18 terms

Heart Transplant

STUDY
PLAY
First Clinical Transplants
-Kidneys
-Made sense because hemodialysis was available as a backup if the graft failed
First Heart Transplant
-South Africa
-1967
Success of Early Heart Transplants
-Post-op survival limited by opportunistic infections and graft rejection
-Most centers discontinued heart transplants in 1970's due to high mortality
-Started again in 1980's with introduction of cyclosporine based immunosuppression
Shift in Diagnosis of People Receiving Heart Transplants Over the Years
Increase in number of non-ischemic cardiomyopathy
Average Age of Recipient vs Donor
-Recipient average is 54
-Donor average is 35
-Overall average age for both has increased for both over the years
Characteristics of Donors' Deaths and Change Over the Years
-Most are from head traumas
-Head trauma has decreased over the years because of helmet use
-Anoxia has increased over the years due to opioids and drug abuse
Why is there a shift of treatment from Cyclosporine + MMF/MPA to Tacrolimus + MMF/MPA
Lower rate of transplant rejection
Indications for Heart Transplant
-Refractory cardiogenic shock requiring balloon pump or LVAD
-Cardiogenic shock requiring continuous inotropic therapy
-Peak VO₂ <10
-NYHA class III or IV
-Recurrent life-threatening ventricular arrhythmias despite treatment (shock, ablation)
-End stage congeintal HF
-Refractory angina without therapeutic options
Indications for Referral to Evaluate for Heart Transplant
-Severe symptoms (dyspnea with rest)
-Episodes of recurrent fluid retention
-Objective evidence of severe cardiac dysfunction (LVEF <30%, etc.)
-Severely impaired functional capacity (inabilit to exercise, peak VO₂ <12)
-One or more hospitalizations for HF in the past 6 months
Absolute Contraindications to Heart Transplant
-Advanced renal failure (GFR 30-50)
-Advanced irreversible liver disease
-Advanced irreversible pulmonary disease (FEV1 <1)
-Advanced irreversible pulmonary artery hypertension
-History of solid organ malignancy with last 5 years
Relative Contraindications to Heart Transplant
-CVA
-Osteoporosis
-Obesity or cachexia
-Acute PE
-Advanced age >70
-Psychological instability
-Substance abuse
-DM
-Lack of social support
Recipient Prioritization for Heart Transplantation
-1A is highest priority→people on mechanical support, or in hospital with high ionotropic support
-1B is second priority→LVAD or ionotropes at home without complication
2 is last priority→meet the requirements for transplants, but are not on mechanical support or ionotropes and are at home
Complications of Heart Transplant - Major Causes of Death
-Infections
-Chronic kidney disease
-Cardiac allography vasculopathy (accelerated CAD)
-Malignancy
Other Complications of Heart Transplant
-Rejection
-Osteoporosis
-HTN
-DM
-Neuropathy
Morbidity Rates in Survivors within 1, 5, 10 Years Post Transplant
-HTN is 70% within 1 year and 90% within 5 years
-Renal dysfunction is 25% within 1 year and 68% within 5 years
-CAV is 7% within 1 year and 47% within 10 years
Post Transplant Outcomes
-Quality of life is generally excellent
-1 year is 98%
-5 year rate is 70%
-20% survive 20 years or longer
Leading Cause of Death with Heart Transplants
-Initially it is graft failure
-Over time it is infection then malignancy
Organ Allocation
-Goes to the highest status 1 patients within 500 miles
-If nobody is eligible it is offered to status 2 patients
-Process repeats in sequence of zones farther away from donor hospital