Heart transplant guidelines
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HEART TRANSPLANT GUIDELINES
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Heart transplant guidelines
- 1. HEART TRANSPLANT INDICATIONS DONOR RECIPIENT CRITERIA
- 2. Questions Should we consider for Transplant ? 1) 45 yr old male with dilated CM, no cath. Why?
- 3. Questions Should we consider for Transplant ? 2) 65 yr female with controlled diabetes and HTN, serum creatinine 1.4.
- 4. Questions Should we consider for Transplant ? 3) 40 yr female, post op stage 2 Ca breast, operated 8 yrs back, got adjuvant CT for 2 yrs. Developed CM.
- 5. Questions Should we consider for Transplant ? 4) 25 yr male patient of 60 kg weight, donor 18 yr female with 35 kg weight.
- 6. Questions contd.. Can transplant be done in ABO incompatible patients What is VO2 max and role in patient selection
- 7. History 1905 • Carrel and Guthrie experiment • HT into neck of animals 1946 • Vladimir Demikhov experiment • Both OT and HT into thorax of dogs 1964 • James D Hardy • First animal to human heart transplant
- 8. 1967 • Christiaan Neethling Barnard • First human to human heart transplant • 3/12/67 1967 • Adrian Kantrowitz • First pediatric heart tranplant • 6/12/67 1968 • Norman Shumway • First human to human heart transplant in US • 6/1/68
- 10. LOUIS WASHKANSKY THE FIRST HUMAN RECIPIENT OF A HEART.
- 11. DENISE DARVAL THE FIRST HEART DONOR
- 12. 1967 • Christiaan Neethling Barnard • First human to human heart transplant • 3/12/67 1967 • Adrian Kantrowitz • First pediatric heart tranplant • 6/12/67 1968 • Norman Shumway • First human to human heart transplant in US • 6/1/68
- 14. Adult and Pediatric Heart Transplants Number of Transplants by Year 187 322 671 1,261 2,357 2,998 3,525 3,822 4,528 4,754 4,735 4,939 4,838 4,802 4,683 4,602 4,515 4,200 4,110 4,044 3,913 3,838 3,807 3,936 4,001 4,013 4,042 4,071 4,163 4,233 4,254 4,477 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 Numberoftransplants JHLT. 2014 Oct; 33(10): 996-1008 2015 JHLT. 2015 Oct; 34(10): 1244-1254
- 15. TRANSPLANTATION IN INDIA • Feb 1968 • KEM, Mumbai • Patient lived for 24 hrs.
- 16. AIIMS Delhi • 3 August 1994 • First successful heart tranplant in INDIA • Devi Ram • Lived for 14 yrs Prof Panangipalli Venugopal
- 17. Adult and Pediatric Heart Transplants Number of Transplants by Year and Location 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 Numberoftransplants Other Europe North America NOTE: This figure includes only the heart transplants that are reported to the ISHLT Transplant Registry. As such, the presented data may not mirror the changes in the number of heart transplants performed worldwide. JHLT. 2014 Oct; 33(10): 996-1008 2015 JHLT. 2015 Oct; 34(10): 1244-1254
- 18. INDIA and heart failure load India – 19 millions heart failure patients 1.5 million added every yr Mortality of 30-40% per yr
- 19. NUMBER OF TRANSPLANTATIONS IN USA: 2,200 Heart Transplantation are being done per year. IN INDIA: Around 150 HEART TRANSPLANTATIONS SINCE 1994
- 20. Indications Recipients selection Donor selection
- 21. Indications 1) Cardiogenic shock or low cardiac output state requiring mechanical assistance (IABP, VAD, TAH) with reversible organ-system damage. 2) Heart failure (refractory low cardiac output state) requiring continuous inotropic support. 3) NYHA classes III-IV ((VO2 < 14 mL · kg−1 · min−1) despite optimal medical therapy and poor 12-month prognosis
- 22. 4) Severe hypertrophic or restrictive cardiomyopathy, NYHA class IV symptoms 5) Refractory angina pectoris despite optimal medical therapy not amenable to coronary revascularization. 6) Recurrent life-threatening ventricular arrhythmia refractory to medical treatment or insertion of ICD 7) Cardiac tumors, unresectable with low probability ofmetastasis
- 23. VO 2 Peak exercise oxygen consumption Risk stratification of heart failure patients 1. Less than 14 ml/kg/min have high mortality risk, will benefit from HT 2. More than 14 ml/kg/min – low risk
- 25. Heart Failure Survival Score (HFSS) 1. Presence or absence of CAD 2. Resting heart rate 3. Left ventricular ejection fraction 4. Mean arterial blood pressure 5. Presence or absence of an intraventricular conduction delay on ECG 6. Serum sodium 7. Peak Vo2
- 26. HFSS score HFSS categories Score 1 Yr survival Low risk More than 8 88 % Medium risk 7.2- 8 60 % High risk Less than 7.2 35%
- 28. ETIOLOGY OF END STAGE HEART DISEASE. DILATED CARDIOMYOPATHY. 45% ISCHEMIC CARDIOMYOPATHY 45% VALVULAR (WILL BE PROBABLY HIGHER IN INDIA) 3% ADULT (CONGENITAL) 2% REDO TRANSPLANTATION 2%
- 29. ISHLT 2011
- 30. Recipient selection Goal : Identify candidates who have a poor prognosis yet lack other comorbidities that significantly increase perioperative mortality or limit patient survival post transplantation
- 31. Recipient selection PVR Infection Age Renal PFT DM Malignancy
- 32. Pulmonary vascular resistance Normal : ≤1.5 Wood units[120 dynessec/cm5] High : > 6 Wood units (320 to 480 dynessec/cm5] Immediate post op : Right HF Neuro – hormonal vasoconstriction and not structural changes.
- 33. Reversibility of PVR SNP, dobutamine, milrinone, PG E1, prostacyclin and inhaled NO Implantation of left ventricular assist device
- 34. Acceptable PVR : Less than 4 Wood units (320 dynes sec/ cm5)
- 35. 26 Heart transplants Fixed Pulmonary hypertension : 5.1+/- 2.8 WU Perioperative mortality 5 % Mid term follow up : 85 % survival at 3 yrs Comparable to transplants without pulmonary hypertension
- 36. Heart transplant receipents were screened with right heart cath PVR Mortality at 3mths More than 2.5 17.9 % Less than 2.5 6.9 %
- 37. Infection Heart transplant is absolutely contraindicated in presence of active infection (pneumonia, septicemia) Post LVAD (BTT) driveline infection and mediastinits : not contraindication
- 38. 149 patients undergone LVAD for BTT 110 successfully tranplanted 7 had signs of drive line infection or mediastinitis Survival between 7 and 103 was similar at end of 1 yr ( 85.7% v/s 82.5%)
- 40. HT with Chronic viral infection ? Prevalence of hepatitis B and hepatitis C infection in chronic HF pts is over 10% Emergence of new antiviral therapies Hepatitis B or C infection is not an absolute contraindication No clear recommendations Practices of individual centers differ
- 42. HIV infection and tranplant HIV infection is widely considered a contraindication for cardiac transplantation Newer anti-retroviral drugs : 10-year survival after seroconversion exceeds 90% Prospective series of liver or kidney transplant recipients with stable HIV disease : graft survival was similar to general population
- 43. Retrospective observation Among 1679 pts – 6 patients were HIV + (4 diagnosed before and 2 serocoverted later) At follow up of 57 +/- 78.9 mths : survival similar to other pts Concomitant ART : dose of calcineurin inhibition reduced and carefully monitored
- 46. Donor selection Donor : unresponsive, no reflexes, without breathing movement and 2 flat ecg 24 hrs apart Investigation ECG ECHO Angiography ( > 45 yrs / smoking)
- 47. Exclusion Prolonged history of hypotension/cardiac arrest Global or regional wall motion defect Severe valvular heart disease Evidence of sepsis HIV/HCV/ HBV infection Active malignancy Size mismatch
- 48. Size mismatch Weight : Generally accepted matching criteria Discrepancy of > 20 % : considered significant Consider Recipient have dilated heart so accommodate slightly larger heart Risk of RV dysfunction high if smaller heart used in case of borderline PVR
- 49. Donor management
- 50. Donor EF < 45 %
- 51. ABO compatibility Essential criteria Like blood transfusion O –ve universal donor AB +ve universal recipient Incompatible transplant – Hyperacute rejection (platelet deposition, granulocyte activation and thrombosis)
- 52. Exceptions to ABO compatibilty 1. Blood gp A A 1 – hyperacute rejection A 2 – less prone for rejection (antigens not displayed readily over surface) Reports of successful skin and renal tranplants of A2 donor in B and O gp pts 2. Infants < 6 mths Deficient B cell response, antibody production to Ag of intestinal E coli delayed. Paucity of neonatal donors More than 80 ABO incompatible infant HT reported
- 53. 85 out of 502 (17%) were ABOi HT ABO c ABO I Ventilator prolonged 36.5 % 49.4% ECMO 13.4 % 23.5% Survival at 12 mths 84% 82%
- 55. Reasons for heart transplantation Michael Huebler et al. Eur J Cardiothorac Surg 2011;39:e83-e89 © 2010 European Association for Cardio-Thoracic Surgery
- 56. Contraindications of pediatric HT Severe irr fixed elevation of PVR Severe hypoplasia of central pulmonary arteries Severe irr disease of other organs
- 57. Heterotopic tranplant Non anatomic position First by Barnard in 1974 in Capetown
- 58. Potential advantages Native heart support transient dysfunction of donor heart Management of elevated pulmonary vascular resistance, supports native RV Small donor heart for a larger recipient Support of the native heart with development of coronary vasculopathy, until retransplantation can be done.
- 59. Current day indications 1. High PVR with no reactivity to pharmacologic intervention 2. If donor heart is considerably smaller (>30 %)
- 60. Problems Intraventricular thrombi (life long anticoagulants) Elevation of after-load due to dyssynchrony of the implanted heart with the native heart Progressive annular dilatation leading to aortic insufficiency Need for permanent pacemaker Heart lung transplantation : other option
- 61. Performed 4 heterotopic HT for PVR bw 4.8 to 6.5 WU One died immediatley, others had 2 1/2 yr, 6 yr and 15 yr survival Result : Inferior to orthotopic HT
- 62. Heart Lung Transplantation First by Denton Cooley in Texas on 15 Sep 1969 (2 mth infant, survived 14 hrs) Walton Lillehei performed second after 3 mths in adult patient
- 63. Indications 1. Eisenmenger syndrome with uncorrected intracardiac defect 2. Uncorrectable CHD with atresia or diffuse severe hypoplasia of pul arteries 3. Severe heart failure with sec PAH unresponsive to vasodilator therapy
- 65. Xeno Tranplant Animal heart to human Famous Baby Fae experiment American infant with HLHS First Xenotransplant Received Bsboon heart Leonard L Bailey in 1984 Future : With better understanding of immunology, may eventually be a reality.
- 72. THANKS
Notes de l'éditeur
- normal serum creatinine range for men is 0.5-1.5 mg/dL. The normal range for women is 0.6-1.2 mg/dL.
- normal serum creatinine range for men is 0.5-1.5 mg/dL. The normal range for women is 0.6-1.2 mg/dL.
- normal serum creatinine range for men is 0.5-1.5 mg/dL. The normal range for women is 0.6-1.2 mg/dL.
- normal serum creatinine range for men is 0.5-1.5 mg/dL. The normal range for women is 0.6-1.2 mg/dL.
- Vladimir Petrovich Demikhov (Russian: Влади́мир Петро́вич Де́михов; (Khutor Kulikovsky, July 18, 1916 – Moscow, November 22, 1998) was a Soviet scientist and organ transplant pioneer, who performed several transplantations in the 1930s and 1950s. Christiaan Barnard, who performed the world's first heart transplant operation from one person to another person in 1967, twice visited Demikhov's laboratory in 1960 and 1963, and considered Demikhov his teacher James D. Hardy (May 14, 1918 – February 19, 2003) was an American surgeon, famous for the first human lung transplant and the first animal-to-human heart transplant.[heart of a chimpanzee, patient died after 90 min
- Christiaan Neethling Barnard (8 November 1922 – 2 September 2001) was a South African cardiac surgeon in CAPETOWN. Barnard experimented for several years with animal heart transplants.[1] More than 50 dogs received transplanted hearts. operation lasted nine hours. The patient, Louis Washkansky, was a 54-year-old grocer, suffering from diabetes and incurable heart disease. The donor heart came from a young woman, Denise Darvall, who had been rendered brain damaged in an accident on 2 December 1967. Washkansky survived the operation and lived for 18 days. However, he succumbed to pneumonia. Barnard performed ten orthotopic transplants (1967–1973), Dirk van Zyl, who received a new heart in 1971, was the longest-lived recipient, surviving over 23 years.[6]
- Adrian Kantrowitz (October 4, 1918 – November 14, 2008) was an Americancardiac surgeon Kantrowitz also invented the intra-aortic balloon pump (IABP), a left ventricular assist device (L-VAD), and an early version of the implantable pacemaker.[1 Within two years, more than 60 teams had replaced ailing hearts in some 150 patients patients vulnerable to deadly infections. Eighty percent of transplant recipients died within a year. Surgeons grew discouraged; by 1970, the number of transplants had plunged to 18 Shumway was the only American surgeon to continue performing the operation after others abandoned it after poor results. In particular he pioneered the use of cyclosporine, instead of traditional drugs, which made the operation safer.[4] He is widely regarded as the father of heart transplantation. From 1968 to 1980, nearly 200 heart transplants were performed at Stanford. About 65% of Shumway's patients survived at least one year, and half hung on for five.
- Jean Borel's discovery of cyclosporine (calcineurin inhibitor), an immunosuppressant drug derived from soil fungus, in the mid 1970s. In 1982 trials results published demostrating benefits over steriods and azathioprine (antimetabolite agent). In 1994 a new drug, tacrolimus or FK-506, originally discovered in a fungus sample, was approved for immunosuppression in transplant patients.
- From 1968 to 1980, nearly 200 heart transplants were performed at Stanford. About 65% of Shumway's patients survived at least one year, and half hung on for five. Inspired by Shumway's success and newer better immunosuppressive agents, the world's surgeons got back into heart transplants. There were 1,647 in 1988. By 2007, the number had jumped to 2,210 in US alone.
- Due to unclear organ donation laws in INDIA, not much progress happened for many yrs In May 1994, organ transplant bill was passed
- MAJORITY us CENTRES PERFORM 10 TO 19 CASES per yr. Due to this critical organ shortage, the recipient selection process and donor allocation system have involved both clinical and ethical issues
- IN general any pt class ¾ HF ref to max medical th, deblitating ischemia not amenable for inter or sx re vas, recu sym V ARR ref to medical / IVD or sx tx.
- In general, the peak Vo (Vo max) provides an objective assessment of functional capacity in patients with HF and is one of the best predictors of when to list an individual patient for cardiac transplantation [8]. Peak exercise oxygen consumption is a factor that has been extremely helpful in identifying lowrisk patients who can continue on medical therapy
- The 2005 American College of Cardiology/American Heart Association HF guidelines (with 2009 update) include peak Vo criteria for cardiac transplantation ** Use of beta blockers has increased survival of heart failure patients, recent studies have shown that we can wait for transplant Till 10-12 ml/kg/min of Vo2 and keep patients above that on medical follow up
- Although peak Vo has often been the major parameter used to guide the selection of heart transplant candidates, a single variable does not provide an optimal risk profile. As a result, several risk models have been developed. One model that has been validated prospectively is the HFSS Heart Failure Survival Score
- Patients with an elevated PVR or a transpulmonary gradient (mean pulmonary artery pressure minus mean pulmonary capillary wedge pressure) above 15 mmHg have an increased risk of right ventricular failure in the immediate postoperative period Fortunately, pulmonary hypertension in most patients with HF is due to neurohumoral vasoconstriction, not structural changes in the pulmonary vasculature, such as calcification or intimal or medial hyperplasia
- transpulmonary gradient (TPG), which is the difference between the mean pulmonary artery pressure and the mean pulmonary capillary pressure. patients with TPG greater than 15 mmHg had higher mortality rates than those with TPG from 10 to 15; the mortality was even lower when the gradient was less than 10 mmHg
- J of american college of cardiology, 1993
- Journal of Transplantation Volume 2013
- emergence of new antiviral therapies has increased survival and quality of life of these pts no clear recommendations as it has been difficult to show that survival after heart transplantation is reduced in the presence of positive hepatitis B or C serology
- Since the frequency of progressive liver disease appears to be more common with hepatitis B than with hepatitis C, many transplant programs will accept candidates who are antiHCV Antibody positive, but not those who are HBsAg positive
- Small anatomical defect like PFO or vsd corrected
- ABO as carbohydrate antigen present over sell surfaces all over body and individual who lack one or more antigens develop antibodies within 6 mths of life
- young children who received an ABOi transplant had equivalent one-year survival and freedom from rejection compared with those who received an ABOc transplant
- Adrain kantrowitz first did pediatric heart tranplant on 6/12/67 in Brooklyn 3 days after C barnard
- Reasons for heart transplantation.
- Sapnish article published in 2008
- Fae had O gp, baboob AB gp, died after 21 days
- Braunwald 10 th edition 2015