2/28/2017. Adult Heart Transplants Donor and Recipient Characteristics UNOS, Retransplant VCM. Other /2015 (N = 24,474)

Transcription

1 1

2 46% 2% 3% 4% 0% 2% 2% CHD HCM ICM NICM RCM 49% 3% 3% 3% 1% 3% 3% Retransplant VCM 42% Other 35% 1/1982 6/2015 1/2009 6/ JHLT Oct; 35(10): UNOS, 2017 Adult Heart Transplants Donor and Recipient Characteristics Pre-operative support (multiple items may be reported) (N = 48,388) (N = 17,666) /2015 (N = 24,474) p-value Hospitalized at time of transplant 59.0% 46.4% 44.1% < On IV inotropes 54.6% % 39.4% < Ventilator 3.3% 3.0% 2.1% < IABP 6.4% 7.0% 6.4% Mechanical circulatory support 22.2% % 44.7% < LVAD 20.1% % 38.1% < RVAD - 4.4% 3 3.2% < TAH 0.5% 2 0.5% 1.4% < ECMO 0.3% 4 0.9% 1.3% < JHLT Oct; 35(10):

3 Indications Stage D Heart Failure Sick enough? Reversible Causes Addressed VO2 max HFSS SHFM INTERMACS Transplant Evaluation SHSS 1 year survival <80% HFSS high/medium risk VO2 Max < 12 ml/kg/min Candidate? Medical Surgical Psychosocial/financial Re-Transplants CHD Defer SHSS 1 year survival >80% HFSS low risk VO2 Max >14ml/kg/min Yes Listing No Palliation 3

4 4

5 Donor Specific Antibodies: (DSA) Antibodies directed against human leukocyte antigens (HLA) are associated with mortality, graft rejection, dysfunction, organ loss, graft vasculopathy Why are they there? Sensitizing event: blood transfusions, pregnancy, prior Tx, surgery, infection Panel reactive antibody (PRA) = percentage of possible donor HLA antigens targeted by the recipient s circulating antibodies. **Percentage estimate of the local donor pool that will be incompatible with recipient** Cross-match testing: recipient s serum combined with donor cells to see if compatible ABSOLUTE CONTRAINDICATIONS 1.Organ transport time >4 hours 2.Confirmed myocardial infarction with systolic dysfunction 3.LVEF <30% 4.Severe valvulardisease not amenable to repair 5.Active infection with transmissible pathogens including, but not limited to HIV, hepatitis B (HBSAg +) or C virus, or highly resistant bacteria 6.Bacterial endocarditis 7.A history of major extracranial or metastatic malignancy 8.Age > 60 years 9.Significant penetrating cardiac trauma RELATIVE CONTRAINDICATIONS 1.Donor recipient mismatch > 6 inches 2.Age years 3.Male donors > 45 years and female donors > 50 years with cardiovascular risk factors and an inability to perform coronary angiography 4.Previous high risk behavior including intravenous drug use or risky sexual activity 5.Donor instability manifested by hypoxia, severe acidosis with ph<7.2, hypotension requiring high dose vasoconstrictors 6.Organ transport time 3-4 hours 5

6 BiatrialAnastomosis Shorter ischemic time Complications Atrial dysfunction due to size mismatch of atrial remnants Arrhythmia (sinus node dysfunction, bradyarrhythmias, and AV conduction disturbances) that necessitate PPM implantation BicavalAnastomosis Can prolong ischemic times Decreases incidence of arrhythmias, the need for a pacemaker, and risk for mitral or tricuspid regurgitation Narrowing of the SVC and IVC make biopsy surveillance difficult Annals of Cardiac Anaesthesia, Vol. 12, No. 1, January-April, 2009, pp Maintain perfusion RV support Early Diuresis Pacing Inotropic support Manage rhythms 6

7 Infection Rejection Mainstay of therapy, inhibits T-cell lymphokine production Trough levels monitored Tacrolimus (Prograf, FK-506)-most widely used Cyclosporine (Gengraf/Neoral) Adverse effects Hyperglycemia Renal dysfunction HTN Tremor Gingival hyperplasia Risk of malignancy 7

8 Adverse effects: Short-term Psychosis, confusion Fluid retention GI symptoms Hyperglycemia Insomnia Increased appetite Long-term Osteoporosis Diabetes Impaired wound healing Hypertension Glaucoma, cataracts 8

9 Rejection Infection Complications Cardiac Allograft Vasculopathy (CAV) Malignancy 9

10 Adult Heart Transplants Relative Incidence of Leading Causes of 50 Death 40 CAV Malignancy (non-lymph/ptld) Graft Failure Renal Failure Acute Rejection Infection (non-cmv) Multiple Organ Failure % of Deaths Days (N=1,474) 31 Days - 1 Year (N=1,416) >1-3 Years (N=986) >3-5 Years (N=813) >5-10 Years (N=2,091) >10-15 Years (N=2,158) >15 years (N=2,632) 2016 JHLT Oct; 35(10):

11 CMV Most common infection after solid organ transplant Wide range of symptoms: -Fever (may be blunted because of weakened immune system) -Abdominal pain, diarrhea, nausea, vomiting -GI bleeding -Pneumonia (lung involvement) -Neurological changes (altered mental status, seizures) -Visual impairment (CMV retinitis) Test of choice CMV PCR +/-biopsy of involved organ Treatment high dose ganciclovir or valganciclovir 11

12 Class I Class II Screen for breast, colon and prostate cancer Skin cancer surveillance Evaluation for post-transplant lymphoproliferative disorder (PTLD) No evidence to support a reduction in immunosuppression in patients with solid tumors unrelated to the lymphoid system Chronic immunosuppression should be minimized as possible, particularly in patients at high risk for malignancy 12

13 13