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2016JHLT. 2016 Oct; 35(10): 1149-1205
2%2%
42%
46%2%
3%
4%0%
3%
3%
35%
49%
3%
3%
3%1%
CHD
HCM
ICM
NICM
RCM
Retransplant
VCM
Other
1/2009 – 6/20151/1982 – 6/2015
UNOS, 2017
Adult Heart TransplantsDonor and Recipient Characteristics
1992-2003(N = 48,388)
2004-2008(N = 17,666)
2009-6/2015 (N = 24,474)
p-value
Pre-operative support (multiple items may be reported)
Hospitalized at time of transplant 59.0% 46.4% 44.1% <0.0001
On IV inotropes 54.6%1 44.6% 39.4% <0.0001
Ventilator 3.3% 3.0% 2.1% <0.0001
IABP 6.4% 7.0% 6.4% 0.1497
Mechanical circulatory support 22.2%2 26.0% 44.7% <0.0001
LVAD 20.1%2 22.2% 38.1% <0.0001
RVAD - 4.4%3 3.2% <0.0001
TAH 0.5%2 0.5% 1.4% <0.0001
ECMO 0.3%4 0.9% 1.3% <0.0001
2016JHLT. 2016 Oct; 35(10): 1149-1205
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Indications
Reversible Causes
Addressed
Transplant Evaluation
SHSS 1 year survival <80%
HFSS high/medium riskVO2 Max < 12 ml/kg/min
Yes
Listing
Stage D Heart Failure
Re-Transplants
CHD
Sick enough?
Defer
SHSS 1 year survival >80%
HFSS low riskVO2 Max >14ml/kg/minCandidate?
Medical
Surgical
Psychosocial/financial
No
Palliation
VO2 max
HFSS
SHFM
INTERMACS
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• Donor Specific Antibodies: (DSA)• Antibodies directed against human leukocyte antigens (HLA) are associated with
mortality, graft rejection, dysfunction, organ loss, graft vasculopathy• Why are they there?
• Sensitizing event: blood transfusions, pregnancy, prior Tx, surgery, infection
• Panel reactive antibody (PRA) = percentage of possible donor HLA antigens targeted by the recipient’s circulating antibodies.
**Percentage estimate of the local donor pool that will be incompatible with recipient**
• Cross-match testing: recipient’s serum combined with donor cells to see if compatible
ABSOLUTE CONTRAINDICATIONS
1.Organ transport time > 4 hours2.Confirmed myocardial infarction with systolic dysfunction3.LVEF < 30%4.Severe valvular disease not amenable to repair5.Active infection with transmissible pathogens including, but not limited to HIV, hepatitis B (HBSAg +) or C virus, or highly resistant bacteria6.Bacterial endocarditis7.A history of major extracranial or metastatic malignancy8.Age > 60 years9.Significant penetrating cardiac trauma
RELATIVE CONTRAINDICATIONS
1.Donor recipient mismatch > 6 inches2.Age 50-60 years 3.Male donors > 45 years and female donors > 50 years with cardiovascular risk factors and an inability to perform coronary angiography4.Previous high risk behavior including intravenous drug use or risky sexual activity5.Donor instability manifested by hypoxia, severe acidosis with pH<7.2, hypotension requiring high dose vasoconstrictors6.Organ transport time 3-4 hours
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Biatrial Anastomosis• Shorter ischemic time• Complications
• Atrial dysfunction due to size mismatch of atrial remnants
• Arrhythmia (sinus node dysfunction, bradyarrhythmias, and AV conduction disturbances) that necessitate PPM implantation
Bicaval Anastomosis• Can prolong ischemic times• Decreases incidence of arrhythmias, the need for
a pacemaker, and risk for mitral or tricuspid regurgitation
• Narrowing of the SVC and IVC make biopsy surveillance difficult
Annals of Cardiac Anaesthesia, Vol. 12, No. 1, January-April, 2009, pp. 71-78
• Maintain perfusion
• RV support• Early Diuresis• Pacing
• Inotropic support
• Manage rhythms
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Infection
Rejection
• Mainstay of therapy, inhibits T-cell lymphokine production
• Trough levels monitored
• Tacrolimus (Prograf, FK-506)-most widely used
• Cyclosporine (Gengraf/Neoral)
• Adverse effects• Hyperglycemia• Renal dysfunction• HTN• Tremor• Gingival hyperplasia• Risk of malignancy
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Adverse effects:Short-term
Psychosis, confusion
Fluid retention
GI symptoms
Hyperglycemia
Insomnia
Increased appetite
Long-termOsteoporosis
Diabetes
Impaired wound healing
Hypertension
Glaucoma, cataracts
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Rejection Infection
Cardiac Allograft Vasculopathy(CAV)
Malignancy
Complications
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Adult Heart Transplants Relative Incidence of Leading Causes of Death
0
10
20
30
40
50
0-30 Days
(N=1,474)
31 Days - 1 Year
(N=1,416)
>1-3 Years
(N=986)
>3-5 Years
(N=813)
>5-10 Years
(N=2,091)
>10-15 Years
(N=2,158)
>15 years
(N=2,632)
% o
f D
ea
ths
CAV Acute Rejection
Malignancy (non-Lymph/PTLD) Infection (non-CMV)
Graft Failure Multiple Organ Failure
Renal Failure
2016JHLT. 2016 Oct; 35(10): 1149-1205
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CMVMost common infection after solid organ transplant
Wide range of symptoms:
-Fever (may be blunted because of weakened
immune system)
-Abdominal pain, diarrhea, nausea, vomiting
-GI bleeding
-Pneumonia (lung involvement)
-Neurological changes (altered mental status,
seizures)
-Visual impairment (CMV retinitis)
Test of choice – CMV PCR +/- biopsy of involved
organ
Treatment – high dose ganciclovir or valganciclovir
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Class I Class II
Screen for breast, colon and prostate
cancer
Chronic immunosuppression should be
minimized as possible, particularly in
patients at high risk for malignancy
Skin cancer surveillance
Evaluation for post-transplant
lymphoproliferative disorder (PTLD)
No evidence to support a reduction in
immunosuppression in patients with
solid tumors unrelated to the lymphoid system
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