Indications for a heart transplant (3)
- Absence of reversible or surgically amenable heart disease
- NYHA class III-IV symptoms despite maximal medical management
- Peak O2 consumption
Recipient risk factors for OHT
- Neuro: cerebrovascular disease
- CV: peripheral vascular disease
- Pulm:
- infection
- Pulm HTn (>5-6wu)
- other intrinsic lung disease
- GI: irreversable liver disease
- GU: kidney disease
- FEN: Diabetes / obesity
- ID: Infection
- Malignancy
- psy: confounding psych disease
- PSA >
- increasing age
Conditions which preclude a donor heart
- HIV +
- significant ventricular arrhythmia
- Echo abnormalities
- global hypokinesis
- significant valvular disease - except ?bicuspid valve
- significant coronary disease
- Acute malignancy - except primary brain
- inadequately treated systemic infection
- HBsAg + - unless recip also pos
- Hep C - unless recip also pos
- Death from CO poisoning with COHb>20%
- Significant cardiac contusion
- significant LVH
- IVDA
Heart Donor criteria
primairy cardiac contraindications
- significant ventricular arrhymia
- significant coronary disease
- Echo: “abnormalities” :
- global hypokinesis
- significant valvular abnormalities
- significant cardiac contusion
- significant LVH
Heart Donor criteria - who should be cath’ed
- anyone older than 45
- hx of smoking
Heart donor - infectious causes for exclusion
- HIV +
- inadequately treated systemic infection
- HbSAg + , unless recipient is +
- Hep C +, unless recipient is +
- Hx of IVDA
Heart donor - issues with carbon monoxide
if COHb > 20% - should be concerned in pts with MVA
heart txp PRA - what level is of concern? what is done?
if PRA > 10% a prospective cross match is performed
heart txp prospective crossmatch -
performed if the PRA > 10%
PRA > 25% very high risk ==> tests recipient sera for anti - HLA ab against donor lymphocytes > + if lymphocyte lysis (prob of hyperacute rejection high)
treatment of high PRA
- Plasmapharesis
- IVIG
- cyclophosphamide
- Rituximab - specific to CD-20
- Photophaeresis
- Totoal bone marrow irridation
OHT:
Recipient pulmonary HTN that is associated with increased M&M
Pulmonary hypertension:
- >6 Wood units & responsive to vasodilators
- not decreasing to 70 mmHg
- transpulmonary gradient > 15 mmHg
Obesity contraindication to heart transplant
Morbid obesity (>140% of predicted ideal body weight)
Criteria for renal function contraindication to heart transplant
Creatinine clearance
Hepatic function contraindicating heart transplant
Bilirubin > 2.5 mg · dL−1 when not due to reversible hepatic congestion,
transaminases > 2 × normal
PVR that puts donor heart RV graft at risk
The critical feature of elevated pulmonary vascular resistance (Rp) is:
pulmonary systolic pressure at completion of CPB during the transplantoperation.
- Donor right ventricle generally poorly tolerates a systolic afterload of more than about 50 mmHg
- overt right ventricular dysfunction above a pressure of 55 to 60 mmHg,
what factors dictate the donor heart’s ability to tolerate pulmonary HTN
Tolerance of the donor right ventricle to elevated afterload conditions (secondary to increased Rp) is partly a function of: 1. donor right ventricular reserves 2. schemic/reperfusion injury 3. possibly donor/recipient size ratio.
Favorable RHC pre OHT
If Rp is elevated, a sustained favorable hemodynamic response (Rp
Persistent PHTN following in OHT candidate
When Rp remains elevated and medical therapy (sometimes over days to several weeks on continuous intravenous [IV] infusions) fails to reduce pulmonary artery systolic pressure below about 60 mmHg, secure conclusions about pulmonary reactivity cannot be made.
In that instance:
implanting a LVAD may be warranted to force reduction of left atrial pressure and promote reversal of the reactive component.
Calcineurin - mechanism of action
- Transcription of NFAT
Immunosuppressive regimine
1 Calcineurin inhibitor 2. Anti proliferation (mTOR) 3. Corticosteroid Monoclonal ab- delay used in Calcineurin inhibitor or treat rejection
Calcineurin inhibitors
- Cyclosporine - binds to cyclophylin
- Tacrolimus - binds to fk binding protein
Side effects of Calcineurin inhibitors
- Nephrotic Syndrome
- Htn
- Hirsuitism
- Gingival hyperplasia (cyclo only)
- Neurotox
- Hepatotox
- Hyperglycemia
Cyclosporine vs Tacrolimus
Calcineurin inhibitors
A. Similar rejection freq
B. Rejection on cyc may reverse w tac
C. Similar nephrotox
D. Dec lipids and htn with tac
E. More hi gluc and and htn w tac
Antiproliferative agents
- MMF
- Azathioprine
