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CardiacCardiac
TransplantatiTransplantati
ononPeter LunnyPeter Lunny
8/7/088/7/08
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HistoryHistory
1967- first transplant by Dr1967- first transplant by Dr
Christiaan BernardChristiaan Bernard
United Network for Organ SharingUnited Network for Organ Sharing
~2000/year since 1990~2000/year since 1990
85% survival at 1 year85% survival at 1 year
77% survival at 3 year77% survival at 3 year
69% survival at 5 year69% survival at 5 year
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CausesCauses
Adult Peds (age dependent)
CAD 45% Congenital artery disease
Dilated Cardiomyopathy 45% Dilated Cardiomyopathy
Valve disease 4% Retransplant
Retransplant 2% Other
Congenital 2%
Misc 2%
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Operative procedureOperative procedure
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PhysiologyPhysiology
A denervated heart that supports normalA denervated heart that supports normal
circulation???circulation???
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PhysiologyPhysiology
A denervated heart that supports normalA denervated heart that supports normal
circulation???circulation???
However does respond to exogenous andHowever does respond to exogenous andendogenous circulating catacholamines.endogenous circulating catacholamines.
SVT -SVT -
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PhysiologyPhysiology
A denervated heart that supports normalA denervated heart that supports normal
circulation???circulation???
However does respond to exogenous andHowever does respond to exogenous andendogenous circulating catacholamines.endogenous circulating catacholamines.
SVT - Vagal manuvers will not work !SVT - Vagal manuvers will not work !
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PhysiologyPhysiology
A denervated heart that supports normalA denervated heart that supports normal
circulation???circulation???
However does respond to exogenous andHowever does respond to exogenous andendogenous circulating catacholamines.endogenous circulating catacholamines.
SVT - Vagal manuvers will not work !SVT - Vagal manuvers will not work !
Atropine will not work in symptomatic bradyAtropine will not work in symptomatic brady
arrhythmias !arrhythmias !
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PhysiologyPhysiology
A denervated heart that supports normalA denervated heart that supports normalcirculation???circulation???
However does respond to exogenous andHowever does respond to exogenous andendogenous circulating catacholamines.endogenous circulating catacholamines.
SVT - Vagal manuvers will not work !SVT - Vagal manuvers will not work !
Atropine will not work in symptomatic bradyAtropine will not work in symptomatic bradyarrhythmias !arrhythmias !
HOWEVER donor hearts are quite sensative to B-HOWEVER donor hearts are quite sensative to B-adrenergic agonists (isoproterenol, dopamine,adrenergic agonists (isoproterenol, dopamine,dobutamine)dobutamine)
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CXRCXR
Cardiomegaly to normal chest
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EchoEcho
Evaluation of cardiac function:Evaluation of cardiac function:
Atrial enlargement 2° to atrial anastamosisAtrial enlargement 2° to atrial anastamosis
with nativewith native atriaatria
Early rejection presents with diastolicEarly rejection presents with diastolic
dysfunctiondysfunction
Severe rejection – biventricular enlargementSevere rejection – biventricular enlargementwithwith hypocontractilityhypocontractility
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ImmunosuppressiveImmunosuppressive
TherapyTherapy
Lifelong triple therapy: Cyclosporine,Lifelong triple therapy: Cyclosporine,
Tacrolimus, prednisoneTacrolimus, prednisone
What we need to know:What we need to know:
✔ cyclosporine levels - acutecyclosporine levels - acute = renal dys= renal dys
acuteacute = acute= acuterejection !!rejection !!
✔ new drugs patient might have started b/cnew drugs patient might have started b/c
of interactionsof interactions with cyclosporinewith cyclosporine
C C l iC C l i
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Common CyclosporineCommon Cyclosporineand Tacrolimus Sideand Tacrolimus Side
EffectsEffectsHypertension
Renal insufficiency
Hirsutism *
Tremor
Gingival Hyperplasia *
Hyperkalemia
Hypomagnesemia
Hyperuricemia
Glucose intolerance
Seizures
Headache
Nausea and diarrhea ( esp Tacrolimus) *cyclosporine only
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RejectionRejection
Hyperacute: against donor tissueHyperacute: against donor tissue
Acute: most common, 75% have at someAcute: most common, 75% have at sometime during the firsttime during the first
6 weeks6 weeks
Endomyocardial biopsies routine post-opEndomyocardial biopsies routine post-op
Atrial/Ventricular dysrhythmia = acute rejectionAtrial/Ventricular dysrhythmia = acute rejectionuntil proven otherwise !!!! GIVEuntil proven otherwise !!!! GIVE
METHYLPREDNISONE 1 g and CALL CARDIOLOGY METHYLPREDNISONE 1 g and CALL CARDIOLOGY TO DO ENDOMYOCARDIAL BIOPSY TO DO ENDOMYOCARDIAL BIOPSY
Chronic: rejection in heart by graft atherosclerosisChronic: rejection in heart by graft atherosclerosisLook forLook for
failure/enzymes/asymmetric wallfailure/enzymes/asymmetric wall
motion/hypocontractilemotion/hypocontractile
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InfectionsInfections
Common early withCommon early with dose of dose of
immunosuppresantsimmunosuppresants
Annual flu shot and non live att vaccines, lowAnnual flu shot and non live att vaccines, lowthreshold for antibiotics, and always think threshold for antibiotics, and always think
CMV!!CMV!!
EARLY LATER ( > 1 MONTH)
GM – Bacilli pneumonia CMV, HSV, VZV, non-A,B hepStaph mediastinitis Listeria, Legionella,Mycobacterium
Enterococcal, GM - UTI Aspergillus,CryptococcalHSV skin infection PCP, Toxoplasma
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Non-infectiousNon-infectious
Maligancies ass. with chronicMaligancies ass. with chronic
immunosuppression : Lymphomproliferativeimmunosuppression : Lymphomproliferativedisorder, B cell lymphoma ass. with EBVdisorder, B cell lymphoma ass. with EBV
Long term steroids : osteopenia, asepticLong term steroids : osteopenia, aseptic
necrosis and compression fracturesnecrosis and compression fractures
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PediatricPediatric
considerationsconsiderations
Rejection monitored by echo not biopsyRejection monitored by echo not biopsy
Triple therapy but try to avoid long termTriple therapy but try to avoid long term
steroidssteroids
Care with chickenpox, if + give VZIGCare with chickenpox, if + give VZIG
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OUR JOBOUR JOB
Treat like normal but always think aboutTreat like normal but always think about
rejection, infection or side effects torejection, infection or side effects to
immunosuppressive therapy !immunosuppressive therapy !
Care using NSAID’s b/c could exacrebateCare using NSAID’s b/c could exacrebate
underlying renal insufficiency 2° tounderlying renal insufficiency 2° to
cyclosporine and tacrolimuscyclosporine and tacrolimus
If in extremis think: rejection - no atropineIf in extremis think: rejection - no atropine
but give steriodsbut give steriods
MI – arrhythmia,MI – arrhythmia,
hyperkalemia ?hyperkalemia ?
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ReferencesReferences
Emergency Medicine; Rosen, Barkin 4Emergency Medicine; Rosen, Barkin 4thth ed.ed.
19981998
Tintinalli, Emergency Medicine 2004Tintinalli, Emergency Medicine 2004
Google imagesGoogle images
WikipediaWikipedia