Download Heart Transplant Powerpoint - Connecticut Society of Medical

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
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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
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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
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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:
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Regulary office visit/follow up – weekly initially
Echocardiogram: Ultrasound of the heart
EKG/electrocardiogram
Regular biopsies as follows:
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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]