Cardiac Cardiac TransplantationTransplantation

By Samantha Glase and Angela By Samantha Glase and Angela WarnockWarnock

ABSOLUTE CRITERIA ABSOLUTE CRITERIA FOR RECIPIENT SELECTIONFOR RECIPIENT SELECTION

Class III or IV on New York Heart Class III or IV on New York Heart Association Functional Classification of Heart Association Functional Classification of Heart DiseaseDisease

–Marked limitation of physical activityMarked limitation of physical activity–Less than ordinary physical activity or rest Less than ordinary physical activity or rest results in fatigue, palpitation, dyspnea, or anginaresults in fatigue, palpitation, dyspnea, or angina–Aerobic capacity less than 11 mL O2 per kg per Aerobic capacity less than 11 mL O2 per kg per minmin

No end-organ damage from diabetes No end-organ damage from diabetes mellitusmellitusNo active cancer for at least five yearsNo active cancer for at least five years

ABSOLUTE CRITERIA ABSOLUTE CRITERIA FOR RECIPIENT SELECTION, contFOR RECIPIENT SELECTION, cont

Pulmonary vascular resistance less Pulmonary vascular resistance less than 15 mm Hgthan 15 mm Hg

No contraindications to No contraindications to immunosupressionimmunosupression

Limited life expectancyLimited life expectancy– No severe disease of other organs No severe disease of other organs

(especially kidneys, liver, lungs)(especially kidneys, liver, lungs)

RELATIVE CRITERIA RELATIVE CRITERIA FOR RECIPIENT SELECTIONFOR RECIPIENT SELECTION

Less than 65 years old Less than 65 years old No ComorbiditiesNo Comorbidities

– Diabetes mellitus (steroids to prevent infection Diabetes mellitus (steroids to prevent infection make glucose control difficult)make glucose control difficult)

– Obesity (BMI <35)Obesity (BMI <35)– Certain Infectious DiseasesCertain Infectious Diseases

Physical Rehab PotentialPhysical Rehab Potential– FVC > 50% of predicted and FEV1 > 1 LiterFVC > 50% of predicted and FEV1 > 1 Liter– AmbulatoryAmbulatory

Psychosocial FactorsPsychosocial Factors– No evidence of substance abuse (alcohol, drug, No evidence of substance abuse (alcohol, drug,

smoking)smoking)– Able and willing to complyAble and willing to comply– Psychological stabilityPsychological stability– Social support system in placeSocial support system in place

CRITERIA FOR DONOR CRITERIA FOR DONOR SELECTIONSELECTION

Looking for ways to expand these criteria to include Looking for ways to expand these criteria to include more donors to decrease waiting time and deaths more donors to decrease waiting time and deaths while waiting. while waiting.

Individual recently died or brain deadIndividual recently died or brain dead AGE: LESS THAN women 40-50 years, men 40-45AGE: LESS THAN women 40-50 years, men 40-45

– new trials using hearts up to 55 years old in both new trials using hearts up to 55 years old in both gendersgenders

Donor gave permission prior to death and donor’s Donor gave permission prior to death and donor’s family consentsfamily consents

Acceptable Ventricular VolumeAcceptable Ventricular Volume No evidence of cancerNo evidence of cancer No evidence of heart trauma or cardiac diseaseNo evidence of heart trauma or cardiac disease No severe infection, HIV, or hepatitis B No severe infection, HIV, or hepatitis B

MATCHING DONOR AND MATCHING DONOR AND RECIPIENTRECIPIENT

United Network for Organ Sharing United Network for Organ Sharing (UNOS) responsible for matching (UNOS) responsible for matching donors to recipientsdonors to recipients

CriteriaCriteria– Blood type compatibleBlood type compatible– Donor heart ischemic time less than five Donor heart ischemic time less than five

hours (geographical restraints)hours (geographical restraints)– Body weight within in 20% (size of the Body weight within in 20% (size of the

heart similar)heart similar)

DONORS NEEDEDDONORS NEEDED

Median waiting time for Median waiting time for transplant is 200 days and many transplant is 200 days and many patients die waiting.patients die waiting.

Factors affecting waiting timeFactors affecting waiting time– blood type—O longest and AB blood type—O longest and AB

shortest waitshortest wait– weightweight– health statushealth status– gender—males longestgender—males longest

HETEROTOPIC HETEROTOPIC TRANSPLANTATION TRANSPLANTATION

PROCEDUREPROCEDURE

““Piggyback Procedure:” Performed only when Piggyback Procedure:” Performed only when the donor’s heart is too small or too weak to the donor’s heart is too small or too weak to pump the blood on its own or with extreme pump the blood on its own or with extreme pulmonary hypertension. pulmonary hypertension.

The original right ventricle pumps the blood The original right ventricle pumps the blood through pulmonary circulation while the donor’s through pulmonary circulation while the donor’s left ventricle pumps blood throughout the body. left ventricle pumps blood throughout the body.

This type of procedure includes increased risk This type of procedure includes increased risk of death and lower lobe atelectasis. of death and lower lobe atelectasis.

It accounts for 1% of all heart transplants, but It accounts for 1% of all heart transplants, but may be a way to increase the donor pool to may be a way to increase the donor pool to include smaller hearts.include smaller hearts.

ORTHOTOPIC ORTHOTOPIC TRANSPLANTATION TRANSPLANTATION

PROCEDUREPROCEDUREAccounts for 99% of all heart transplants. Recipient’s heart is Accounts for 99% of all heart transplants. Recipient’s heart is

removed (except for a portion of the atria) and the donor heart is removed (except for a portion of the atria) and the donor heart is attached.attached.

PROCEDUREPROCEDURE The heart is removed from donor with vessels being transected as The heart is removed from donor with vessels being transected as

far away from the heart as possible (e.g. pulmonary artery at far away from the heart as possible (e.g. pulmonary artery at bifurcation, inferior vena cava at diaphragm). The heart is stored in bifurcation, inferior vena cava at diaphragm). The heart is stored in cold saline until ready for transplantation.cold saline until ready for transplantation.

Recipient’s sternum is cut open with striker saw and pericardium is Recipient’s sternum is cut open with striker saw and pericardium is opened.opened.

The recipient’s heart is incised along the atrioventricular groove so The recipient’s heart is incised along the atrioventricular groove so that a portion of both atria are preserved, which is theorized to that a portion of both atria are preserved, which is theorized to preserve atrial contractility, SA node function, and tricuspid valve preserve atrial contractility, SA node function, and tricuspid valve function. function.

The aorta and pulmonary artery are removed at the valves leading The aorta and pulmonary artery are removed at the valves leading out of the heart.out of the heart.

ORTHOTOPIC ORTHOTOPIC TRANSPLANTATION TRANSPLANTATION PROCEDURE, contPROCEDURE, cont

The donor left atria is opened (incision The donor left atria is opened (incision through the pulmonary veins) and through the pulmonary veins) and attached to the recipient’s residual left attached to the recipient’s residual left atria. The right is done in a similar atria. The right is done in a similar fashion.fashion.

The great vessels are then attached. The great vessels are then attached. De-airing occurs before the final vessel De-airing occurs before the final vessel (the aorta) is closed.(the aorta) is closed.

Often an adjustable (controls on the Often an adjustable (controls on the outside) pacemaker is implanted outside) pacemaker is implanted during the operation.during the operation.

Pericardium left open to save timePericardium left open to save time Sternum closed with wireSternum closed with wire

VIDEOVIDEO

http://www.ctsnet.org/realmedia/ohttp://www.ctsnet.org/realmedia/oht1.ram ht1.ram

SURVIVAL RATESSURVIVAL RATES

Three Months 90%Three Months 90% One YearOne Year 85% 85% Three YearsThree Years 79% 79% Five YearsFive Years 70% 70% Ten YearsTen Years 50% 50%

FAILURE OF FAILURE OF TRANSPLANTTRANSPLANT

Transplantations are unsuccessful for two Transplantations are unsuccessful for two main reasons: infection and rejection. main reasons: infection and rejection.

INFECTIONINFECTION Leading cause of death immediately Leading cause of death immediately

after surgeryafter surgery Decreased incidence after two years Decreased incidence after two years

post operationpost operation Most often due to bacterial or viral Most often due to bacterial or viral

infection, rarely fungalinfection, rarely fungal

REJECTIONREJECTION

GENERAL FACTSGENERAL FACTS Most patients will experience an Most patients will experience an

episode of rejection at least once.episode of rejection at least once. Body’s immune system attacks Body’s immune system attacks

donated heartdonated heart Result of a failure of Result of a failure of

immunosuppressant therapyimmunosuppressant therapy

SIGNS OF REJECTIONSIGNS OF REJECTION

endomyocardial biopsy shows endomyocardial biopsy shows abnormal results (diagnostic)abnormal results (diagnostic)– routine biopsies performed frequentlyroutine biopsies performed frequently

Low grade feverLow grade fever Rapid decrease or increase in blood Rapid decrease or increase in blood

pressurepressure Easily fatiguedEasily fatigued Change in heart rate or rhythmChange in heart rate or rhythm

IMMUNOSUPPRESSANT IMMUNOSUPPRESSANT THERAPYTHERAPY

Three main classification of drugs are used to Three main classification of drugs are used to suppress the immune system and prevent suppress the immune system and prevent rejectionrejection

1.1. Cyclosporine: inhibits the activation of killer T Cyclosporine: inhibits the activation of killer T cells (specific)cells (specific)

2.2. Prednisone: steroids to Prednisone: steroids to – Suppress the lymphatic systemSuppress the lymphatic system– Depress antibodiesDepress antibodies– Decrease number of white blood cellsDecrease number of white blood cells

3.3. Azathioprine: reduces number of white blood Azathioprine: reduces number of white blood cells and plateletscells and platelets

OTHER PROBLEMS ASSOCIATED OTHER PROBLEMS ASSOCIATED WITH TRANSPLANTWITH TRANSPLANT

HypertensionHypertension– Due to cyclosporine (immunosuppressant) Due to cyclosporine (immunosuppressant)

vasoconstricting the renal arteryvasoconstricting the renal artery Activates the sympathetic system and rennin-Activates the sympathetic system and rennin-

angiotensin systemangiotensin system Can use Ca++ channel blockers or ACE inhibitorsCan use Ca++ channel blockers or ACE inhibitors

AtherosclerosisAtherosclerosis– Not caused by plaqueNot caused by plaque– Due to increased Ca++ influx causing Due to increased Ca++ influx causing

constrictionconstriction– Can be treated by Ca++ channel blockers Can be treated by Ca++ channel blockers

OTHER PROBLEMS ASSOCIATED OTHER PROBLEMS ASSOCIATED WITH TRANSPLANT, contWITH TRANSPLANT, cont

Weight GainWeight Gain Exercise Exercise

IntoleranceIntolerance Muscular Muscular

WeaknessWeakness OsteoporosisOsteoporosis

NephropathyNephropathy Valvular InsufficiencyValvular Insufficiency HypercholesterolemiHypercholesterolemi

aa LymphomaLymphoma MalignancyMalignancy

TO BECOME AN ORGAN TO BECOME AN ORGAN DONORDONOR

1. Indicate your wish on your driver’s license2. Carry an organ donor card

• http://www.organdonor.gov/newdonorcard.pdf

• 1-888-ASK-HRSA3. Talk about your wishes with your family and

friends