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