Cardiac Transplant Ricci Wells, RN, BSN

Nurse ManagerCardiac Transplant/VAD/Advanced Heart Failure

Mid America Heart InstituteSaint Luke’s Hospital of Kansas City

Objectives:➢ History of Transplant

➢ Pre transplant Process

➢ Implantation

➢ Post transplant process

➢ Post transplant complications

Heart TransplantHistory

First heart transplant was performed in

1967 in Cape Town, South Africa by

Dr. Christaan Barnard

Heart Transplant“A new and disquieting look at transplants: The year they changed hearts”

“By 1971, 150 heart transplants world-wide with near 100% mortality from

rejection or infection.”

Volume of Heart Transplants at SLH

0

5

10

15

20

25

30

35

40

45

50

Consultants:

Pulmonary, ID, GYN/Urology, GI, Psych, CTS,

Social Worker, Dietitian and Chaplain

If indicated: Endocrinology, Neurology

Labwork:

CBC, BMP, Coag, Lipids, CrCl, Serologies (HIV,

RPR, Hep B, Hep C), Toxicology, PSA (males),

Quant gold TB, Urine nicotine, ABO, CVM, VZ,

EBV

Testing/procedures:

Immunizations, CXR, PFT, MVO2, CT chest, Echo,

RHC, Carotid duplex, PV duplex, Panorex, Abd

sonogram, Pap smear/mammogram (females),

colonoscopy (pts over 50)

Evaluation Process

Heart Transplant Candidate Selection

End stage cardiac disease with <50% 1 year

survival as defined by:• Stage D HF despite optimal medical and device therapy.Peak VO2 <12 or 50% predicted

>10% decrease on serial peak VO2

Selected unstable pts with higher VO2 may be considered.

• Intractable angina not amendable to percutaneous or surgical

therapy.

• Intractable ventricular dysrhythmias not amendable to

antiarrhythmic or percutaneous/surgical ablation.

• No expectation of improvement with alternative medical or

surgical treatment

Heart Transplant Exclusion Criteria

• Age 66 years or greater. Selected patients greater than 65 years of

age may be considered on individual basis.

• Severe pulmonary HTN (PVR > 4)

• Irreversible renal or hepatic dysfunction – may consider dual organ

transplant for renal failure

• Systemic disease including but not limited to cirrhosis, severe

COPD, hx of cancer, symptomatic PAD/PVD, end organ diabetic

disease, poorly controlled diabetes and active hepatitis.

• Malignancy – varies by type and date of diagnosis

• Active infection

• Evidence of nicotine/alcohol/illegal substance use currently or

within the past 6 months.

• Morbid obesity with BMI > 35. Selected patients with BMI 36 – 40

may be considered on an individual basis.

• History of noncompliance

• Psychosocial or cognitive instability

• Lack of family/social support

• Lack of adequate financial coverage for ongoing transplant care.

Coordination of Transplant

➢ Once donor/recipient are matched and heart is

accepted, surgeon and timing are coordinated

➢ Transplant Coordinator notifies CVOR team

(Recipient team and Donor team)

➢ Local donor vs. Non-local donor

Removal of Donor Heart(Cardiectomy)

➢ Aorta and Pulmonary Artery

➢ Superior Vena Cava and Inferior Vena Cava

➢ Heparin IV given (300 units/kg)

➢ Cross clamp aorta

➢ Cardioplegia infused

De Vega Annuloplasty

Post Transplant Recovery Process

CVICU – 24 to 48 hours

• Arrives sedated and intubated

• Maintain Hemodynamic stability

• Manage ventilation and oxygenation

• Recovery from anesthesia, pain management

• Wean from ventilator – goal is within 6 hours

• Monitor drainage output

Surgical Telemetry floor – 6 to 9 days (with no complications)

• Continue to monitor hemodynamic stability

• Patient increase ambulatory status

• Post transplant education (RN’s, Dietitian, Pharmacist, Physicians, Social

Workers, etc…)

POST TRANSPLANT SCHEDULE

Clinic Visits – post transplant week 2, 3, 4, 6, 8, then monthly for 1st year,

every 3 months x 2 years and then every 6 months for life.

• Cardiac Biopsy at each visit up to 6 months and then as needed.

• AlloMap testing starting at 4 months through 3rd year.

• ECHO

• Stress Echo

• Chest x-ray

• ECG

• Lab – CSA/Tac levels, BMP, CBC, CMV, FLP

• Coronary angiogram at 6 weeks (baseline), 1, 3, 6, 10 years

Annual visits – additional Lab: TSH, Vitamin D level, HgbA1C, PSA,

testosterone

Bone density testing

Colonoscopy (> 50 yrs old every 5 years), Mammogram,

pap smear, prostate exam

Endomyocardial Biopsy

■ Standard for evaluating rejection

■ Done in the CV Cath Lab by the Transplant Cardiologist

■ No biopsies after 3 years unless symptomatic of rejection or have stopped

medications and may not need if Allomap scores are acceptable.

Endomyocardial Biopsy

AlloMap Test

■ Molecular gene expression testing – Blood sample to detect the absence of rejection.

■ Genes from WBC are analyzed

■ Results give an AlloMap score of 0 to 40

■ Draw at 4th and 5th month clinic visit with biopsy and compare the results of allomap with biopsy.

■ Our protocol is 4 – 6 months score < 30 and greater than 6 months score < 34.

■ At 6 month clinic visit, if allomap score is < 34 and biopsies have been negative, do not need further biopsies unless otherwise indicated.

Triple drug therapy

Steroid

Prednisone*

Calcineurin Inhibitor

Cyclosporine

FK506

Tacrolimus*

Antimetabolite

Azothiaprin

Mycophenolate*

Immunosuppression

Medication Side Effects

■ Tacrolimus – Headaches, tremors, tingling hands/feet, nausea/vomiting/diarrhea, HTN, decrease renal function, increase K+ and cholesterol, increase blood sugars

■ Cyclosporine – Tremors, hair growth, high blood pressure, increase K+ and cholesterol levels, muscle cramps, headaches

■ Mycophenalate – Nausea/vomiting/diarrhea, low WBC, anemia, increase risk of skin cancer

■ Steroids – Low WBC, HTN, osteoporosis, skin tears and bruising, increased appetite, sleeping difficulties, hair growth, mood swings, increase blood sugars, thrush

How do we treat med side effects?

■ Check levels of meds and consider lower dose.

■ Other medications to treat side effects.

Post transplant guidelines

■ Sternal precautions

■ Keep track of daily vital signs, weight, blood sugars

■ Visitors/family – masks, good hand washing

■ Pets

■ Travel

■ Tattoos/piercings/acrylic nails

■ Vaccinations

■ Dental care

Complications

■ Rejection – Cellular and AMR

■ Coronary Disease/Graft Vasculopathy

■ Cancer

■ Infection

Heart TransplantComplications

Infection

Drug side effects

Cancer

Coronary artery disease

Hypertension

Renal dysfunctionRejection

Rejection

Acute Cellular Rejection – Surface cell antigens of donor heart

are recognized as foreign. Production of T cells.

■ Most common type of rejection

■ Signs and symptoms – “flu like” If severe, HF symptoms

and sometimes no symptoms at all.

Grading system – 0, 1R, 2R, 3R

■ 0 – No rejection - no treatment as long as therapeutic levels

■ 1R – Mild rejection – no treatment as long as therapeutic levels

■ 2R – Moderate rejection – protocol based with increase in oral

prednisone

■ 3R – Severe rejection – Admit, Solumedrol IV or Thymo protocol,

aggressive hemodynamic support (inotropes, IABP), activate for re-

transplant

Heart TransplantCellular Rejection

Rejection

Antibody Mediated Rejection (AMR) – Antibodies bind

to antigens on the endothelial surface

■ Not as common

Grading system

■ AMR 0 – both histological and immunopathological studies are negative

■ AMR 1 – Histopathological alone

■ AMR 2 - Both histological and immunopathological findings are positive

■ AMR 3 – Severe AMR

■ Diagnose and Treatment – Lab (PRA, DSA), Echo, Biopsy, maximize immunosuppression

Rejection

■ Hyper-acute: Rare, happens in the OR or immediate post op. Rapid tissue necrosis.

Prognosis is poor. Fortunately incidence is < 1%. Risk factors – ABO mismatch

and antibodies to donor cells

■ Acute: First couple of months, incidence decreases with time. Occurs if

noncompliance with meds.

■ Chronic: > 6 months after transplant.

Coronary Disease/Vasculopathy

■ A rapid and progressive form of CAD characterized by diffuse intimal stenosis that

effects entire length of vessel.

■ Intimal lesions can develop rapidly

■ Unlike CAD, calcification is rare in transplanted hearts

■ Clinical manifestations may include – increased fatigue, SOA, HF, dysrhythmias,

sudden death.

■ Diagnostic testing – Coronary angiogram with IVUS (intravascular ultrasound)

Coronary Angiogram with IVUS

Coronary Disease/Vasculopathy

Who is at risk?

■ Donor > 40 yrs old

■ Younger recipients

■ Older donor into young recipient

■ Continuation of smoking

■ Obesity

■ Ischemic time

■ Pre transplant diagnosis

■ Female diabetic donors

■ Intolerant to statin therapy

■ Diabetes

■ Chronic or multiple rejections

■ History of CMV infection

Constanzo MR et al, Are there specific risk factors for fatal allograft vasculopathy? An analysis of over 7,000 cardiac transplant patients. J Heart Lung Transplant 20:152,2001

Coronary Disease/Vasculopathy

Preventative Treatment

■ Modification of risk factors – weight loss, lipid reduction, control of HTN, control of

DM, medical therapy (statins)

Treatment

■ Revascularization procedures – PTCA or CAB but are limited options because of

nature of diffuse disease.

■ Only definitive treatment is re-transplantation

Cancer

Several factors have contributed to the increase in post transplant malignancies.

1. Improved graft survival and longer exposure to immunosuppression.

2. Use of more potent immunosuppression.

CancerSkin Cancer – most common

■ 38% of all malignancies

■ SCC more frequently than BCC

■ Older recipients

■ Skin lesions are more aggressive

and incidence of multiple lesions

is higher

■ Relapses and metastasis are

more common

DeSalvo TG, The differing hazard of lymphoma vs. other malignancies in the current era.J Heart Lung Transplant 17:7,1998

Cancer

Post Transplant Lymphoproliferative Disease (PTLD) – Involves wide spectrum of

disorders that range from benign hyperplasia to malignant lymphomas.

■ Incidence ranges from 2% in kidney recipients to 10% in heart/lung recipients.

■ Risk factors – intense immunosupression, EBV infection, CMV infection, type of

transplant

■ May or may not be symptomatic

Cancer

Prevention of Cancer

■ Smoking cessation

■ Routine self exam of skin

■ Sun precautions – avoid sun exposure, wear protective clothing, sunscreen

■ Routine cancer screening – colonoscopy, prostate exam, mammogram, pap smear

Heart TransplantInfection

Who is at risk ?

Older recipients

Debilitated recipient

Ventilator dependent

Previous sternotomy

Older donor into debilitated recipient

All of our patients

Young JB et al, Determinants of early graft failure following cardiac transplantation,A 10 year multi-institutional, multi-variable analysis J Heart Lung Transplant 20:212, 2001

Constanzo MR et al, Are there specific risk factors for fatal allograft vasculopathy? An analysis of over 7,000 cardiac transplant patients. J Heart Lung Transplant 20:152,2001

Infection■ Respiratory Infection is most common (colds and

pneumonia)

Treatment - Antibiotic prophylaxis for 1 year after transplant

■ CMV (Cytomegalovirus) – GI tract is the most common site of CMV infection

Treatment – Antibiotic prophylaxis, depends on donor/recipient CMV + or –

■ Thrush – most common early due to high dose of steroids.

Treatment – Nystatin swish and swallow

With all these potential complications, medication side effects, multiple

tests, procedures and clinic visits……

Why would anyone want a transplant?

Questions

Bibliography

■ Transplantation Transplant Secrets, Linda Ohler and Sandra Cupples, 2003

■ Core Curriculum for Transplant Nurses, Linda Ohler and Sandra Cupples, 2008

■ Young JB et al, Determinants of early graft failure following cardiac transplantation,

A 10 year multi-institutional, multi-variable analysis J Heart Lung Transplant 20:212, 2001

■ Constanzo MR et al, Are there specific risk factors for fatal allograft vasculopathy?

An analysis of over 7,000 cardiac transplant patients. J Heart Lung Transplant 20:152,2001

■ DeSalvo TG, The differing hazard of lymphoma vs. other malignancies in the current era.

J Heart Lung Transplant 17:7,1998