stehlik and James Kirklin. Josef began the 32nd Annual Report with a Focus theme of Early Graft Failure - Mortality or Retransplantation within 30 days of transplant. Now over 40% of patients who underwent heart transplant were previously supported by LVAD. The hazard ratio of 30-day early graft failure in heart transplant correlates unfavorably with increasing donor age by multivariable analysis. Donor age just above 30 crosses unity then up to just under age 55 where the risk of 30-day early graft failure doubles. Also, freedom from chronic allograft vasculopathy has improved over the last decade when compared to the prior decade from 85% to 86% at 5 years which although statistically significant (0.03), may not be clinically significant. Nevertheless, there has been an obvious drop in early graft failure from 3% to 1% in the last 5 - 7 years. The proportion of children undergoing heart transplantation from mechanical support is close to 30%, most from VAD support. In lung transplantation, the incidence of early graft failure has shown improvement from 2005-2008 to 2009-2013 eras. There has been a 35% reduction in incidence to 2% at 30 days in the most recent era. Those undergoing lung retransplantation are twice as likely to experience 30-day early graft failure at 4%. Josef concluded his report showing the strength of the US Dollar versus the Euro increasing nearly 25% over the last 12 months.

Dr. Kirklin outlined the MCSD report with a review of its history, acknowledgements, an important point on its governance, enrollment update and some data from implants. From January 2013 - December 2014 there have been nearly 6000 implants, 87% between 40 - 80 year olds with nearly two-thirds from Intermacs profiles 2 and 3, progressive decline (sliding) or stable but dependent on inotropes, respectively. About 55% are bridged to either transplant or candidacy and another 40% are implanted for destination therapy. An LVAD is used 93% of the time. The one-year survival is 80%. Most deaths are related to multisystem organ failure, neurologic causes, heart failure, infection and hemorrhage. Jim concluded that the first IMACS annual report will be submitted for publication very soon with a detailed analysis of adverse events and the first multivariable risk factor analysis.

Herman Reichenspurner followed with his Presidential Address focusing on "Our Obligations Toward the Next Generation through Youth and Enthusiasm." Throughout his presentation, he showed the importance of the Platforms provided by ISHLT, plus an individual's enthusiastic contribution, can result in an opportunity for a Career within ISHLT. The International Society, which began as a small gathering of about 15 cardiologists and cardiac surgeons in 1981, has grown to its internationally diverse membership of over 3000 members, representing nearly 50 countries, who manage patients with end-stage heart and lung diseases across the globe. ISHLT has broadened its scope from transplantation to mechanical support and replacement. There is enthusiasm with research, high quality scientific meetings, and an important scientific journal along with many research grant possibilities sponsored by our Society. For individual involvement, there are 11 different Councils with the Council for Junior Faculty Trainees highlighted for our youth. Each Council functions independently with similar structure and workforces along with unified term limits for consistency within our expanding Society. The Junior Faculty Council in particular emerged in 2008 as an independent council for the interest of our younger members. Activities and symposia are now part of the Annual meeting giving many opportunities for our youth to be involved. There is now an international transplant fellowship database, a "job board" and an online repository of teaching slide sets in thoracic transplantation. Hermann highlighted the Grants and Awards Program and displayed the past recipients of the Caves Award. He also pointed out the importance of the International and Inter-Society Coordination Committee (I2C2) and its role in facilitating liaisons with other organizations in order to develop joint standards and guidelines with other medical and scientific societies. With an International vision there have been provisions to work with governmental organizations such as the Ministries of Health and grant funding organizations which have opened doors to exchange scientific information and collaboration. Finally, he summarized the Board actions including the creation of a Governance Task Force and the initiation of a Strategic Planning Process. Hermann paralleled his personal experience and ascendency to this year's President with the evolution and expansion of ISHLT. He summarized for emphasis that ISHLT provides the ideal platform for young clinicians and scientists, but it requires Youth and Enthusiasm, as demonstrated by the Federal Youth Ballet, choreographed by John Neumeier.

In tune with the expectations of high quality health care with focus on certain never events, Wolfgang Müller-Pietralla, who heads the department of Future research and Trend Transfer within the Volkswagen Group from Wolfsburg, Germany, delivered his innovative presentation of Vision ZERO - Cutting Edge Technology for Ultimate Protection. He demonstrated a Volkswagen driving on auto-pilot with many high tech feature and sensors to reduce automobile accidents, thus exemplifying the focus on safety; a lesson we must take from the automobile industry and apply to health care in ISHLT for the safety of our patients.

The Pioneer Lecture, From Allogeneic to Xenogeneic Heart and Lung Transplantation - A 30-Year Journey, was given by Bruno Reichart. He captivated the audience with his opening slide and references to Hotel Le Negresco and Lewis Carroll's little Alice asking the Cheshire cat, "Would you tell me, please, which way I ought to go from here?" The cat, forever grinning from ear to ear, responds, "That depends a good deal on where you want to get to." Bruno recounted his experience with the ever quotable Norman Shumway, who teaches us "nothing is routine," "the best way to predict the future is to invent it," and "xenotransplantation will be the future - and always will be." Bruno shared with us the importance of animals for what we do, from anti-lymphocyte globulin produced by Bavarian horses to research on piglets, rhesus monkeys and baboons. Along the way, he displayed the similarities of hearts from the white, black and yellow patients with reference to the United Colors of Benetton to reiterate the combat against the culture of hatred in all forms. He described his accomplishments and experience from Cape Town, across South Africa and then to "the toaster" - Grosshadern Hospital of Ludwig-Maximilians-University (LMU) in Munich. His notable contributions included, among others, the possibility of cardiac xenotransplantation, improvement of lung preservation with low-potassium, and the use of simvastatin on chronic allograft vasculopathy. He concluded with the importance of bringing together immunologists, bio-engineers, virologists, primatologists, ethicists and clinicians by coordinating the Collaborative Research Center at LMU which included the Technical Universities of Munich and Dresden, the Medical University of Hannover, researchers at the Helmholtz Center in Munich, the Friedrich Loffler Institute, the German Primate Center, the Paul Ehrlich Institute and the Robert Koch Institute.

The second day of the Plenary sessions was opened by Francis Delmonico MD, Professor Surgery, Harvard Medical School, Executive Director of Istanbul Custodian Group, Advisor of the World Health Organization, Medical Director of the New England Organ Bank, and Professor Willem Weimer of Erasmus Medical Center in Rotterdam.

Dr. Delmonico put together the Declaration of Istanbul on Organ Trafficking and Transplant Tourism and presented his talk on Fighting Transplant Commercialism: The Impact of the Declaration of Istanbul. He informed us that organ trafficking is a highly lucrative business, a global phenomenon, and is possibly underestimated at up to 10%. He advocated for all of us to prohibit transplant commercialism because it targets the impoverished and vulnerable leading to inequity or injustice. Transplant tourism is to be forbidden by law. He referred us to - Organ Trafficking and Transplant Tourism: The Role of Global Professional Ethical Standards - The 2008 Declaration of Istanbul. Transplantation 2013; 95:1306-12. The WHO Guiding Principle of Transparency advocates such practices while simultaneously ensuring personal anonymity and protecting the privacy of donor and recipients. He also referred us to the recent article on Organ Transplantation for nonresidents of the United States: a policy for transparency. Am J Transplant 2014; 14:1740-3. Now that we are educated, we must advocate and participate by fighting against such transplant-related atrocities which are criminal. We must play a pivotal role.

Professor Weimer's presentation was on Tackling Transplant Commercialism: A Criminological Approach. His main message was: It is just not enough to say "STOP." Human Organ Transplant Commercialism is a billion dollar industry, rounding out the top ten just behind the gold industry. From a survey of nearly half transplant professionals in The Netherlands who had treated patients who traveled abroad for kidney transplantation, 70% were either suspicious or certain that the kidney was purchased. He suggested what works to guard against using a "top-down" and "bottom-up" approach. Bottom-up measures include: dissuade patients from purchasing organs from abroad, advocate for health insurance regulations, encourage patients to bring their donors from abroad and simplify national visa procedures for kidney transplantation. Also, we must strive for self-sufficiency by expanding living kidney donation, optimizing deceased donation, participating in home-based education programs, removing disincentives to donate, implementing incentives to donate such as lifelong health insurance exemption. Top-down measures, though controversial, might include withholding medical records or refusing care and disclosing patient information to the authorities, particularly when there are threats. From the referenced article, Policy Statement of Canadian Society of Transplantation and Canadian Society of Nephrology on Organ Trafficking and Transplant Tourism, Transplantation 2010;90:817-20, "Physicians should not prescribe medications or otherwise facilitate obtainment of medications that will be used during the transplantation of a purchased organ?"

Later on the second day, April 17, 2015, we had the Annual Business Meeting. Our Editor-in-Chief of the Journal, Dr. Mandeep Mehra described the rise of the source normalized impact per paper (SNIP) measure, which weighs citations based on the number of citations in a subject field. He pointed out that "all citations are not created equal." The SCImago Journal Rank (SJR) showed a near doubling in three years. This measure ranks journals by "average prestige per article." He further showed that the relative impact of mechanical support and citations increased by 250%. The primary features of the Journal we can expect include: State of Art Series, Junior Faculty Engagement, Online Video Content and Supplementary Material, Thematic Issues, the New Cover and the Virtual Microscope.

Stuart Sweet delivered the Treasurer's Report, showing a near doubling of the net worth of ISHLT in six years. Key plans for 2015 include: support of disciplined financial decision making, oversee an ISHLT audit and evaluate changing the Society's investment policies to apportion some of our excess fund balance for income generation.

On the final day of Plenary Sessions, I did not attend. The Awards Presentations were scheduled, followed by Consensus Reports on Antibody Mediated Rejection in Lung Transplantation, given Dr. Debbie Levine, and Listing Criteria in Heart Transplantation by Dr. Mandeep Mehra. The Plenary Sessions ended with what I am very sure was a lively debate by our talented and illustrious speakers, Heather Ross and Marshall Hertz on The Q's: Quagmire of The Quantity/Quality Quandary; Live Long, Don't Prosper version by Heather and Live Fast, Die Young by Marshall. I am sorry I missed this, but it did conjure up, at least in my mind, James Dean and his immortalized quote, "Dream as if you'll live forever. Live as if you'll die today." ■

Disclosure Statement: The author has no conflicts of interest to disclose.

References: All photos taken by Christian Roy.

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