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CARDIAC TRANSPLANTATION

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

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CARDIAC TRANSPLANTATION

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  1. CARDIAC TRANSPLANTATION Dr V Jonker Dept Cardiothoracic Surgery University of the Free State

  2. 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

  3. 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

  4. BASIC OBJECTIVE • Prognosis < 50% without transplantation • To id relativelyhealthypatients, with end stage cardiac disease, refractoryto medical therapies, with potential to resume a normal active life and maintain medical compliance

  5. INDICATIONS • Systolic HF EF< 35% • IHD with intractable angina • Intractable arrhythmia • Hipertrophic CM • Congenital heart disease without severe fixed PHT

  6. 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

  7. CONTRAINDICATIONS • Relative • PVR/ CVA • COPD • PUD/ Diverticulitis • IDDM with TOD • Past CA • Active alcohol/ drug abuse • Psychiatric illness- non compliant • Absence of psychosocial support

  8. 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

  9. PREREQUISITES • 55-65 Y • Optimal medical management • ACE-I • Beta Blockers • Digoxin • Aldosterone • Treat surgically reversible causes • CABG • Valves • Remodeling • CRT

  10. RECIPIENT MANAGEMENT • General assessment • Cardiovascular assessment • Functional capacity • Hemodynamic assessment • Assessment of Etiology • Immunologic evaluation • Infectious disease screening • Psychosocial evaluation

  11. 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 %

  12. 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

  13. RECIPIENT MANAGEMENT cont.(3. Etiology) • ECG, Holter, Echo, Angio • PET, Thallium, MRI • Endomyocardial biopsy

  14. 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

  15. RECIPIENT MANAGEMENT cont.(5. Infective disease screening) • Hep A, B, C • Herpes • HIV • Toxoplasmosis • Varicella • Rubella • E Barr • Tuberculin skin test

  16. 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

  17. 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

  18. DONOR SELECTION • Ischaemic Time • Age • Size • Cardiac Fx/ Use of inotropic support • Expansion for marginal dodors

  19. 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

  20. 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

  21. 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

  22. 4. Cardiac Fx/ Inotropic support • No set exclusion criteria • Individualize • Age • Underlying anatomy

  23. 5. Expansion: Marginal donors

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