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Cardiac transplantation

Candidate Selection

  • “End stage…failure to respond to maximal therapy”
  • Most often from idiopathic dilated or ischaemic cardiomyopathy
  • Need to identify those who are likely to have sudden death or progressing heart failure
  • Adequacy of therapy prior to evaluation is key
  • Useful guidelines include
    • Ejection Fraction < 20%
    • Peak O2 consumption < 10cc/kg/min

Cardiac Donor

  • Only 10-20% of brain dead patients with suitable hearts become donors
  • Cardiac transplantation is currently limited by donor availability
  • Need to consider
    • Age
    • Level of inotropic support
    • Cardiovascular risk factors
    • Substance abuse
    • Donor body weight 80-120% of recipient’s weight
  • Intensive fluid management of the donor is important

Surgery

Donor cardiectomy

  • Operation usually proceeds as follows
  • Visualize/palpate the heart
  • Divide the SVC, left superior pulmonary vein and  incise IVC
  • Clamp aorta and administer cardioplegia
  • Avoid coronary sinus injury during liver procurement
  • Divide aorta and pulmonary artery

Recipient Operation

  • Open RA along the AV groove anteriorly
  • Extend this incision to coronary sinus inferiorly and to the right atrial appendage posteriorly
  • Aorta and main pulmonary artery are divide at the valve commissures
  • Incise roof of the left atrium between the aorta and SVC
  • Connect the atrial incisions and extend the incision to the left atrial appendage
  • Incision is then extended along the AV groove posteriorly to the coronary sinus
  • Donor pulmonary veins are connected to fashion a left atrial cuff
  • Left atrial anastomosis is completed and a vent is placed
  • Right atrial anastomosis is completed
  • Great vessels are anastomosed
  • Postoperatively
    • Pacing wires are inserted
    • Inotropic support is administered
    • Immunosuppression is achieved using tacrolimus
    • Transvenous myocardial biopsies required weekly for first month

Complications of cardiac transplantation

  • Cardiac
    • Ventricular dysfunction
    • Sinus node dysfunction
    • Tricuspid regurgitation
    • Allograft rejection
    • Allograft coronary artery disease
  • Infection
    • Bacterial
    • Viral
    • Parasitic
    • Fungal
  • Non-cardiac
    • Non-infectious renal insufficiency
    • Hypertension
    • Osteoporosis
    • Malignancy

Allograft coronary artery disease

  • Leading cause of death more than 1 year after transplantation
  • Equivalent to
  • "Chronic rejection" in renal allografts
  • "Vanishing bile ducts" in hepatic allografts
  • "Bronchiolitis obliterans" in pulmonary allografts
  • Prevalence of angiographically detectable disease
    • 1 year post-transplantation - 10-2O%
    • 5 years post-transplantation -  30-50%

Post-transplant infection

  • Postoperative infections are not uncommon
  • Infection bacterial are most common followed by viruses, fungi, and protozoa
  • Viral infections are most common in first 6 months
  • Common infections included herpes and CMV
  • Fungal infections most common in first 2 months
  • Candidiasis is the most common severe fungal infection
  • Aspergillosis is also a significant cause of death

Outcome

  • Typical survival figures are:
    • One year - 80%
    • 3-5 years - 70%
    • 10 years - 40%
  • Risk factors for death include
    • Previous transplant
    • Preoperative ventilator dependence
    • Age  (<5 or >60 recipient)
    • Ischemic time >3.5 hours (donor)
  • Most common causes of early death
    • Cardiac complications (40%)
    • Rejection (19%)
    • Infection (16%)
  • Infection is the most significant factor in late deaths, accounting for 40%

Bibliography

Garlicki M.  What is new in heart transplantation.  Ann Transplant 2005;  10:  49-50

Webber S A,  McCurry K,  Zeevi A.  Hear and lung transplantation in children.  Lancet 2006;  368:  53-69.

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