heart transplant : patient selection and transplant emergency · king chulalongkorn memorial...
TRANSCRIPT
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Heart transplant : patient selection and transplant emergency
Sarinya Puwanant, MD, FASE
Medical director of heart failure and transplant cardiology King Chulalongkorn Memorial Hospital
And Chulalongkorn University
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Goals of Treatment of Heart Failure
Prolonged life Improved QOL and functional capacity
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Heart Transplant
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Review of United Network for Organ Sharing data identified 20,999 recipients of heart transplants
from 1997 to 2007.
J Thorac Cardiovasc Surg 2010;140:700-8
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J Thorac Cardiovasc Surg 2010;140:700-8
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Thailand: Recipient shortage
Center • จฬุาลงกรณ์
• ศิริราช
• ราชวิถี
• บํารุงราษฎร์ • รามาฯ
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Heart transplantation activities at King Chulalongkorn Memorial Hospital
Total n= 138
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King Chulalongkorn Memorial hospital
138 Heart
Transplants
6 HEARTMATE
Ventricular Assist Devices (LVADs)
30+ Years of
experiences
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31 years on December 2018
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1 year survival 89% 5 year survival 70% Median survival 12 years
Survival of heart transplant recipients
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2013-2016 1 year survival = 86%
Kittipibul V and Puwanant S Unpublished
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แพงไหม?
30 บาท จายใหนะคะ ประกันสงัคม - ยังไมครอบคลุมคะ
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Indications Refractory cardiogenic shock requiring intra-aortic
balloon pump counterpulsation or left ventricular assist device (LVAD); requiring continuous intravenous inotropic therapy (i.e., dobutamine, milrinone, etc.);
Peak VO2 < 10 ml/kg/min NYHA class of III or IV despite maximized medical and resynchronization therapy;
End-stage congenital HF with no evidence of pulmonary hypertension;
Recurrent life-threatening left ventricular arrhythmias despite an implantable cardiac defibrillator, antiarrhythmic therapy, or catheter-based ablation;
Refractory angina without potential medical or surgical therapeutic options.
Pump
Electricity
Water pipe
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Advanced age (>65-70yr) Irreversible hepatic, renal, or pulmonary dysfx Active infection, AIDS, Systemic disease with life expectancy < 2 years despite
transplant , Systemic disease (active SLE, amyloid) Recent , active cancer (within 5 yrs) Psych illness, poor compliance, Drug additiction Pulmonary hypertension with PVR > 6 Wood units or 3 Wood units after vasodilator Significant COPD (FEV1<1) Severe PAD or CVD Acute PE, Severe Obesity PRA (Panel Reactive Antibody) > 10%
Contraindications
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Patient Selection
Case based learning
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a) RM
b) Transplant c) OMT
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Vo2 max = 12 ml/kg/min
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Heart transplant (OHTX) evaluation
RAP= 15 PCWP 28 PAP =65/30 (42) TPG = 42-28=14 CO=2.2 PVR =6.2
RAP 8 PCWP 20 PAP =45/22 (30) TPG= 30-20=10 CO 2.6 PVR = 3.8
Choices 1) Pulm vasodilator test 2) Diuresis 3) HL transplant
Diuresis
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PH before heart transplant
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Few words about donor selection
Perfect donor needed Clinical-Hemodynamics CXR ECG Echo Coronary Angiography
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Life Post Heart Transplant Immunosupressive agents: CNI, MMF, Steroid Rejection CMV Infection Non-CMV Infection Malignancy
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Transplant Emergency Fellows should know
Cardiac Allograft Rejection
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Cardiac Allograft Rejection
Acute Cellular Rejection Antibody-Mediated Rejection Coronary Artery Vasculopathy
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Symptoms of rejection Symptoms of HF
Feeling tired or weak Shortness of breath Swelling of your feet, hands, or ankles Sudden weight gain Reduced amounts of urine Nausea or loss of appetite
Fever or chills Fast or irregular heartbeat Drop in blood pressure Flu-like aches and pains Dizziness or fainting
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Endomyocardial Biopsy
Biopsies are performed via a transjugular approach weekly and then every other week for several months
Monthly biopsies continue for 6 to 12 months in many programs and for years thereafter in some.
Complication includes pericardial tamponade or tricuspid insufficiency
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Acute Cellular Rejection
• common from the first week to several years after transplantation
• 40% of patients during the first year after surgery. • T cell activation, moderated by interleukin-2, a cytokine.
Interleukin-2 is produced by CD4 + cells and to a lesser extent by CD8 + cells and exerts both an autocrine and a paracrine response.
• Endomyocardial biopsy remains the gold standard for the diagnosis of acute rejection.
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Grade 1R Rejection
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Grade 1R Rejection myocyte damage
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Grade 1R with 1 focus of myocyte damage
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2R rejection: multi-local infiltrate +Myocyte damage
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3R rejection
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Acute Cellular Rejection 2004 System 1990 System Grade 0 R No rejection Grade 0 No rejection
Grade 1 R, mild
Interstitial and/or perivascular infiltrate with up to one focus of myocyte damage
Grade 1, mild
A—focal Focal perivascular and/or interstitial infiltrate without myocyte damage
B—diffuse Diffuse infiltrate without myocyte damage
Grade 2 R, moderate Two or more foci of infiltrate with associated myocyte damage
Grade 2, moderate (focal)
One focus of infiltrate with associated myocyte damage
Grade 3 R, severe
Diffuse infiltrate with multifocal myocyte damage ± edema, ± hemorrhage, ± vasculitis
Grade 3, moderate
A—focal Multifocal infiltrate with myocyte damage
B—diffuse Diffuse infiltrate with myocyte damage
Grade 4, severe
Diffuse, polymorphous infiltrate with extensive myocyte damage ± hemorrhage ± vasculitis
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AMR: Antibody-mediated Rejection
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C4d stain
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Immunofluorescence positivity for C4d in capillaries with “doughnut” appearance
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Risk Factors for AMR
Female Elevated pre-transplant panel-reactive antibodies (PRAs) Positive donor-specific crossmatch Prior sensitization to OKT3 Cytomegalovirus (CMV) seropositivity Prior implantation of ventricular assist device Retransplantation
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Coronary Artery Vasculopathy (CAV)
• After 3 years • Before 1 year-early-
poor prognosis • 30% to 40% of heart
transplant recipients within 5 years
• Rapidly progress • Lack of Angina • Detection of CAV:
DSE (sens 80% spec 88%) vs. CAG + IVUS
• Rx: Statin+Everolimus • Rx: Retransplant
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Revascularization procedures for CAV are only palliative, no survival benefit
Circulation. 2008;117:2131-2141
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Circulation. 2008;117:2131-2141
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Sample case A 36 yo M Post OHTX 2 years presented with HF at the
ER. What should we do? Diuresis and DC home after no HF EMBx CAV Echo
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Sample case A 17 yo M Post OHTX 6 Months presented with dyspnea
and abd pain -acute cholecystitis and low BP. What should we do? Review history Meticulous Physical Exam Echo Steroid MCS if needed
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Sample case A 54 yo M Post OHTX 2 weeks at CVT ward presented
with VT VF. What should we do?
Cardioversion Amiodarone Xylocaine Review H and P (PRA, H/O rejection, Cyclo/FK
levels, K, Mg, LVEF) Steroid MCS if needed
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Conclusions Heart Transplant is one standard treatments for heart
failure. Heart transplant improves survival, functional capacity,
and QOL Disease exchange Pre-Peri-Post are all important steps for good transplant
outcomes Cardiologist: Know how and when to refer; Know how to
evaluate RHC, Know transplant Emergency
Case Referral : 081-383-9302
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Thank you
Thank you