Post Operative Management in Heart Transplant นพ พ ชร อ องจร ต ศ ลยศาสตร ห วใจและทรวงอก จ ฬาลงกรณ

Post Operative Management in Heart Transplant นพ พ ชร อ องจร ต ศ ลยศาสตร ห วใจและทรวงอก จ ฬาลงกรณ

Art of Good Cooking Good Ingredient Good donor + OK recipient Good technique Good team Good timing Good organization Well practice

Heart Transplant: Peri-op Issues Donor Surgical techniques Peri operative graft Failure Imm-suppressive and rejection management Renal function management

Issues: medium long term Renal function management Transplant Allograft Vasculopathy Malignancy CMV infection

Donor Management Matching Donor cardiovascular care Donor procurement and preservation

Donor Cardiovascular Care Minimize effects of brain dead physiology DI Hormone Vascular tone Fluid+ Electrolyte deranged Over Innotropic drug Low Hct Low plasma osmolarity

Donor-recipient Matching Size: Greater than 80% of recipient body weight Blood type: Identical or compatible HLA-matching: Generally not done Direct X match only in preformed antibody found in recipient

Donor Procurement and Preservation Preservative agent St Thomas Cardioplegia Blood Cardioplegia Celsior HTK solution Custodiol

Donor Procurement and Preservation Ischemic Time Optimum time : less than 4 hours Acceptable to 6 hours On arrival blood cardioplegia technique in long ischemic time case

Surgical Techniques

Surgical Complications Bleeding Mal alignment Flow obstruction Tricuspid regurgitation

Immediate Post Op Complications Pumping failure Renal failure Rejection Bleeding

Pumping Failure Graft preservation and Ischemic time Hyper acute rejection Acute rejection Right heart failure Pulmonary hypertension?

Right Side Heart Failure Most common cause of death in peri operative Right ventricle is more prone to ischemic injury Thin wall - less reserve muscle contraction Room temperature exposed

Right Heart Failure High CVP Distended Rt ventricle Tricuspid regurgitation High Pulmonary artery pressure(pap) +/- Low PAP but distended RV very bad sign

Treatments of RV Failure Decompress right side Optimal preload volume Over fill increases Tricuspid regurgitation Lower Pulmonary vascular resistance Maximum ventilation support Drugs : NTG, Isuprel, Primacor, Viagra Nitric Oxide, Illoprost Increase RV contraction Mechanical support : IABP Ventricular assist device

Left Side Failure Mostly from donor heart issues Donor pre transplant condition Ischemic time Myocardium Preservation Acute rejection is rare Mostly result of reperfusion injury

Treatments of LV Failure Rest myocardium : Empty beating heart Optimal innothropic drugs Optimal environment for myocardium recovery Preload / Afterload Blood gas, Electrolyte, acid base,calcium etc Mechanical Support IABP VAD

Ventricular Assist Device

Bi Ventricular (a) Cannulation for CentriMag Assist BiVAD Device Takayama H. et al.; Interact CardioVasc Thorac Surg 2011;12:110-111

Rejection

Immunosuppressive Therapy CNI Cyclosporine A FK 506 Antimetabolite Azathioprine Mycophenolate Steroid Adrenocortical steroids Lymphocytolytic Therapy Anti-thymocyte globulin (ATG)

Induction Therapy RATG: Reduce Acute rejection Periop acute renal failure Long term rejection Increase Infection

Standard Triple therapy Preoperative Azathioprine: 4 mg/kg IV Intraoperative Methylprednisolone: 500 mg Postoperative Cyclosporine: 2-6 mg/kg po bid based on trough levels and renal function Azathioprine: 2 mg/kg/day Methylprednisolone: 125 mg IV every 8 hours for 3-4 doses, followed by prednisone Prednisone: (beginning after Methylprednisolone)1 mg/kg/day tapering over 1 week to 0.5 mg/kg/day,

Maintenance Immunosuppression Goal Lowest overall level of immunosuppression to prevent rejection Cyclosporine levels Low therapeutic after 1-2 years Azathioprine 1-2 mg/kg/day after 1-2 years Prednisone 0-0.1 mg/kg/day after 1 year

Problem with CNI Renal toxicity esp during critical period Injured and recovering myocardium Injured renal after CPB Compromised cardiac output and renal perfusion

CNI free Regimens m TOR inhibitor Sirolimus (Rapamune) Everolimus (Certican) No renal toxicicty Higher rate of rejection in de novo used.

Strategies :Renal Shutdown Immediate Post Op Prolonged Induction Higher rate of infection CNI free regimen de novo Higher rate of rejection Lower CNI combined with mtor Forget kidneys and protect heart Renal transplant after kidney transplant?

Rejection Endomyocardial biopsy Acute rejeciton Hospital Out-patient

Rejection

Rejection

Rejection

TREATMENT OF REJECTION GRADE Mild Moderate Moderate Severe None or oral corticosteroid augmentation Oral corticosteroid augmentation or IV corticosteroids IV corticosteroids +/- ATG or OKT3

Infection Most of fatal infection in post op heart transplant came from Colonized pre transplant (poor condition recipient) Consequences of prolong postop heart failure; prolong intubation CMV is the most common infection problem in medium and long term

Infection Pre transplant prolong intubation is the most important risk factor in post transplant infection Prolong post transplant intubation must be avoid Post op renal failure contribute to fatal infection

Infection Bacterial - Most Common Viral Fungal

Infectious Prophylaxis Pathogenic Organism Cytomegalovirus Herpes simplex Toxoplasmosis Pneumocystis Oral candidiasis Prophylactic Agent Gancyclovir, Acyclovir, IVIg Acyclovir Pyrimethamine and Leucovorin TMP/SMX, Dapsone, Pentamidine Nystatin, Mycelex troches

Peri operative Renal Failure Poor renal perfusion Poor cardiac function Post cardio pul bypass injury CNI toxicity in not fully recovered renal Induction Therapy : give renal toxic free window period

Renal Failure Most important side effect of cyclosporin from afferent arteriolar vasoconstriction and direct tubular cell injury; Dose related to some extent and will improve with reduction in the Cyclosporin dose

Peri operative renal failure Extended induction technique Intermittent RATG after complted normal induction duration Follow CD 3 CNI free until renal recover Significantly increase infection

Common Dilemmas Poor cardiac function Cannot extubate Cannot start oral CNI Prolong use of RATG : over suppress Infection flare up

Common Dilemmas Poor cardiac function Poor urine flow Cannot start oral CNI Higher risk of rejection

Conclusions Donor recipient condition Most important Right side heart failure is the most common cause of operative dead Prolong poor cardiac function leaded to prolong intubation and fatal infection Post operative care is the most difficult aspect in heart transplant

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