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. |