CARDIAC TRANSPLANTATION
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CARDIAC TRANSPLANTATION
Dr V Jonker
Dept Cardiothoracic Surgery
University of the Free State
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HISTORY
1905 Alexis Carrel, Charles Guthrie canine 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
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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
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BASIC OBJECTIVE
Prognosis < 50% without transplantation To id relatively healthy patients, with
end stage cardiac disease,refractory to medical therapies, with potentialto resume a normal active life and maintain medical compliance
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INDICATIONS
Systolic HF EF< 35% IHD with intractable angina Intractable arrhythmia Hipertrophic CM Congenital heart disease without severe fixed
PHT
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CONTRAINDICATIONS
Absolute Age > 70y Fixed PHT with
PVR > 5 Woods units TPG >15mm/Hg
Systemic illness that will limit survival CA other than skin HIV/ AIDS SLE/ Sarcoid – Active/ multisystem involvement Irreversible renal/ hepatic dysfunction
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CONTRAINDICATIONS
Relative PVR/ CVA COPD PUD/ Diverticulitis IDDM with TOD Past CA Active alcohol/ drug abuse Psychiatric illness- non compliant Absence of psychosocial support
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Patient Selection - UNOS Based on survival & quality of life expected to be gained
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
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PREREQUISITES
55-65 Y Optimal medical management
ACE-I Beta Blockers Digoxin Aldosterone
Treat surgically reversible causes CABG Valves Remodeling
CRT
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RECIPIENT MANAGEMENT
General assessment Cardiovascular assessment
Functional capacity Hemodynamic assessment
Assessment of Etiology Immunologic evaluation Infectious disease screening Psychosocial evaluation
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RECIPIENT MANAGEMENT cont. (1.General) Principle : exclude and manage reversible
causes General assessment
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 %
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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
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RECIPIENT MANAGEMENT cont.(3. Etiology) ECG, Holter, Echo, Angio PET, Thallium, MRI Endomyocardial biopsy
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RECIPIENT MANAGEMENT cont.(4.Immunologic) ABO typing + AB screen HLA typing Panel reactive AB level
If PRA > 10%: Prospective cross match If PRA > 25% : Preop Plasmapheresis, iv
immunoglobulins, cyclophosphamide
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RECIPIENT MANAGEMENT cont.(5. Infective disease screening) Hep A, B, C Herpes HIV Toxoplasmosis Varicella Rubella E Barr Tuberculin skin test
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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
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DONOR MANAGEMENT Assessment & evaluation
History & physical exam (trauma, “down time”, CPR) 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
Male > 40y Female > 45y
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DONOR SELECTION
Ischaemic Time
Age
Size
Cardiac Fx/ Use of inotropic support
Expansion for marginal dodors
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1. Ischaemic Time
Cold ischaemia +/- 4 hours Mortality especially older donors Graft vasculopathy Innovatavive approaches
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
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2. Age
Was 30 years Now up to 50-55 years ISHLT additional measures minimize risk Older- graft vasculopathy
Undetected CAD Age-related endothelial dysfunction
Newer immunosuppressive agents – older donors
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3. Size
Donor-recipient mismatch < 30 % Use body weight to estimate body size Undersized
Gradual increase in LV mass Risk in PHT – Post transplant RV
Oversized Problematic only in
Acute massive MI Multiple previous cardiac operations- adhesions
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4. Cardiac Fx/ Inotropic support
No set exclusion criteria Individualize
Age Underlying anatomy
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5. Expansion: Marginal donors