Surgery

Heart Transplant

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Heart Transplant, Heart Transplantation, Cardiac Transplantation, Cardiac Transplant, Heart Graft

  • See Also
  1. Transplantation
  2. Solid Organ Transplant
  3. Bone Marrow Transplant
  4. Transplant Rejection
  • Indications
  1. Cardiomyopathy
  2. Refractory Heart Failure (NYHA Class III to IV)
  3. Refractory Angina or Arrhythmias (uncommon)
  4. Hemodynamic instability
  5. Peak VO2 <14 ml/kg/min
  • Contraindications
  • Relative
  1. Age over 65 to 70 years
  2. Limited survival due to systemic illness
  3. Fixed Pulmonary Hypertension (PVR >5 Woods units)
  4. Malignancy
  5. HIV Infection
  6. Hepatitis B infection
  7. Hepatitis C infection
  8. Malignancy within the last 5 years
  • Protocol
  1. Virtual cross-matching (prescreen via computer known HLA mismatches)
  2. Transplant at a large volume center if match found
    1. All Heart Transplant centers perform at least 10 transplants per year
    2. Large volume centers perform upwards of 30 transplants per year
  • Physiology
  • Nerve Disruption
  1. Unlike vascular supply, nerves are not reconnected during transplant
  2. Efferent parasympathetic vagal nerve disruption
    1. Resting Heart Rate is increased to 80 to 110, due to lack of vagal tone
    2. Cardiac tissue is more responsive to Adenosine (use 25% of typical SVT dose)
    3. Vagal Maneuvers have no effect
    4. Atropine has no effect
  3. Efferent sympathetic vagal nerve disruption
    1. Tachycardia response to stressful stimuli is blunted
  4. Afferent nerve disruption
    1. Typical Anginal symptoms (e.g. Chest Pain) are initially absent
    2. A small subset (20%) will partially reinnervate within 2 years
    3. Post-transplant Myocardial Ischemia may present with Fatigue, Shortness of Breath, especially with exertion
  • Findings
  • Post-Transplant EKG
  1. Always compare to prior EKGs
    1. Even subtle changes may suggest coronary vasculopathy or Transplant Rejection
  2. Sinus Tachycardia at rest (80 to 110 bpm) in most cases
    1. New Atrial Fibrillation or Bradycardia may indicate Transplant Rejection
  3. Premature Ventricular Contractions (PVCs) are common and benign
  4. Right Bundle Branch Block is common
  5. EKG Axis varies based on transplant orientation
  6. EKG in Acute MI follows same patterns as for non-transplanted hearts
  • Complications
  1. Diarrhea (may require change in anti-rejection medications)
  2. Infection (e.g. Fever or Leukocytosis)
    1. Many transplant patients will initially be covered with prophylactic Antibiotics
    2. Consider Sepsis, Urinary Tract Infection or Pneumonia
    3. Consider opportunistic infection (e.g. Pneumocystis jiroveci Pneumonia, Cytomegalovirus or fungal infection)
      1. Most transplant patients are on CMV prophylaxis to prevent CMV infection
      2. Cytomegalovirus (CMV) is the most common opportunistic infection in transplant patients
      3. CMV may be acquired or reactivated after transplant
      4. Presents with pneumonitis, enteritis with Diarrhea or generalized infection
    4. Infections follow a pattern based on time from transplant
      1. Month 1: Nosocomial infection (e.g. CAUTI, VAP, SSI)
      2. Month 1-6: Opportunistic infection (CMV, EBV, fungal and Parasitic Infections, Tuberculosis)
      3. Month 6+: Community acquired infection (e.g. Pneumonia) and opportunistic infections
  3. Rejection
    1. Typically occurs within first year of transplant (much lower risk later)
    2. Absolute compliance with anti-rejection drugs is critical
      1. Cardiac Transplant patients are not HLA matched
      2. Even missing 1-2 doses risks Transplant Rejection
        1. Consider short course of high dose Corticosteroids for missed doses (consult transplant team)
    3. Findings
      1. EKG changes (compare to old ekgs; even subtle changes may indicate rejection or coronary vasculopathy)
      2. New signs of Heart Failure or Left Ventricular Dysfunction
      3. New Arrhythmias (esp. Bradycardia, Atrial Fibrillation)
      4. New exertional symptoms
      5. Peripheral Edema
      6. Hemodynamic instability
    4. Management
      1. Consult transplant team
      2. Consider high dose Methylprednisolone 30 mg/kg up to 1 gram
      3. Obtain Echocardiogram as soon as possible
      4. Manage Hypotension
        1. Small fluid boluses (e.g. 10 ml/kg in children or 500 ml in adults)
        2. Consider Vasopressors (Epinephrine is preferred over Norepinephrine)
        3. In RSI and sedation avoid agents with myocardial depression (e.g. Propofol) which will be worse in transplant
      5. Manage Arrhythmias
        1. Decrease Adenosine dose to 25% of typical Supraventricular Tachycardia dose
        2. Atropine will be ineffective in Bradycardia
  4. Top causes of death
    1. Malignancy
    2. Graft failure
    3. Cardiac Allograft vasculopathy
      1. Patient monitored lifelong for this after transplant
      2. Treated with Cardiac Risk Reduction, Statins, revascularization, CMV prevention
  • Management
  • Anti-Rejection Protocol
  1. Precautions
    1. Even missing 1-2 doses can significantly increase risk of rejection
    2. Consider short-course of high dose Corticosteroids when anti-rejection medication doses have been missed
      1. Consult with patient's Cardiac Transplant team
  2. Immunosuppression Induction (50% of cases)
    1. Initial intense multi-drug Immunosuppression following transplant
  3. Maintenance: Three drug protocol for first year (then Corticosteroids tapered off and 2 drugs continued)
    1. Calcineurin Inhibitor (Tacrolimus or Cyclosporine)
      1. Nephrotoxic Drugs (avoid all NSAIDs and other Nephrotoxins)
      2. Risk of Hypertensive Emergency including PRES
    2. Mycophenolate Mofetil (Cellcept) or other antimetabolite (e.g. Azathioprine)
      1. Gastrointestinal side effects and cytopenias are common
    3. Corticosteroids tapered over 6-12 months and discontinued by 12 months
  1. Routine management of comorbidity (e.g. Diabetes Mellitus)
  2. Osteoporosis
  3. Annual complete physical
  4. Malignancy screening
  5. Keep Vaccinations up-to-date (Avoid Live Vaccines)
    1. Pneumovax every 2-5 years
    2. Influenza annually
    3. HPV Vaccine for younger women
  • Prognosis
  1. HLA mismatch decreases survival and in proportion to the number of HLA mismatches
  2. Survival Half-Life following Cardiac Transplantation
    1. Overall survival: 10 year Half-Life
    2. Survival beyond 1 year: 13 year Half-Life
  3. University of Minnesota data as of 2009
    1. Survival at 1 year: 87%
    2. Survival at 3 years: 79%
    3. Survival at 5 years: 72%
  • References
  1. Gatz and Swaminathan in Swadron (2022) EM:Rap 22(11): 10-2
  2. Claudius, Ruttan and DeFabio in Swadron (2022) EM:Rap 22(11): 13