Download CARDIAC TRANSPLANTATION

CARDIAC
TRANSPLANTATION
Dr V Jonker
Dept Cardiothoracic Surgery
University of the Free State
HISTORY
 1905 Alexis Carrel, Charles Guthrie canine
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heterotopic cardiac transplantation
1960 Norman Shumway, Richard Lower orthotopic
canine model – surgical technique
1964 James Hardy first human cardiac
transplantation with chimpanzee xenograft
1967 Christiaan Barnard first human-to human
cardiac transplantation
1970 Recipient selection standardized
1977 Distant donor heart procurement
1980 Cyclosporin A
 ISHLT 2000-2500 transplants annually
 US waiting list 2y
 Selection Status 1a,1b, 2
 Added alterations on blood type( type O),
body size (<30% mismatch), status level and
duration on level
BASIC OBJECTIVE
 Prognosis < 50% without transplantation
 To id relatively healthy patients, with
end stage cardiac disease,
refractory to medical therapies, with potential
to resume a normal active life and
maintain medical compliance
INDICATIONS
 Systolic HF
EF< 35%
 IHD with intractable angina
 Intractable arrhythmia
 Hipertrophic CM
 Congenital heart disease without severe fixed
PHT
CONTRAINDICATIONS
 Absolute
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Age > 70y
Fixed PHT with
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PVR > 5 Woods units
TPG >15mm/Hg
Systemic illness that will limit survival
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CA other than skin
HIV/ AIDS
SLE/ Sarcoid – Active/ multisystem involvement
Irreversible renal/ hepatic dysfunction
CONTRAINDICATIONS
 Relative
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PVR/ CVA
COPD
PUD/ Diverticulitis
IDDM with TOD
Past CA
Active alcohol/ drug abuse
Psychiatric illness- non compliant
Absence of psychosocial support
Patient Selection - UNOS
 Based on survival & quality of life expected to be gained
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compared to medical/ surgical alternatives
Patients considered: re-evaluated 3 monthly
Status 1A
 Mechanical circ. Assist
 Mechanical circ. Support >30d + complications
 Mechanical ventilation
 Continuous high dose inotropes + LV monitoring
 Life expectancy < 7d
Status 1B
 L/RVAD > 30d
 Continuous inotropes
Status 2
 Not 1A/ 1B
PREREQUISITES
 55-65 Y
 Optimal medical management
 ACE-I
 Beta Blockers
 Digoxin
 Aldosterone
 Treat surgically reversible causes
 CABG
 Valves
 Remodeling
 CRT
RECIPIENT MANAGEMENT
 General assessment
 Cardiovascular assessment
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Functional capacity
Hemodynamic assessment
 Assessment of Etiology
 Immunologic evaluation
 Infectious disease screening
 Psychosocial evaluation
RECIPIENT MANAGEMENT cont.
(1.General)
 Principle : exclude and manage reversible
causes
 General assessment
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Systemic approach and evaluation
 Blood work
 Kidney, liver, thyroid profile + other indicated
 Diabetes - TOD
 Pulmonary function tests (CI’s) :
 FEV1/ FVC < 40-50%
 FEV1
<50 %
RECIPIENT MANAGEMENT cont.
(2.Cardiovascular assessment)
 Functional capacity – Transplant indication
 pVO2 (VO2 max)
< 14-15mL/kg/min
 pVO2
< 55%
 If pVO2 > 15mL/kg/min- biannual evaluation
 Hemodynamic assessment
 RHC
 Evaluate severity and prioritize
 PHT evaluation – Assess reversibility
 Guide therapy while waiting
 6-12 months if stable Sx, too well for transplantation
 3 monthly if PHT present
RECIPIENT MANAGEMENT cont.
(3. Etiology)
 ECG, Holter, Echo, Angio
 PET, Thallium, MRI
 Endomyocardial biopsy
RECIPIENT MANAGEMENT cont.
(4.Immunologic)
 ABO typing + AB screen
 HLA typing
 Panel reactive AB level
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If PRA > 10%: Prospective cross match
If PRA > 25% : Preop Plasmapheresis, iv
immunoglobulins, cyclophosphamide
RECIPIENT MANAGEMENT cont.
(5. Infective disease screening)
 Hep A, B, C
 Herpes
 HIV
 Toxoplasmosis
 Varicella
 Rubella
 E Barr
 Tuberculin skin test
RECIPIENT MANAGEMENT cont.
(6. Psychosocial)
 Organic/ Psychiatric illness
 Differentiate from cognitive deficit secondary
to low CO
 20 % Px non compliant
 Alocohol, tabacco
 Stop smoking 6m prior to being considered
DONOR MANAGEMENT
 Assessment & evaluation
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History & physical exam (trauma, “down time”, CPR)
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ABO
Time of death
Cause of brain death
Viral serology
Drug/ alcohol abuse
Hemodynamic evaluation
Pressor/ inotropic support
Urine output
CPK,Troponin
12 lead ECG
Echocardiogram
Coronary angio
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Male > 40y
Female > 45y
DONOR SELECTION
 Ischaemic Time
 Age
 Size
 Cardiac Fx/ Use of inotropic support
 Expansion for marginal dodors
1. Ischaemic Time
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Cold ischaemia +/- 4 hours
Mortality especially older donors
Graft vasculopathy
Innovatavive approaches
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Glutamate/aspartate infusate
Controlled warm blood cardioplegia
Block intracellular Ca overload
Preserve intracellular adenosine levels
 Paediaric time polonged
 Smaller- improved preservation
 Physiological age, scarring
 Less inotropic support
 Absence of hypertrophy
2. Age
 Was 30 years
 Now up to 50-55 years
 ISHLT additional measures minimize risk
 Older- graft vasculopathy
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Undetected CAD
Age-related endothelial dysfunction
 Newer immunosuppressive agents – older
donors
3. Size
 Donor-recipient mismatch < 30 %
 Use body weight to estimate body size
 Undersized
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Gradual increase in LV mass
Risk in PHT – Post transplant RV
 Oversized
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Problematic only in
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Acute massive MI
Multiple previous cardiac operations- adhesions
4. Cardiac Fx/ Inotropic support
 No set exclusion criteria
 Individualize
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Age
Underlying anatomy
5. Expansion: Marginal donors