60 cardiac transplantation

8/14/2019 60 Cardiac Transplantation

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CardiacCardiac

TransplantatiTransplantati

ononPeter LunnyPeter Lunny

8/7/088/7/08



HistoryHistory

1967- first transplant by Dr1967- first transplant by Dr

Christiaan BernardChristiaan Bernard

United Network for Organ SharingUnited Network for Organ Sharing

~2000/year since 1990~2000/year since 1990

85% survival at 1 year85% survival at 1 year





CausesCauses

Adult Peds (age dependent)

CAD 45% Congenital artery disease

Dilated Cardiomyopathy 45% Dilated Cardiomyopathy

Valve disease 4% Retransplant

Retransplant 2% Other

Congenital 2%

Misc 2%



Operative procedureOperative procedure



PhysiologyPhysiology

A denervated heart that supports normalA denervated heart that supports normal

circulation???circulation???






However does respond to exogenous andHowever does respond to exogenous andendogenous circulating catacholamines.endogenous circulating catacholamines.

SVT -SVT -







SVT - Vagal manuvers will not work !SVT - Vagal manuvers will not work !








Atropine will not work in symptomatic bradyAtropine will not work in symptomatic brady

arrhythmias !arrhythmias !




A denervated heart that supports normalA denervated heart that supports normalcirculation???circulation???



Atropine will not work in symptomatic bradyAtropine will not work in symptomatic bradyarrhythmias !arrhythmias !

HOWEVER donor hearts are quite sensative to B-HOWEVER donor hearts are quite sensative to B-adrenergic agonists (isoproterenol, dopamine,adrenergic agonists (isoproterenol, dopamine,dobutamine)dobutamine)



CXRCXR

Cardiomegaly to normal chest



EchoEcho

Evaluation of cardiac function:Evaluation of cardiac function:

Atrial enlargement 2° to atrial anastamosisAtrial enlargement 2° to atrial anastamosis

with nativewith native atriaatria

Early rejection presents with diastolicEarly rejection presents with diastolic

dysfunctiondysfunction

Severe rejection – biventricular enlargementSevere rejection – biventricular enlargementwithwith hypocontractilityhypocontractility



ImmunosuppressiveImmunosuppressive

TherapyTherapy

Lifelong triple therapy: Cyclosporine,Lifelong triple therapy: Cyclosporine,

Tacrolimus, prednisoneTacrolimus, prednisone

What we need to know:What we need to know:

✔ cyclosporine levels - acutecyclosporine levels - acute = renal dys= renal dys

acuteacute = acute= acuterejection !!rejection !!

✔ new drugs patient might have started b/cnew drugs patient might have started b/c

of interactionsof interactions with cyclosporinewith cyclosporine

C C l iC C l i



Common CyclosporineCommon Cyclosporineand Tacrolimus Sideand Tacrolimus Side

EffectsEffectsHypertension

Renal insufficiency

Hirsutism *

Tremor

Gingival Hyperplasia *

Hyperkalemia

Hypomagnesemia

Hyperuricemia

Glucose intolerance

Seizures

Headache

Nausea and diarrhea ( esp Tacrolimus) *cyclosporine only



RejectionRejection

Hyperacute: against donor tissueHyperacute: against donor tissue

Acute: most common, 75% have at someAcute: most common, 75% have at sometime during the firsttime during the first

6 weeks6 weeks

Endomyocardial biopsies routine post-opEndomyocardial biopsies routine post-op

Atrial/Ventricular dysrhythmia = acute rejectionAtrial/Ventricular dysrhythmia = acute rejectionuntil proven otherwise !!!! GIVEuntil proven otherwise !!!! GIVE

METHYLPREDNISONE 1 g and CALL CARDIOLOGY METHYLPREDNISONE 1 g and CALL CARDIOLOGY TO DO ENDOMYOCARDIAL BIOPSY TO DO ENDOMYOCARDIAL BIOPSY

Chronic: rejection in heart by graft atherosclerosisChronic: rejection in heart by graft atherosclerosisLook forLook for

failure/enzymes/asymmetric wallfailure/enzymes/asymmetric wall

motion/hypocontractilemotion/hypocontractile



InfectionsInfections

Common early withCommon early with dose of dose of

immunosuppresantsimmunosuppresants

Annual flu shot and non live att vaccines, lowAnnual flu shot and non live att vaccines, lowthreshold for antibiotics, and always think threshold for antibiotics, and always think

CMV!!CMV!!

EARLY LATER ( > 1 MONTH)

GM – Bacilli pneumonia CMV, HSV, VZV, non-A,B hepStaph mediastinitis Listeria, Legionella,Mycobacterium

Enterococcal, GM - UTI Aspergillus,CryptococcalHSV skin infection PCP, Toxoplasma



Non-infectiousNon-infectious

Maligancies ass. with chronicMaligancies ass. with chronic

immunosuppression : Lymphomproliferativeimmunosuppression : Lymphomproliferativedisorder, B cell lymphoma ass. with EBVdisorder, B cell lymphoma ass. with EBV

Long term steroids : osteopenia, asepticLong term steroids : osteopenia, aseptic

necrosis and compression fracturesnecrosis and compression fractures



PediatricPediatric

considerationsconsiderations

Rejection monitored by echo not biopsyRejection monitored by echo not biopsy

Triple therapy but try to avoid long termTriple therapy but try to avoid long term

steroidssteroids

Care with chickenpox, if + give VZIGCare with chickenpox, if + give VZIG



OUR JOBOUR JOB

Treat like normal but always think aboutTreat like normal but always think about

rejection, infection or side effects torejection, infection or side effects to

immunosuppressive therapy !immunosuppressive therapy !

Care using NSAID’s b/c could exacrebateCare using NSAID’s b/c could exacrebate

underlying renal insufficiency 2° tounderlying renal insufficiency 2° to

cyclosporine and tacrolimuscyclosporine and tacrolimus

If in extremis think: rejection - no atropineIf in extremis think: rejection - no atropine

but give steriodsbut give steriods

MI – arrhythmia,MI – arrhythmia,

hyperkalemia ?hyperkalemia ?



ReferencesReferences

Emergency Medicine; Rosen, Barkin 4Emergency Medicine; Rosen, Barkin 4thth ed.ed.

19981998

Tintinalli, Emergency Medicine 2004Tintinalli, Emergency Medicine 2004

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WikipediaWikipedia

60 cardiac transplantation

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