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HEART TRANSPLANTATION. MARTIN SUSSMAN MILPARK HOSPITAL. ISSUES. Improvements in survival with medical therapy impacted on old indications for HT. Remain survival and QOL benefits for HF pts despite this Exercise testing strongly recommended, not routinely performed in JHB Peak VO2 < 12.

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HEART TRANSPLANTATION

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Heart transplantation l.jpg

HEART TRANSPLANTATION

MARTIN SUSSMAN

MILPARK HOSPITAL


Issues l.jpg

ISSUES

  • Improvements in survival with medical therapy impacted on old indications for HT.

  • Remain survival and QOL benefits for HF pts despite this

  • Exercise testing strongly recommended, not routinely performed in JHB

    • Peak VO2 <12


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INDICATIONS

  • End stage heart failure of any cause – on maximal medical therapy, no alternative therapy, eg revascularisation, valve repair/replacement

    • ICD 10 codes I 40, I 41, I 42, and I 43 (acute myocarditis of any cause and associated with any other illness or disease, chronic cardiomyopathy of any cause or associated disease or illness)


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INDICATIONS 2

  • A definitive list, incorporating every possible condition is complex, of necessity incomplete, and potentially inappropriately limiting.

  • The 3 important “safety nets” are

    • All patients are screened by a multidisciplinary team before being listed

    • Exclusion criteria are more important

    • Sickest patients get operated first – majority in ADHF, or multiple recent admissions in HF


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EXCLUSION CRITERIA

  • Pulmonary hypertension

  • Severe co-morbidity not expected to improve with heart transplant –heart/lung, heart kidney/liver?

  • Malignancy

  • Malnutrition

  • Advanced age


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EXCLUSIONS 2

  • Interplay between donor quality and following relative contra-indications to ensure optimal utilisation of scarce resource

    • Age, DM, PVD, obesity, cancer, renal function

    • Negative factors are cumulative, but no weighting for each

    • Role for alternate listing system


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PULMONARY HYPERTENSION

  • Right heart catheterisation for all HT candidates

    • Repeat 3-6 monthly while on waiting list

    • If PAP >50mm Hg, PVR > 3 Wood units, or TPG > 15 mm Hg, trial of vasodilators, inotropes for 24-48 hours, MCS. Irreversible PHT if non responder.

    • NO ABSOLUTE CUT-OFF, but if PVR remains > 5, TPG > 16, with PAP > 60, mortality is increased

    • If PVR drops <2.5, but SBP also drops below 85mm Hg, risk is increased


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MALIGNANCY

  • Type, curability, recurrence risk.

  • Ensure no metastatic disease.

  • No absolute time line, but 5 years is mentioned as arbitrary cut-off


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DIABETES

  • Duration

  • No end-organ damage - NOT C/I, but still worse outcome

  • With end organ damage – relative to absolute C/I

  • Hypoglycamia unawareness and autonomic dysfunction increase concern


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MALNUTRITION

  • Obesity – BMI > 30 is C/I

  • Undernutrition – BMI < 21 males, 19 females


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RENAL FUNCTION

  • Must decide role of HF – reversibility

  • Irreversible, with creat > 300, is a strong C/I


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URGENCY

  • Acute decompensated heart failure – if BP < 115 mm Hg, urea and creatinine elevated, on inotropes


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Recommended Schedule for Heart Transplant Evaluation


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Evaluation of multi-organ function


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Preventive and malignancy


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Infectious serology and vaccination


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F/U EMB, ANGIOGRAPHY

  • EMB

  • ANGIOGRAM + IVUS 1-2 YEARLY

Biopsy 1, 2, 3, 4, and 5: Weekly

Biopsy 6, 7, and 8: Every 14 days

Biopsy 9 and 10: Every 3 weeks

Biopsy 11, 12, and 13: Every 4 weeks

Subsequent biopsies during

the 1st year after HT: Every 5 to 6 weeks


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NEW DEVELOPMENTS

  • Harvesting

  • Organ transport

  • MCS

    • Centres of excellence


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FEES

  • Harvesting heart – 75 units.

    • Insertion IC drain under local – 86 units.

    • Tonsillectomy and adenoids – 115 units

    • Diagnostic coronary angiogram – 140 units


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Estimated U.S. Average 2008 First-Year Billed Charges Per Transplant

Estimated U.S. Average 2008 First-Year Billed Charges Per Transplant


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FEES 2

  • Heart transplant – 875 units

  • Lung transplant – 600 units


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Generic Drug Immunosuppression in Thoracic Transplantation:An ISHLT Educational AdvisoryPatricia A. Uber, PharmD,a Heather J. Ross, MD,b Andreas O. Zuckermann, MD,c Stuart C. Sweet, MD,dPaul A. Corris, MD,e Keith McNeil, MD,f and Mandeep R. Mehra, MBBSa

1. Clinicians should educate their patients to inform

the coordinating center if a change in either the

labeling or appearance of their immunosuppressive

medications suggests that a generic drug substitution

has occurred.

2. Clinical care coordinating centers must develop

structured approaches for the education of all personnel

with regard to use of generic immunosuppressants.

3. In unique clinical situations, where critical drug

dosing represents a fine balance, caution should be

exercised in the use of generic immunosuppression.

4. Heightened vigilance to adverse sequelae and closer

therapeutic drug monitoring is indicated until a

stable immunosuppression milieu can be established


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