1. Critical Care of Heart Transplantation

2. Heart Transplant 1960s: First heart transplants performed 1980s: Anti-rejection meds became available (Cyclosporine) Today: About 80% of heart transplants are alive two years after the operation 50% percent survive 5 years 9/6/20152dr.yekehfallah-phd of nursing -2015

3. Clinical Indications for Heart Transplant Ischemic cardiomyopathy Idiopathic cardiomyopathy Viral cardiomyopathy Congenital heart disease Valvular heart disease 9/6/20153dr.yekehfallah-phd of nursing -2015

4. Heart Transplant Contraindications Absolute Contraindications I. A. Systemic illness that will limit survival despite heart translplant. II. Neoplasm III.. HIV/AIDS CDC definition of CD4 count of < 200 cells/mm3. IV. SLE or Sarcoid that has multisystem involvement and is still active. V. Any systemic illness with a high probability of recurrence in the transplanted heart VI. B. Fixed pulmonary hypertension. 9/6/20154dr.yekehfallah-phd of nursing -2015

5. Heart Transplant Contraindications Relative Contraindications Age over 65 Peripheral vascular disease. Asymptomatic carotid stenosis > 75% or symptomatic carotid stenosis of less severity Uncorrected abdominal aortic aneurysm > 4 – 6 cm Systemic infection making immune suppression risky HIV, HBV, CMV (positive donor to negative recipient) Severe pulmonary disease 9/6/20155dr.yekehfallah-phd of nursing -2015

6. Transplant Evaluation Left and/or Right Heart Catherization Echocardiogram EKG 24 hour Holter Monitor Carotid and peripheral doppler flow studies Cardiopulmonary Stress Test Metabolic exercise test that determines the maximal oxygen consumption 9/6/20156dr.yekehfallah-phd of nursing -2015

7. Transplant Evaluation Pulmonary Chest radiograph CT Chest PFT’s – baseline screening, spirometry 9/6/20157dr.yekehfallah-phd of nursing -2015

8. Transplant Evaluation Renal Urinalysis 24 hour urine for creatinine clearance Renal ultrasound Gastrointestinal Stool guiac Abdominal ultrasound CT abdominal and pelvis Colonoscopy 9/6/20158dr.yekehfallah-phd of nursing -2015

9. Transplant Evaluation Antibody screen HLA typing Infectious disease serologies General laboratory studies Bone density scan Cancer screens – gender specific tests 9/6/20159dr.yekehfallah-phd of nursing -2015

10. Social Services, Psychiatry, Neuropsychiatry Consults and Evaluation Compliance Support Depression Anxiety Substance abuse Finances Knowledge deficits 9/6/201510dr.yekehfallah-phd of nursing -2015

11. Medical Management of Patients on Waiting List Comprehensive CHF Management Program 9/6/201511dr.yekehfallah-phd of nursing -2015

12. Patient Education Disease Process Medication Use Lifestyle Changes Fluid Restriction Sodium Restriction Pre Transplant Immunizations Clinic Follow up 9/6/201512dr.yekehfallah-phd of nursing -2015

13. Donor Selection Donor Factors Important for Organ Recovery Age < 45years, younger donors are better Hemodynamics - CVP CPR history –Any down time secondary to presumed cardiac arrest? Echo: LVEF, LV wall thickness, Valves,Anomalies EKG – No Q waves Effect of high dose vasopressors Traumatic injury to the heart 9/6/201513dr.yekehfallah-phd of nursing -2015

14. Donor Selection Negative serologies No active systemic infection No extracranial malignancies No history IV drug use Coronary Angiography for donors over 40yrs of age 9/6/201514dr.yekehfallah-phd of nursing -2015

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22. Major Post Transplant Complications Rejection Infection Cardiac allograft vasculopathy (CAV) Hypertension Nephrotoxicity Malignancy 9/6/201522dr.yekehfallah-phd of nursing -2015

23. Rejection Invasive surveillance biopsies are the best established method for following patients Typically 13-15 biopsies are done in the first year Each biopsy requires a minimum of 3 samples from 3 different sites to be meaningful A new biopsy grading has been developed for widespread adoption 9/6/201523dr.yekehfallah-phd of nursing -2015

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26. International Society For Heart and Lung Transplantation Standardized Grading For Cardiac Biopsies Rejection gradeDescription 0No evidence of rejection 1 - Mild A - Focal Focal perivascular and/or interstitial infiltrate without myocyte damage B - DiffuseDiffuse infiltrate without myocyte damage 2 - Moderate (focal)One focus of infiltrate with myocyte damage 3 - Moderate A - Multifocal Multifocal infiltrate with myocyte damage Multifocal B - Diffuse Diffuse infiltrate with myocyte damage 4 - SevereDiffuse polymorphous infiltrate with extensive myocyte damage ± edema ± hemorrhage ± vasculitis 269/6/2015dr.yekehfallah-phd of nursing -2015

27. GRADE 1A GRADE 2 GRADE 1B 9/6/2015dr.yekehfallah-phd of nursing -201527

28. GRADE 4 GRADE 3A GRADE 3B Threshold Mandatory For Therapy 9/6/201528dr.yekehfallah-phd of nursing -2015

29. Treatment of Rejection Rejection without hemodynamic compromise Oral prednisone (100 mg daily for 3 days) IV steroids Decision dependent on grading severity and time post transplantation Steroid resistant rejection with or without hemodynamic compromise Cytolytic antibodies; IVIG; plasmapheresis; photopheresis; anti-B cell antibodies; rapamycin; methotrexate; cyclophosphamide; total lymphoid irradiation 9/6/201529dr.yekehfallah-phd of nursing -2015

30. Long Term Challenges Renal failure and metabolic adverse effects Cardiac allograft vasculopathy Malignancy 9/6/201530dr.yekehfallah-phd of nursing -2015

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32. Heart Preservation Device 1) Thermoelectric cooler 2) Intermittent perfusion 3) Preservation solution 9/6/201532dr.yekehfallah-phd of nursing -2015

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34. Transmedics, Inc 9/6/201534dr.yekehfallah-phd of nursing -2015

35. Heart Preservation Device: 2nd Generation Devices 9/6/201535dr.yekehfallah-phd of nursing -2015

36. Postoperative Transplant Management 9/6/201536dr.yekehfallah-phd of nursing -2015

37. Survival Following Transplant Operative mortality rate is between 5- 10% Other leading causes of mortality include: Infection (15-20%) Acute RV failure Rejection 9/6/201537dr.yekehfallah-phd of nursing -2015

38. Postoperative Management Complicated by Denervation Global ischemic injury associated with perfusion injury Myocardial dysfunction Dysrhythmia Hypertension Pulmonary Hypertension 9/6/201538dr.yekehfallah-phd of nursing -2015

39. Infection Post Transplant: Prophylaxis Viral - CMV Pneumocystis carinii Fungal Based on recipient and donor serologies Toxoplasmosis TB Cocci 9/6/201539dr.yekehfallah-phd of nursing -2015

40. TRANSPLANT REJECTION Three types of transplant rejection Hyperacute Acute Chronic 9/6/201540dr.yekehfallah-phd of nursing -2015

41. Signs of Rejection Edema Increased fatigue Intolerance of exercise Onset of low grade fever Increase in weight Exertional dyspnea Enlarged heart silhouette Rub (pericardial friction) EKG voltage decreased Jugular venous distention Cardiac dysrhythmias New S3 or S4 Onset of hypotension Echocardiogram changes 9/6/201541dr.yekehfallah-phd of nursing -2015

42. Immunosuppression Balance 9/6/201542dr.yekehfallah-phd of nursing -2015

43. Recovery Phase Hospital Discharge 9/6/201543dr.yekehfallah-phd of nursing -2015

44. Home Assessment Weight Blood pressure Heart rate Temperature Blood sugar monitoring 9/6/201544dr.yekehfallah-phd of nursing -2015

45. Routine Testing Lab work Chest X-ray EKG Endomyocardial biopsy and or AlloMap Echocardiogram Bone Densitometry 9/6/201545dr.yekehfallah-phd of nursing -2015

46. Transplant Clinic Visits Health Maintenance follow-up Continuing education Psychosocial issues 9/6/201546dr.yekehfallah-phd of nursing -2015

47. Cardiac Rehabilitation Heart rate response to exercise is blunted and delayed Increase in heart rate is caused by circulating catecholamines Maximum heart rate is achieved after exercise is completed Deceleration of heart rate is gradual and prolonged. 9/6/201547dr.yekehfallah-phd of nursing -2015

48. Long Term Follow Up Management and Complications 9/6/201548dr.yekehfallah-phd of nursing -2015

49. Medical Issues Immunosuppression Infection Rejection Coronary artery vasculopathy Hypertension Hyperlipidemia Diabetes Osteoporosis Obesity Renal insufficiency Gastrointestinal disorders Reduced exercise tolerance Malignancy Poor compliance Depression 9/6/201549dr.yekehfallah-phd of nursing -2015

50. Quality of Life Issues The functional effect of an illness and its consequent therapy upon a patient, as perceived by the patient Reproduction and Sexuality Recurrent Disease Travel Adjustment 9/6/201550dr.yekehfallah-phd of nursing -2015

51. Mental and Emotional Health Quality of Life Psychiatric Disorders Body Image Social Adaptation Family Dynamics Financial Burdens 9/6/201551dr.yekehfallah-phd of nursing -2015

52. Return to Work vs Disability Issues Insurance Employment Vocational Rehab Disabilities 9/6/201552dr.yekehfallah-phd of nursing -2015

53. Yearly Evaluation Cardiac catherization with Intravascular Ultrasound Echo Dobutamine Stress Echo Abdominal Ultrasound Chest X-Ray Bone Density Scan Labs 24-hour urine for creatinine clearance Cancer Screens 9/6/201553dr.yekehfallah-phd of nursing -2015

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