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Heart Transplant: From Soup to Nuts Connecticut Society of Medical Assistants Conference March 25, 2017 Lynn O’Bara, APRN Nurse Practitioner Heart Transplant Program at Hartford Hospital History • First Transplant at Hartford Hospital was in November 20, 1984 (almost 33 years ago as of 11/2017) by Dr. Henry Low. The recipient was about 30 years old at the time of his transplant; he is doing well now in his 60’s. • World's longest-surviving heart transplant • The man who held the Guinness World Record for longest surviving heart transplant patient died , 33 years after his life-saving operation. (Published February 11, 2016 FoxNews.com) • John McCafferty, 73, underwent the transplant on October 20, 1982 at Harefield Hospital in West London, BBC News reported. At 39, he was diagnosed with dilated cardiomyopathy. • McCafferty was originally told he'd have five years to live when he received the transplant. • Cause of death: Sepsis and Renal failure Outline • Pre-Transplant Phase: will discuss pre-transplant evaluation/process to determine candidacy • Transplant Phase: Considerations of donor options/matching donor and recipient; surgery; inpatient recovery • Donor/recipient communication and considerations • Post Transplant phase: Recipient’s “new normal” and considerations in the first year and beyond • Post transplant complications – concerns for their future Survival Data Post Transplant • Survival: • 1 year survival: 88% • 5 year survival: 75% • 10-year survival: 56 % • Post heart transplant most patients return to their normal levels of activity; < 30 % return to work for many different reasons • Above from the NIH website; updated 1/3/2012 • HH SRTR (national heart transplant registry data (December 2015 data looking at Tx from 7/1/13 – 12/31/2015): • HH Graft survival observed: 95.65; expected 89.37 with National graft survival rates of 90.21 • HH patient survival observed: 95.65; expected 89.81 with National graft survival 90.52 Pre-Transplant Phase • Number of candidates on waitlist for heart transplant as of 3/24/17 at 8:05 am: 3,999 • Waiting for life saving organ: 118, 214 • Transplant (all) performed January/February 2017: 5,367 • Total # of donors for this time period: 2,554 • HH heart waitlist has approximately 18 candidates waiting • Above per OPTN data Deaths on Waitlist • Region 1 (CT, ME, MA, NH, RI): In 2016 there were 284 deaths • All 11 regions/entire US: 6,248 deaths in 2016 • Thus far in 2017 Region 1: 35 deaths; All regions: 936 • Organ Donation is important! Indications for Transplant • End stage cardiomyopathy due to refractory cardiogenic shock, dependence on IV inotropes for adequate organ perfusion, and/or peak O2 consumptions (VO2)less or equal than 10 mg/kg/min with achievement of anaerobic threshold. • Severe symptoms of ischemia that consistently limit routine activities/not amendable to bypass surgery • Recurrent symptomatic ventricular arrhythmia refractory to all therapeutic modalities • Peak VO2 of 11 to 14 mg/kg/min (or less than 55% of predicted) and major limitations of pt’s daily activities done by Cardiopulmonary Stress Test (CPET) • Recurrent unstable angina ischemia not amenable to other interventions • Recurrent intractable heart failure symptoms with hemodynamic instability and fluid balance +/- cardio-renal syndrome Alternatives to Transplant = Heart Failure Treatments • PO medications (Beta Blockers, ACE Inhibitors, Diuretics) • Continuous IV medications • LVAD/Mechanical circulatory support • Hospice/Palliative Care LVAD – Left Ventricular Assist Device or Mechanical Circulatory support Heart TX Waitlist Status • Status 1A: ICU on multiple IV inotropes or high dose single inotropes OR ventilated OR LVAD complication • Status 1B: Low dose IV inotropes (can be at home); all VAD pts (without complications) • Status 2: Poor prognosis (CPET shows peak MVO2 less than 14 mg/kg/min; usually home on PO medications) • Status 7: ON HOLD; not active which happens for various reasons • This is under review/discussion and most likely will be changing in the next year or 2 Heart Transplant Evaluation • Cardiac/Vascular Testing • • • • • • • Cardiopulmary stress test (CPET) Right heart catheterization Left heart catheterization (if applicable) Echocardiogram EKG Carotid u/s ABI • Pulmonary Testing • CXR • PFT • TB testing (TB quant) • Laboratory Testing: Viral Serologies (CMV, EBV), LFT, CBC, Comprehensive Metabolic Panel, Nutrition Labs (Vitamin D, Albumin, Prealbumin, Transferrin, Total Protein), Lipid panel, Hgb A1C, BNP Heart Transplant Evaluation • • • • • • Vaccines/consult with ID MD (Dr. Lawlor) Cancer Testing: PSA, Mammograms, PAP smears, Colonoscopy, CT scan of chest esp if previous surgeries Dental Consult Bone health: DEXA and Vitamin D Consults with Transplant Team: Social Worker, Psychologist, Financial Coordinator, Dietitian/RD, Pharmacist, Transplants surgeon, Transplant cardiologists • Consents/Regulatory documents: Multi-listing Brochure, SRTR data, Surgical Consent, Donor Option Consent, Process Consents • Tissue Typing (HLA/PRA)/ABO MDC Meeting • Transplant team meets to discuss candidacy for listing • All team members weigh in • Teams: surgeon, cardiologist, financial coordinator, social worker, psychologist, dietitian, RN, APRN, pharmacist, patient’s PCP and/or cardiologist • Need to be sure no financial or social issues MDC Decision 1. List: Determine STATUS (1A, 1B, 2; usually never list at UNOS STATUS 7 which is inactive status) 2. Not to list 3. List once additional testing/consults obtained and patient cleared Patient gets a letter regarding listing status (Listed or Not Listed) Contraindications to TX • Poor prognosis that Transplant will not fix • Cancers (relative) • Irreversible and severe hepatic or renal disease (unless combined transplant) • Active HIV with viral load or opportunistic infections • Fixed pulmonary HTN • Severe Lung disease • Severe vascular disease • Unmanageable psychiatric disorder The Waiting Game • Patients are Months to Years on wait list depending on ABO, Status (1A, 1B, 2) • Patient needs annual renewal of transplant evaluation (update work up as needed) • Patients are recommended to discuss any travel (outside a few hours form HH) with the team; if STATUS 1A – we recommend NO traveling • Patients have access to the transplant team during this time; this includes social worker, finance coordinator, dietitian, psychologist. These pts are invited to our transplant support group • Patients NEED to call if they anticipate any insurance changes; this is EXTREMELY important so that we can be sure both transplant and post care is covered Sensitized Patients • Increased PRA – panel reactive antibodies • PRA can increase with blood products, pregnancies, LVAD • Desensitizing protocols: Complicated with risk The Call…We have a donor! • Pt is called and needs to be NPO going forward • Pt will either come in or wait by the phone for further instructions • OR time is dependent on donor considerations, travel times, and procurement team considerations • We make every effort to protect both donor and recipient anonymity; only donor information that may affect the outcome is given to recipient. This information may include extended donor criteria (age > 45; less than perfect heart – valve issue/CAD, PHS increased risk donor) Donor considerations • Matching size of donor with size of recipient (don’t want to put small heart in big space or vice versa) • Donor age and history (PHS increased risk) • Ischemic Time (ideally less than 4 hours); consider travel time • Quality of organ Transplant Phase • Surgery times vary; longer times if LVAD is being explanted • Surgery is has similar course as any open heart surgery • Patients recover on B9I and then to B9E • Patients require inotropes in the immediate post op period to assist the heart • As with most heart surgeries post heart transplant also have chest tubes, external pacemaker • Usually extubated within 24 to 48 hours • Post heart TX pts require diuresis post transplant Orthotopic Heart Transplant Transplant Phase • Need to watch for sinus node dysfunction; initially paced • Arrhythmias are uncommon and if any ventricular or atrial arrhythmias are noted post transplant may be associated with rejection • Heart is denervated during transplant therefore lack of parasympathetic tone which leads to higher than average resting heart rates and decrease in heart rate variability • Over time reinnervation will occur but at varying degrees amongst transplant recipients. • Bicaval approach; no longer see extra P wave as noted in Biatrial aproach Patient Education • Start as soon as possible with Medications • Transplant RN/APRN will also continue transplant education that started in the PRE transplant phase • Transplant Dietitian will also see pt for education re: food safety/heart healthy diet • Patient receive Heart Transplant Binder in the PRE TX phase • Education topics: Reducing infection risks, Nutrition/food safety, Incision care, Emotional Care (donor considerations/Prednisone), Activity (all pts expected to participate in Cardiac Rehab), Medication, Complications and s/s to look for, Emergency access, and first year restrictions (no new pets/plants, no traveling, no renovations) Transplant Education • Nutrition education • • • • Clean, Separate, Cook and Chill Water safety Heart healthy diet Discourage eating out for the first 6 months to one year post transplant = defer to RD • Dietitian: Charlotte Meucci, RD Donor/Recipient Communication • Minimal information given to Donor/Recipient about each other • Benefits of loss of anonymity: • Emotional Impact • Opportunity of recipient to express joy and gratitude • Identifying or humanizing with a person whom you may have had an extended anonymous relationship • Control and empowerment • Ease of direct contact (removing middle man) • An opportunity to share the family member with the donor family • Increasing Donation Donor/Recipient Communication • Risks of loss of anonymity: • Emotional impact • Unpredictable consequences (unwanted communication/unable to end contact) • Differences – cultural, religious, moral, social • Pain, sadness, resentment, a feeling of responsibility for the donor family • Difference in response in family members • Anxiety that family member may not think the recipient was worthy of the gift • Anxiety about what to say/do • Decreasing donation • Recipient/Donor families may need to sign a “consent” when with loss of anonymity Donor/Recipient Communication • Video…… Post Transplant Complications • Surveillance: • • • • Regulary office visit/follow up – weekly initially Echocardiogram: Ultrasound of the heart EKG/electrocardiogram Regular biopsies as follows: • • • • Weekly X4 Every other week X4, Monthly X3, Every other month X3 Endomyocardial Biopsy Echocardiogram EKG Types of Rejection 1. Acute Cellular Cellular rejections: diagnosed by looking at heart tissue obtained during biopsy 2. Antibody Mediated Rejecion 3. Hyperacute rejeciont: less common; happens minutes/hours post transplant; usually do to PRA/ABO 4. Chronic /Cardiac Allograft Vasculopathy Chronic - Cardiac Allograph vasculopathy (CAV): diagnosed with angiogram/IVUS 5. Antibody mediated rejection (AMR) /non cellular: diagnosed using blood test looking for donor specific antibodies and/or immunostaining of heart tissue obtained from biopsy • Importance of taking immunosuppression as directed – keep a list and do NOT go by medications bottles (frequent titration of meds) Acute Cellular Rejection • Acute rejection common; as you get further for transplant decreased risk • S/S: heart failure (left or right); arrhythmias, fever, syncope • Grading system: • 0R No rejection • 1R 1A/1B/2 mild; interstitial and/or perivascular infiltrate with up to 1 focus of myocyte damage • 2R 3A moderate; 2 or more foci of infiltrate with associated myocyte damage • 3R 3B/4 severe; diffuse infiltrate with multifocal myocyte damage +/- edema, hemorrhage, vasculitis • Greater than 2R is very concerning Cont. Complications…Infection • First year balancing rejection and infection • CMV/ cytomegalovirus: Pt on Valcyte esp if CMV mismatch; s/s GI complaints and neutropenia common • On prophylaxis; duration varies based on immunosuppression • Reduce infection risk with masks, etc usually just in the first year • Neutropenia is common (usually drug related) Post Transplant Complications • Cancers: needs routine screenings (colonoscopy, gender appropriate screening, dermatologist for routine skin checks, sunscreen) • Osteoporosis (increased risk DT steroids): DEXA scans, Vitamin D levels; DT HH pre transplant initiated we have reduced post transplant fractures • Hypertension/Hyperlipidemia: all pts on pravastatin or other statin • CAV – Left heart cath/angiogram at one year and 4 years post transplant; may include IVUS (measures intimal thickness) • Mood: anxiety/moodiness/depression can be prednisone driven; also consider pt has to process where the heart came from • Elevated blood sugars/diabetes: Common even if not diabetic pre transplant Post transplant • First year is intense for pts – poly pharmacy, many appts (labs, office visits, biopsies, Cardiac Rehab, etc); may settle a bit at 6 month mark; by one year at their “new normal” • Patients may return to work when ready – usually they need a year; some go back within months • F/u care includes: • office visits with transplant team, • last routine biopsy is at 2 years (one year, 18 mos, 2 year) • Allomap testing done btw year 1 and 2 q 3 mos with echo and then after 2 years every 6 months w/ echo • CAV surveillance: left heart cath one year and 4 years post transplant; with stress tests on “off” years/annually • Don’t under estimate the affect of prednisone on patients – post heart transplant we use HIGH doses Questions regarding Heart Transplant Patients • Email me with Questions: [email protected]