cardiac transplantation
DESCRIPTION
CARDIAC TRANSPLANTATION. Dr V Jonker Dept Cardiothoracic Surgery University of the Free State. HISTORY. 1905 Alexis Carrel, Charles Guthrie canine heterotopic cardiac transplantation 1960 Norman Shumway, Richard Lower orthotopic canine model – surgical technique - PowerPoint PPT PresentationTRANSCRIPT
CARDIAC TRANSPLANTATION
Dr V Jonker
Dept Cardiothoracic Surgery
University of the Free State
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
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 potentialto 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 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
CONTRAINDICATIONS
Relative 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
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
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
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
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
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
DONOR SELECTION
Ischaemic Time
Age
Size
Cardiac Fx/ Use of inotropic support
Expansion for marginal dodors
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
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
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
4. Cardiac Fx/ Inotropic support
No set exclusion criteria Individualize
Age Underlying anatomy
5. Expansion: Marginal donors