The gift of life

Update on heart

trans plan tat ion Joan Miller, RN

With the dramatic achievements of

transplantation come difficult decisions

for patients and families. After this

update on heart transplantation, a

mother describes her family’s decision to have their son

be a donor. Then a heart transplant

recipient tells about her second

chance to live.

vv hen South African surgeon Christaan Barnard performed the first human-to-human

cardiac transplant in 1967, transplan- tation was hailed as a panacea for all cardiac ills. Initial efforts were applied to the entire spectrum of cardiac symp- toms and diseases: coronary arterio- sclerosis, congenital heart disease, val- vular heart disease, and cardiomyo- pathies. Widespread failures during the first two years of transplantation brought with them the equally irra- tional concept that no cardiac disease deserved transplantation.

Although improvements in drug therapy and other techniques have broadened the choice of therapy for pa- tients with a wide variety of cardiac dis- ease, certain cardiac conditions pro- gress to the point where no medical reg- imen or conventional procedure will improve the patient’s symptoms or alter the progress of the disease. In such cir- cumstances, cardiac replacement may be indicated.

At Stanford (Calif) University Medi- cal Center, we receive an average of 250 to 300 referrals each year from physi- cians interested in sending patients to us for cardiac transplantation.

Approximately 8Wo of these patients are refused early because of obvious contraindications, such as age or com- plicating disease in other organ sys- tems. The remaining 20% come to Stan- ford for evaluation. Fifteen percent are officially accepted as suitable candi- dates, 3% die before a donor becomes available, and 1% undergo transplan- tation. More than 225 transplants have now been performed at Stanford.

We prefer that our recipients be less than 50 years of age and have had car- diac disease for less than 5 years. They must have a fixed pulmonary vascular resistance of less than 8 Wood units. Renal and hepatic dysfunction seconda- ry to cardiac decompensation cannot be

AORN Journal, July 1982, Vol36, No 1 45

severe, and no evidence of active infec- tion or recent pulmonary infarction can be present.

The recipient evaluation includes a standard medical history, physical ex- amination, electrocardiogram, chest x-ray, right and left cardiac catheteriza- tion, and laboratory studies to rule out active infection or other systemic dis- ease that would limit transplant sur- vival. If the transplant team agrees the patient’s prognosis is poor and no lesser surgical procedure will benefit, cardiac transplantation is recommended. The prognosis, recommendations, and al- ternatives are presented to the patient and his family along with a comprehen- sive overview of our program and the current survival statistics. Upon receipt of the patient’s informed consent, tissue typing is done. When a suitable donor becomes available, the transplant is perfomed.

Distant heart procurement. Finding a heart remains one of the major limiting factors in our program. Approximately 20% of our accepted recipients die before a heart can be found for them. In 1977, the development of a cardioplegic solu- tion capable of preserving the myocar- dium for up to four hours enabled us to

Joan Miller, RN, is cardiac transplant coordi- nator for cardiovascular surgery at Stanford (Calif) University Medical Center. She is a di- ploma graduate of Sacred Heart Hospital School of Nursing, Pensacola, Fla.

begin harvesting hearts at other hospi- tals. This led to our establishing a work- ing relationship with the Regional Organ Procurement Association (ROPA) in Los Angeles. This associa- tion has been extremely beneficial to us in our search for donors. We routinely send serum to ROPA on all accepted recipients. Over the last two years, al- most two-thirds of our donors have been referred by them.

Most of our donors (75%) are victims of cranial trauma (with vehicular acci- dents accounting for the mqjority) and cerebral vascular accidents (20%), with the remainder from other causes 5%. Men far outnumber women (187 to 53). The mean age is 25 years, but we have used donors as young as 12 and as old as 51.

We have found the ideal donor to be under 35 years old

0 to have no evidence of infection 0 to have no severe chest trauma 0 to have experienced no prolonged

0 to be stable without high doses of

0 to have no history of previous heart

In addition to increasing the scope of our donor pool, we find distant heart procurement also better meets the needs of the donor’s family during their time of acute loss and grief.

Immunosuppression. Because rejec- tion is a concern in every case, we begin immunosuppression in cardiac recipi- ents immediately prior to the operation. Stanford researchers have spent years working on many combinations of available immunosuppressive drugs. For many years, our three primary drugs were prednisone, azathioprine, and rabbit antithymocyte globulin (RATG) .

Fifteen months ago, we began using a new agent-cyclosporin-A-in place of azathioprine. For two years we had

cardiac arrest

inotropic support

disease.

46 AORN Journal, July 1982, Vol36, No 1

studied the drug in the laboratory, examining its immunosuppressive ef- fects on heterotopic rat hearts and het- erotopic and orthotopically placed cardi- ac allografts in primates, as well as in a combination of heart-lung allograft models. Primate experiments were per- formed to evaluate the immunosup- pressive potential of this agent as well as its toxic effects in animals more close- ly related to man. The results of these experiments were encouraging because of the ability of the drug to prolong graft survival as well as its supposed lack of toxic effects.

Although graft rejection does occur in all experimental systems so far studied, the results in all cases were superior to those in animals treated with conven- tional immunosuppressive agents.

We recently discontinued the routine administration of rabbit antithymocyte globulin. While we feel RATG is a pow- erful tool to be used when a rejection episode occurs that cannot be controlled with high-dose steroid intervention, we believe cyclosporin-A and prednisone alone are sufficient during the early postoperative period and minimize the risk of oversuppressing the patient’s immune system.

Cyclosporin-A is initially given at a

Test results show increased graft survival, fewer toxicity problems.

ra te of 18 mglkglday and tapered rapidly to a maintenance dose of 5 to 8 mg/kg/day by 4 to 6 months. Prednisone therapy is begun at an initial dose of 1 mglkglday and tapered to 0.5 mg/kg/day

at 1 month, and 0.2 mg/kg/day at 2 months.

We give the lowest possible doses of immunosuppressive agents because of the side effects secondary t o these drugs. These include the following:

0 infection malignancy cataracts aseptic necrosis in

hips ankles shoulders

osteoporosis. Add to this the potential side effects of cyclosporin:

0 renal dysfunction hepatic dysfunction hypertension mild tremor mild hirsutism headache.

We have seen all of these. One last complication of immunosuppression with cyclosporin-A, both in our labora- tory studies and in the clinical setting, has been the development of apparently malignant lymphoproliferative disease. The total cumulative number of patient years of follow-up available from all centers using cyclosporin-A is currently too small to allow valid conclusions re- garding the incidence of such tumors. Patients receiving conventional immu- nosuppressive therapy, however, are also subject to this complication.

Rejection. Early sensitive and accu- rate diagnosis of impending graft rejec- tion is essential in the early postopera- tive period and critical to long-term survival. Immediately after the trans- plant, we initiate meticulous clinical and immunological surveillance tech- niques for detection of graft rejection. These include physical examination, electrocardiography, immunological monitoring, and serial endomyocardial biopsy.

AORN Journal, July 1982, Vol36, No 1 47

The biopsy allows us to diagnose re- jection before the development of func- tional graft impairment. Percutaneous transvenous biopsy of both right and left ventricles with a specially designed biopsy forceps was first described in 1962. The technique did not become popular, however, because of its limited clinical applicability. The biopsy was first used in our clinical program in 1972, employing a biopsy forceps modi- fied and designed by Philip Caves, MD, to provide greater manipulability.

The procedure requires 10 to 15 min- utes and is performed under local anes- thesia. The right internal jugular vein is cannulated with a cardiac catheteri- zation sheath. The biopsy forceps is then passed through the sheath and ad- vanced under fluoroscopic control to the region of the apex of the right ventricle where specimens 2 to 3 mm in size may be obtained from different sites of the right side of the interventricular sep- tum.

More than 6,000 biopsy procedures have been performed in consecutive re- cipients since introduction of the biopsy technique at Stanford. Morbidity rates associated with this procedure are ex- tremely low. Premature ventricular contractions occur in approximately 20% of patients. Transient supraventri- cular arrhythmias have occurred in 3% of cases, pneumothorax in 0.4%.

Routine biopsies frequently reveal evidence of mild rejection in patients who are entirely asymptomatic and ex- hibit no clinical signs of rejection. Since the procedure can be performed percu- taneously, rapidly and safely, it can be repeated as often as necessary to assess graft histology.

Infection. The biopsy also allows us to determine when a rejection episode is under control, and we can stop high- dose steroid intervention. Infection is a major threat to the life of any immuno- suppressed host, and overtreatment for

rejection can be equally as fatal as un- dertreatment.

Since the currently available meth- ods for the prevention and reversal of graft rejection result in generalized immunosuppression, infection remains the main source of both morbidity and mortality for the cardiac transplant re- cipient.

In our series, 81 of 139 (58%) deaths have been due to infection. The second most common cause of death among these patients has been uncontrollable acute rejection (17%). A third important cause of death has been acute right heart failure (five patients), a result of long-standing pulmonary hyperten- sion. Survival. Our survival statistics have

improved steadily. In the early years, 1968 to 1973, the one-year survival rate was 42%. In 1974, we instituted regular use of the endomyocardial biopsy and added rabbit antithymocyte globulin. Our one-year survival increased to 63% with a gradual attrition to 40% at five years. The current one-year survival for patients on cyclosporin-A is 76%, but the number of patients is small, many patients are still at risk, and it is diffi- cult to predict if that percentage will hold.

We have witnessed a renewed interest in heart transplantation.

Of the 116 patients who have sur- vived the critical first year, 85% are re- habilitated to a degree that they can make a free choice of what to do with their lives. Some return to full-time

48 AORN Journal, July 1982, Vol36, No I

employment or i t s equivalent. Others, fully ret ired before the onset o f the i r illness, have chosen to remain so.

Whi le cardiac transplantat ion s t i l l has a way to go, we are encouraged by the steady increase in the number of procedures done worldwide. Fol lowing the init ial rush to jump on the trans- plant bandwagon, interest fe l l off due to i t s difficulties. In the last f ive years, however, more centers are beginning to

do cardiac t ransp lan ta t ion , as im- provements in immunosuppress ive therapy reduce the r isks. Last year alone, more than 100 procedures were performed.

We are very pleased with th is re- newed interest; we feel transplantation offers a high-quality therapeutic alter- native to patients with otherwise un- treatable cardiac disease.

lodophor implicated in patient infections Contaminated iodophor solution was the culprit in infections in five patients in an Atlanta hospital. The April 23 Morbidity and Mortality Weekly Report reported the patients became infected with Pseudomonas aeruginosa after their indwelling peritoneal catheters were wiped with 4 x 4 gauze pads soaked with Prepodyne solution.

During the period March 9 to April 12, four of the patients developed peritonitis, and one developed a skin infection at the catheter insertion site. Three of the patients who developed peritonitis were using an automatic peritoneal dialysis machine; one used only a bottle cycling machine. Each time their catheters were connected to or disconnected from machine tubing, they were wiped with the gauze pads.

Infection control personnel at the hospital tested the dialysate solution, internal areas of the dialysis machines, and small plastic containers filled with the Prepodyne solution. All cultures were negative except the iodophor, which yielded a pure culture of P aeruginosa.

Subsequent testing by the Centers for Disease Control (CDC) in Atlanta confirmed intrinsic contamination of Prepodyne solution, lot C109756, in one of two unopened one-gallon containers. The product was manufactured by West Chemical Products for AMSCO/Medical Products Division. AMSCO has voluntarily withdrawn the implicated lot. CDC and the federal Food and Drug Administration are

investigating the source and extent of the contam ination.

using the product may wish to review patient infections caused by P aeruginosa and notify appropriate local or state health departments about any unusual problems.

CDC suggests that personnel in hospitals

Supervisor honored in naming of suite Jersey City (NJ) Medical Center dedicated its surgical suite to the memory of the late Marie Condon, RN, during “Nurses Day” activities May 6. She served the hospital for 43 years.

“The designation of the surgical area as the Marie Condon Operating Room Pavilion reflects the hospital’s high regard for the contributions of an outstanding individual and the dedicated nurses who follow in her footsteps today,” F Dennis Harrington, the medical center’s executive director, remarked.

High point of the program honoring the former operating room supervisor was the unveiling of a plaque to be mounted in Condon’s honor at the entrance to the third floor surgical unit.

Following the dedication, guests were invited to attend a luncheon during which the hospital honored its nursing staff in conjunction with Gov Thomas Kean’s proclamation of May 6 as “Nurses Day” in New Jersey.

AORN Journal, July 1982, Vol36, No I 49