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Cardiac transplant

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Criteria for selection of recipients

Criteria for selection of donors

Perioperative care

Immunosuppression

Complications

Heart-lung transplant

Criteria for selection of recipients

  • symptomatic and refractory cardiac failure, usually with a LV ejection fraction of < 20% and a raised LVEDP
  • transpulmonary pressure gradient (MPAP - MLAP) <15 mmHg
  • psychologically stable, motivated, well-supported and informed patient
  • no evidence of present malignancy
  • no evidence of sepsis
  • single organ failure
  • age:
    • dilated cardiomyopathy 60 years or less
    • IHD: 55 or less

  • absence of generalized atheroma, active peptic ulceration, recent PE and poor lung function

Criteria for donor selection

  • age:
    • females: 50 or less
    • males: 45 or less

  • infection: HIV and HBsAg -ve
  • haemodynamics:
    • normal ECG
    • stable
    • CVP 8 mmHg or less
    • inotropes: dopamine at 5-10 mcg/kg/min or less
    • no significant congenital or acquired cardiac defect

Perioperative care

Usual care of post cardiac surgical patient plus:

  • after transplantation cardiac output maintained by establishing a heart rate of 90-110/min using epicardial atrial pacing or isoprenaline infusion
  • adequate preload important: maintain CVP and PCWP at 8-15 mmHg
  • elevated pulmonary vascular resistance (especially if > 6 Wood units): infusion of prostaglandin E1 via central line + adrenaline/noradrenaline via LA line
  • serious ventricular failure unusual. May be due to poor donor organ selection, poor graft preservation, long ischaemic time. Rarely due to hyperacute rejection due to ABO blood group mismatching or preformed antibodies. Manage with combination of pulmonary vasodilators and inotropes ± IABP ± re-transplantation

Immunosuppression

Combination of azathioprine, prednisolone and cyclosporin A. In cases of overwhelming sepsis immunosuppression should be stopped. Cyclosporin acts synergistically with prednisolone to cause hypertension

Complications

Renal failure

Renal failure occurring in postoperative period almost always direct result of cyclosporin nephrotoxicity

GI problems

Major source of morbidity and mortality. Include prolonged ileus, peptic ulceration, ischaemic bowel and cholelithiasis

Rejection

Diagnosed on basis of endomyocardial biopsy. Treat with pulsed steroids. If not successful try OKT3

Infection

  • lungs are major source of infection
  • bacteria: both gram +ve and -ve; fungal: Candida and Aspergillus; viral: CMV
  • CMV infection may be reactivation, superinfection or primary infection. Most common mode of transmission is via donor heart. Ganciclovir drug of choice for prophylaxis (CMV-mismatched transplants) and treatment

Graft atherosclerosis

  • common. 30-40% of transplant recipients at 3 yrs and 40-60% at 5 yrs
  • if it involves small vessels re-transplantation may be the only definitive solution
  • silent ischaemia due to denervation of heart

Survival

  • 90% 1 year and 78% 5 year

Heart-lung transplantation

Postoperative care

  • similar to that of cardiac transplant patients
  • physiology of transplanted lung:
    • no bronchial arterial supply
    • no pulmonary innervation below anastamosis
    • no lymphatic drainage of lung

  • aim for negative fluid balance in early post-op period
  • aggressive physiotherapy +/- bronchoscopic toilet to clear secretions: denervation prevents reflex clearing of secretions below anastamosis
  • daily peak flow
  • immunosuppression as for heart transplants
  • lung function tests, transbronchial lung biopsy and endomyocardial biopsy are used to assess rejection

Complications

  • bleeding due to extensive dissection and systemic pulmonary collaterals in congenital heart disease
  • other early complications:
    • anastamotic dehisience
    • acute reperfusion injury of lung (presents as pulmonary oedema) due to long ischaemic times or inadequate protection with the pulmonary "plegia" solution
    • infection (3 times as common in heart-lung as heart recipients). Major cause of mortality in first 6 months. Chest is major source of infection

  • rejection. Major cause of mortality after 6 months

Further reading

Branch JM, Harrison GA. Heart and lung transplantation. In Oh TE, Intensive Care Manual, 4th ed.

© Charles Gomersall July 1999

 

©Charles Gomersall, April, 2014 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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