Cardiac Transplantation
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Contents |
Indications
- refractory cardiogenic shock
- dependence on intravenous inotropic support
- VO2max < 10-14 mL/kg/min (severely limited functional capacity) despite optimal medical therapy
- severe ischemia (limiting functional capacity) despite optimal medical therapy not amenable to reperfusion ( CABG, PCI)
- recurrent significant ventricular arrhythmia refractory to therapy [2]
- insufficient indication alone
- low LV ejection fraction
- history of NYHA HF class 3 or 4 [2]
- other criteria considered (may be center-dependent)
- < 60 years of age
- strong psychosocial support system
- free of extra- cardiac organ dysfunction that would complicate recovery
- exhausted all other therapeutic options
- Survival:
- 90% at 1 year
- 65-70% at 5 years
Contraindications
- (may be center-dependent)
- diabetes with end-organ damage, nephropathy, retinopathy
- major chronic disabling illness
- severe pulmonary hypertension
- severe peripheral vascular disease
- active infection
- significant chronic & likely functional impairment of other vital organs ( renal failure, cirrhosis, COPD ...)
- active substance abuse (including smoking)
- obesity
- current mental or psychosocial instability
- active or recent malignancy [2]
Complications
- acute cellular rejection
- most recipients experience 2-3 rejections during the 1st 6 months
- rejection after 12 months is uncommon unless immuno- suppression has been decreased
- patients > 55 years of age experience less rejection
- rejection severity is graded by histopathologic changes on endomyocardial biopsy
- acute humoral rejection
- interstitial edema with deposition of immunoglobulin & complement
- rarely observed > 6 weeks after transplantation
- presents with severe left ventricular dysfunction
- infection secondary to immunosuppression
- effects of immunosuppression are maximal 6-12 weeks after transplantaion
- most frequent cause of death in the 1st year following transplantation
- bacterial infections are common in the 1st month
- viral & opportunistic infections occur later
- pneumonitis is the most common early & late infection
- 30% of patients experience at least 1 major infection after transplantation
- cytomegalovirus
- most important infectious cause of morbidity
- generally occurs 6-12 weeks following transplantation
- post-transplant coronary artery disease ( CAD) is the primary cause of death >1 year after transplant
- cyclosporine-induced hypertension
- obesity & hyperlipidemia
- increased risk of malignancy
- skin cancer
- B-cell lymphoma associted with Epstein-Barr virus- induced B- cell proliferation
- lung cancer [4]
- HCV seropositive donor confers survival disadvantage [3]
Management
- endomyocardial biopsy is used to assess rejection
- absence of or non-specific signs/symptoms of mild to moderate rejection
- low grade fever, exertional dyspnea, malaise, mild hypotension & tachycardia
- weekly for 1st pre-operative month
- biweekly for next 2 months
- then reduce to 2-4 times/year
- clinical manifestations of severe rejection
- cyclosporine
- glucocorticoids
- azathioprine
- severe rejection
- antithymocyte globulin ( ATG)
- monoclonal antibody OKT3 ( Muromonab-CD3)
- plasmapheresis for acute humoral rejection
- treatment of cyclosporine-induced hypertension
- Ca+2 channel blockers are 1st line agents
- addition of 2nd agent often required
- treatment of hyperlipidemia
- assessment of coronary artery disease
- angina pectoris does not occur because of lack of innervation
- routine ECG to assess silent ischemia/ infarction
- thallium[201]/ MIBI scintigraphy generally unreliable
- dobutamine echocardiography generally unreliable
- coronary angiography is generally method of choice
- intracoronary vascular ultrasonography may be better than angiography
- retransplantation is only treatment for multivessel disease
- lymphoma often regresses following reduction in immunosuppression
More General Terms
Additional Terms
References
- Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 125
- Medical Knowledge Self Assessment Program (MKSAP) 11, 15, American College of Physicians, Philadelphia 1998, 2009
- Gasink LB et al, Hepatitis C virus seropositivity in organ donors and survival in heart transplant recipients. JAMA 2006, 296:1843 PMID: [1]
- Qamar AA and Rubin RH Poorer outcomes for recipients of heart allografts from HCV-positive donors: Opening the silos. JAMA 2006, 296:1900 PMID: [2] - Engels EA et al. Spectrum of cancer risk among US solid organ transplant recipients. JAMA 2011 Nov 2; 306:1891. PMID: &dopt=Abstract
- Heart Transplantation: NIH Institute and Center Resources [3]
