Professional Documents
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Heart Transplantation: Dr. K V Siva Krishna
Heart Transplantation: Dr. K V Siva Krishna
4500
4000
Number of transplants
3500
3000
4,939
4,838
4,802
4,754
4,735
4,683
2500
4,602
4,528
4,515
4,477
4,254
4,233
4,200
4,163
4,110
4,071
4,044
4,042
4,013
4,001
3,936
3,913
3,838
3,822
3,807
2000
3,525
2,998
1500
2,357
1000
1,261
322
187
500
671
North America
3500
3000
2500
2000
1500
1000
500
60 Myopathy CAD
50
40
30
20
ISHLT
cardiac transplantation during childhood aged less than 1 year.
Registry of the International Society of Heart and Lung Transplantation. J Heart Lung
Transplant 2007;26:796–807
Cardiac transplantation aged from 1 to 10 years
Registry of the International Society of Heart and Lung Transplantation. J Heart Lun
Transplant 2007;26:796–807
Adult and Pediatric Heart Transplants
Kaplan-Meier Survival
(Transplants: January 1982 – June 2013)
100
Median survival = 11 years
Median survival conditional on surviving 1st year = 13 years
75
Survival (%)
50
N = 112,521
N at risk at 30 years = 16
25
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Years
2015
JHLT.2015
JHLT. 2014Oct;
Oct;34(10):
33(10):1244-1254
996-1008
Adult and Pediatric Heart Transplants
Kaplan-Meier Survival by Age Group
(Transplants: January 1982 – June 2013)
100
Adult (N=100,806)
Pediatric (N=11,384)
75
p < 0.0001
Survival (%)
50
25
Median survival (years):
Adult=10.3; Conditional=13.0
Pediatric=15.3; Conditional=20.0
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Years
2015
JHLT.
JHLT. 2015
2014 Oct;
Oct; 34(10):
33(10): 1244-1254
1009-1024
Surviving stars
Louis Washkansky was the first recipient of heart transplant in South Africa by Dr Christian Barnard. He survived the
operation and lived for 18 days
Tony Huesman is the world's longest living heart transplant recipient who survived 31 years. He received a heart in 1978
at the age of 20 after viral pneumonia severely weakened his heart. Huesman died on August 10, 2009 of cancer. He was
operated at Stanford University under heart transplant pioneer Dr Norman Shumway
Elizabeth Craze, now 32 years old, an IT employee working for Facebook in Palo Alto is one of the youngest successful
heart transplant recipients in the world who received transplant at the age of two years and 10 months
Indications for heart transplantation
The ACC/AHA guidelines include the following indications for
cardiac transplantation:
1. Refractory cardiogenic shock requiring intra-aortic balloon pump
counterpulsation or left ventricular assist device (LVAD);
2. Cardiogenic shock requiring continuous intravenous inotropic
therapy (i.e., dobutamine, milrinone, etc.);
3. Peak VO2 (VO2max) less than 10 mL/kg per min;
4. NYHA class of III or IV despite maximized medical and
resynchronization therapy;
5. Recurrent life-threatening left ventricular arrhythmias despite an
implantable cardiac defibrillator, antiarrhythmic therapy, or catheter-
based ablation;
6. End-stage congenital HF with no evidence of pulmonary
hypertension
7. Refractory angina without potential medical or surgical therapeutic
options.
ESC: Features that must be met before consideration for heart transplant
which are more specific and include, functional, structural and symptoms
parameters:
1. Severe symptoms, with dyspnea at rest or with minimal exertion
(NYHA class III or IV);
2. Episodes of fluid retention (pulmonary or systemic congestion,
peripheral edema) or of reduced cardiac output at rest (peripheral
hypoperfusion);
3. Objective evidence of severe cardiac dysfunction (at least one of
the following):
• Left ventricular ejection fraction less than 30%,
• Pseudonormal or restrictive mitral inflow pattern on Doppler
echocardiography,
• High left and/or right ventricular filling pressure
• Severely impaired functional capacity demonstrated by one of the
following: inability to exercise, 6-minute walk test distance less than
300 m (or less in women or patients who are age 75 and older), or
peak oxygen intake less than 12 to 14 mL/kg/min;
4. One or more hospitalizations for HF in the past 6 months.
• Recipient Evaluation and Selection
Techniques
cavo-atrial junction
BIATRIAL TECHNIQUE
incision is ideally made : medially through
The SVC is doubly ligated and the right
the ostium of the coronary sinus and
atrium is opened from the lateral IVC
laterally through the floor of the fossa
toward the right atrial appendage, to avoid
ovalis
the sinus node
Donor heart The superior vena caval cuff is trimmed at
the level of the azygous vein opening and
more if adequate recipient cuff is present
Connecting incisions
between each of
the 4 pulmonary veins
Orthotopic heart transplantation: bicaval anastomosis
technique
Suturing the LA
The right atrial anastomosis is initiated at the superior end of the atrial incision. A
long 3-0 Prolene suture is used and the suture ends are carried both inferiorly and
superiorly to first complete the septal anastomosis, and then they are joined at the
lateral wall of the septum.
Completed orthotopic heart transplantation
Reperfusion
Look for LA anastomotic site
bleed
RA RV site
Inotropic support
Vasodilators
CPB separation
• May develop bradyarrythmias
– Require direct acting sympathomimetics, pacing
• Most grafts recover normal ventricular function
– Dysfunction secondary to ischemia
– Concern with early recognition of right ventricular failure
• RV failure
– PVR > 4 Woods units with little or no reversibility preop
– Low CO with elevated CVP (> 15) and elevated PAP (>
40). PCWP may be low.
• The most common reason for failure to
wean a heart transplant recipient from
cardiopulmonary bypass is right-sided
heart failure, evidenced by a low cardiac
output despite a rising central venous
pressure.
Heterotopic heart transplantation
Heterotopic heart transplantation involves a donor heart being connected in parallel with
the recipient heart. The end result involves four surgical anastomoses: at the levels of
the right atria, left atria, aortas, and pulmonary trunks.
• Advantages to the heterotopic technique compared with
the traditional orthotopic approach.
• The native heart basically functions as an “assist device”
and usually can maintain circulation during:
• I. recovery of donor heart function from ischemia
sustained during transplantation.
• 2. severe rejection episodes.
• 3. the period of adaptation of a small donor heart to the
demands of the circulation.
• 4.the period of adaptation during which the PVR
decreases after transplantation and
• 5. a period of chronic rejection, while the patients awaits
retransplantation.
• There are, however, a few distinct disadvantages
inherent in heterotopic transplantation that cannot be
ignored.
• These include:
• I. the continuing risk of embolic episodes originating from
thrombi in the poorly contracting native left ventricle;
• 2. angina, which may be secondary to persistent
ischemia in the native myocardium, and
• 3. functionally significant right lower lobe atelectasis
secondary to the position of the heterotopic heart. This
can be a source of persistent pulmonary dysfunction and
recurrent pneumonia.
Post transplant physiology
• Cardiac denervation is an inevitable consequence : a
denervated donor heart.
• The atrial remnant of the recipient remains innervated,
but no impulses will cross the suture line.
• As a result, the donor atrium is responsible for heart rate
generation.
• The transplanted heart has a higher intrinsic rate and
reduced rate variability.
• Resting heart rates range from 90 to 110 beats per
minute.
• Normal responses to changes in position, e.g. orthostatic
changes, are lost as are the variations in response to
stimuli such as the Valsalva manoeuvre, carotid sinus
massage.
• Intrinsic functions such as cardiac impulse formation and
conduction are intact.
• The Frank-Starling mechanism is also intact
• In the innervated heart, the normal acute response to a
sudden reduction in intravascular volume is a
simultaneous increase in both heart rate and contractility.
• In the denervated heart, however, the initial response via
the Frank-Starling mechanism is an increase in stroke
volume dependent on an adequate left ventricular end
diastolic volume.
• The increased contractility secondary to heart rate is a
secondary effect and is dependent on circulating
catecholamines.
• The transplanted heart is, therefore, critically preload
dependent; higher filling pressures are needed.
Early Post-operative Care of
the
Heart Transplant Recipient
Peri-operative and Post-operative Monitoring:
• Recommendations on the Post-operative Monitoring
of Heart Transplant Recipients
• Class I:
• Peri-operative monitoring of heart transplant recipients
should include (1) continuous ECG monitoring; (2)
postoperative 12-lead ECG; (3) invasive arterial pressure
monitoring; (4) direct measurement of RAP or CVP; (5)
measurement of left atrial or pulmonary artery wedge
pressure (PAWP); (6) intermittent measurement of CO;
(7) continuous measurement of arterial oxygen
saturation; (8) intra-operative TEE; (9) continuous
assessment of urinary output.
• Level of Evidence: C.
Hemodynamic Management
Increased BMI
African Americans
Renal Insufficiency
Hypertension Hyperlipidemia
• The excess risk of • Typically,
hypertension is related • total cholesterol, low-density
primarily to the use of lipoprotein (LDL) cholesterol,
• Calcineurin inhibitors and triglycerides increase by 3
because of both direct effects months after transplantation
of the drugs on the kidney and then
and the associated renal • generally fall somewhat after
insufficiency that also is the first year.
highly prevalent. The
• Cyclosporine increases serum
incidence of hypertension
LDL cholesterol and binds
may be lower with tacrolimus
than with cyclosporine • to the LDL receptor, decreasing
its availability to absorb
• Post-transplantation
cholesterol
hypertension is difficult to
control and often requires a • from the bloodstream.
combination of several
antihypertensive agents..
• Malignancy
• Neoplastic disorders after cardiac transplantation arise
from three major causes: preexisting malignancies,
transmission of malignancy from donor to recipient, and
de novo malignancy arising after transplantation.
• Tumors most likely to recur in heart transplant recipients
are carcinoma of the lung, lymphoma, skin cancer, and
carcinoma of the bladder
• The incidence of de novo recipient malignancy is
approximately 100 times that of the non–age-controlled
general population.
The basic options for treatment of PTLPD
(1) reduction of immunosuppression,
(2) surgical extirpation,
(3) chemotherapy,
(4) antivirals,
(5) anti–B-cell antibodies,and
(6) cell-based therapies
• Cardiac allograft vasculopathy: annual incidence
rate of 5% to 10%.
• CAV is detectable by angiography in 8% of
survivors within the first year, in 32% within the
first 5 years, and in 43% within the first 8 years
after HTx.
• Severe CAV is positively correlated with
persistent inflammation and a higher degree of
HLA mismatch.
• In contrast with eccentric lesions seen in atheromatous
disease, CAV results from neointimal proliferation of
vascular smooth muscle cells, so that it is a generalized
process.
• Characterized by concentric narrowing that affects the
entire length of the coronary tree, from the epicardial to
the intramyocardial segments, leading to rapid tapering,
pruning, and obliteration of third-order branch vessels
• The first clinical manifestation of CAV may be
myocardial ischemia and infarction, heart failure,
ventricular arrhythmia,or sudden death.
• Angina is rare because of denervation of the
heart.
Pathophysiology is multi factorial
• Invasive Detection of CAV
• Intravascular Ultrasound Intravascular ultrasound (IVUS)
is the most sensitive tool for the diagnosis of CAV. IVUS
allows a reproducible view of both actual lumen diameter
and the appearance and thickness of the intima and
media
• Rapidly progressive CAV, defined as an increase of 0.5
mm in maximal intimal thickness within the first year after
HTx, is associated with a significantly increased risk of
all-cause death, myocardial infarction, and the
subsequent development of angiographically severe
CAV.
• Coronary Angiography
• Coronary angiography is still the standard for the
diagnosis of CAV in most transplant centers, and the
angiographic detection of significant epicardial coronary
stenoses conveys a poor prognosis.
• CAV is detectable by angiography in 30% to 50% of HTx
survivors after 5 years
• Noninvasive Screening
• Dobutamine Stress Echocardiography The sensitivity of
dobutamine stress echocardiography compared with
coronary angiography is 80%.
• When intimal thickening by intravascular ultrasound is
taken as the “gold standard,” dobutamine stress
echocardiography shows specificities of up to 88%.63
• Single-Photon Emission CT
• Annual myocardial single-photon emission CT (SPECT)
has a high negative predictive value and appears to be
well suited to screening for significant CAV.
• Multidetector CT
• MDCT with adaptive multisegment reconstruction has a
sensitivity and specificity of 86% and 99%, respectively
• Biomarkers and Gene Profiling
• Elevated C-reactive protein concentrations are
associated with progression of CAV,
• Whereas persistently elevated levels of troponin I
are associated with a significantly increased risk
for subsequent development of CAV.
• The clinical use of brain natriuretic peptide (BNP)
levels as a predictor of survival after HTx remains
controversial.
• Therapeutic Options
• Statins
• Vasodilators
• Endothelial Protection
• Infection and CAV ( CMV INFECTION)
• Immunosuppression: mTOR inhibitors
• The use of everolimus from the time of
HTx has shown to preserve the coronary
artery lumen at 1 year.
• Emerging New Strategies for the Prevention or
Treatment of CAV
• Three different strategies for CAV are emerging: (1)
inhibition of growth factors, cytokines, and circulating
antibodies; (2) cell therapy; and (3) tolerance
induction.
• New therapeutic strategies should be directed against
matrix formation
• Sensitive methods for detecting circulating antibodies
and improved therapeutic strategies
(eg:photophoresis) against these antibodies are
currently under investigation.
• FUTURE PERSPECTIVES
• Need for improved immunosuppression with less
rejection, cardiac allograft vasculopathy and side
effects
• Need for better non-invasive methods to detect
acute and chronic rejection
• Need to focus on improved survival and quality
of life
• Challenges in performing long-term adequately
powered multi-centered trials
Thank you