Heart transplantation involves replacing a failing heart with a healthy donor heart. It is considered for patients with advanced heart failure who do not get relief from medications. Key steps include evaluating the recipient and donor, matching them based on blood type and size, performing the surgery by removing the recipient's heart and suturing in the donor heart, and providing lifelong immunosuppression drugs to prevent rejection. Long term challenges after transplantation include organ rejection, infection, coronary artery disease in the transplant heart, and cancer due to immunosuppression.

1. Heart Transplantation
DR. KEWAL KRISHAN
MBBS MS MCH DNB MNAMS FIACS (CTVS)
ADVANCED FELLOW, MAYO CLINIC & MOUNT SINAI, USA
PROGRAM HEAD, HEART TRANSPLANT & VENTRICULAR ASSIST DEVICES
SENIOR CONSULTANT CARDIAC SURGEON
MAX SUPERSPECIALITY HOSPITAL, SAKET, NEWDELHI
1

2. Advanced Heart Failure -
Definition
 Patients have significant cardiac dysfunction and
marked symptoms:
 dyspnea, fatigue
 end-organ hypoperfusion at rest
 or with minimal exertion despite maximal medical
therapy
 AHA Stage D
 Refractory symptoms requiring specialized
interventions to manage symptoms or prolong life
Goodlin et al, Journal of Cardiac Failure Vol. 10 No. 3 2004
Hunt SA et al JACC 2001;38:2101–13.

3. INTERMACS Profiles 1-3
Interagency Registry for Mechanical Circulatory Support
‘Frequent Flyer’
Stevenson, JHLTX; 09:535

4. INTERMACS Profiles 4-7
Stevenson, JHLTX; 09:535
‘Housebound’
‘Class IIIb’

5. DegreeofCirculatorySupport
IABP
PARTIAL SUPPORT
CI* ↑15% CI ↑30-60%
ECMO
+
FULL SUPPORT
CI ↑100%
Levitronix CentriMag
Abiomed BVS 5000
Abiomed AB 5000
Abiomed Impella 5.0 LP
Abiomed Impella 5.0 LD
TandemHeart pVAD
Abiomed Impella 2.5 LP
Short-term MCS Devices
*CI – cardiac index

6. Class I Indications for Cardiac
Transplantation
 Cardiogenic shock requiring mechanical assistance.
 Refractory heart failure with continuous inotropic infusion.
 NYHA functional class 3 and 4 with a poor 12 month prognosis.
 Progressive symptoms with maximal therapy.
 Severe symptomatic hypertrophic or restrictive cardiomyopathy.
 Medically refractory angina with unsuitable anatomy for
revascularization.
 Life-threatening ventricular arrhythmias despite aggressive medical
and device interventions.
 Cardiac tumors with low likelihood of metastasis.
 Hypoplastic left heart and complex congenital heart disease.

7. When to think of Cardiac Transplantation
 Patients should receive maximal medical therapy before being
considered for transplantation. They should also be considered
for alternative surgical therapies including CABG, valve repair /
replacement, cardiac septalplasty, etc.
 VO2 has been used as a reproducible way to evaluate potential
transplant candidates and their long term risk.
 Generally a peak VO2 >14ml/kg/min has been considered “too
well” for transplant .
 Peak VO2 10 to 14 ml/kg/min had some survival benefit,
 Peak VO2 <10 had the greatest survival benefit.

8. Evaluation of Cardiac Transplantation
Recipient
 Right and Left Heart Catheterization.
 Cardiopulmonary testing ( VO2 max).
 Labs including BMP, CBC, LFT, UA, coags, TSH, UDS, ETOH
level, HIV, Hepatitis panel, PPD, CMV IgG, RPR / VDRL, PRA
(panel of reactive antibodies), ABO and Rh blood type,
lipids.
 CXR, PFT’s including DLCO, EKG.
 Substance abuse history
 Mental health evaluation and social support.
 Financial support.
 Weight no more than 140% of ideal body weight.

9. Cardiac Donor
 Brain death is necessary for any cadaveric
organ donation. This is defined as absent
cerebral function and brainstem reflexes with
apnea during hypercapnea in the absence of
any central nervous system depression.
 There should be no hypothermia, hypotension,
metabolic abnormalities, or drug intoxication.
 If brain death is uncertain, confirmation tests
using EEG, cerebral flow imaging, or cerebral
angiography are indicated.

10. Matching Donor and Recipient
 ABO blood type (match or compatible),
 Donor weight to recipient ratio (must be 75% to 125%),
 Response to PRA ( Panel Reactive Antibodies)
 The PRA is a rapid measurement of preformed reactive anti-HLA
antibodies in the transplant recipient. In general PRA < 10 to 20%
then no cross-match is necessary. If PRA is > 20% then a T and B-
cell cross-match should be performed.

11. Case Study
 A 42 yeears old gentleman with C/O EPIGASTRIC PAIN for
the LAST 3 YEARS
 Breathlessness for the last 2.5 yrs
 Orthoponea for the last 10 months ( off & on)
 DM(+) SINCE LAST 3 YEARS
 SMOKER SINCE LAST 1O YEARS
11

12. Case Study
 FIRST EVALUATED – 1 YR BACK-HOSPITALISED DUE TO ACUTE
HEART FAILURE
 Due to frequent admissions ( INTERMACS 4) SUGGESTED BY
CARDIOLOGIST FOR HEART TRANSPLANT DUE TO DCMP WITH
SEVERE LV DYSFUNCTION
 The patient first time saw me in Dec.2014.
12

13. Case Study
 RIGHT HEART CATH-DONE WITH SWAN-GANZ CATHETER
SHOWED- PVR=287
- SVR=1326
 AFTER DOBUTAMINE INFUSION FOR 24 HOURS- PVR=192
 PFT-WITHIN NORMAL LIMIT
 DURING LAST 6 MONTHS-He HAD 3 EPISODES OF ACUTE HEART
FAILURE-HOSPITALISED and -MANAGED CONSERVATIVELY WITH
INOTROPES AND DIURETCS
13

14. 14

15. Case Study
 CALL RECEVED FROM B.L. KAPOOR HOSPITAL FOR A+ DONOR
 AT 10.30PM PATIENT( Recepient) WAS CALLED TO REACH HOSPITAL
 PT REACHED MAX HOSPITAL AT AROUND 11 PM AND WAS
IMMEDIATELY ADMITTED FOR HEART TRANSPLANTATION
 CTVS TEAM REACHED BLK HOSPITAL FOR ASSESSMENT OF DONOR
 57 YEARS MALE PATIENT
 ADMITTED AFTER ROAD-TRAFFIC ACCIDENT WITH HEAD INJURY
 DECLARED BRAIN DEAD ON 31/7/15 AT 11 AM AND RECONFIRMATION
DONE AFTER 6 HOURS at 5.15 PM ACCORDING TO LEGAL
REQUIREMENTS ( Human organ Act)
15

16. Case Study
 ALL LAB INV. OF DONOR- with in acceptable limits
 2-D ECHO- SHOWED NO REGIONAL WALL MOTION ABNORMALITY,
LVEF=50%
 CORONARY ANGIO=NORMAL
 DONOR WAS TAKEN TO O.T. AFTER MIDNIGHT
 AFTER PAINTING AND DRAPING-MEDIAN STERNOTOMY WAS DONE
 HEART INSPECTED VISUALLY
 AFTER CONFIRMATION OF GOOD DONOR HEART-RECEPIENT WAS
WHEELED-IN MAX HOSPITAL O.T.
16

17. Case Study
 AT BLK HOSPITAL UROLOGY AND HEPATOBILIARY TEAM STARTED
ORGAN DISSECTION OF KIDNEYS AND LIVER
 MEANWHILE LINES WERE INSERTED AND PT. WAS BEING PAINTED
AND DRAPED FOR SURGERY AT MAX HOSPITAL
 ONCE OTHER TEAMS WERE READY FOR ORGAN HARVESTING-
HEART WAS TAKEN OUT AFTER CROSS-CLAMPING AND
CARDIOPLEGIA
17

18. 18

19. Case Study
 RECEIPIENT CARDIECTOMY WAS DONE AND DONOR HEART
WAS SUTURED IN the SEQUENCE OF
LEFT ATRIUM→IVC→PULMONARY ARTERY→AORTA →SVC
DE-AIRING WAS DONE AND CROSS-CLAMP WAS RELEASED
AFTER GIVING 500MG METHYLPREDNISOLONE
 HEART STARTED BEATING
 WEANED OFF CPB SLOWLY &DECANNULATION DONE
 CHEST CLOSED IN LAYERS AFTER PUTTING CHEST TUBES
 PT WAS SHIFTED TO ICU AT 7.30 AM ON 1/8/15
19

20. Bicaval Approach
 Left atrial
anastomosis
performed
 Separate inferior and
superior vena caval
anastomosis
20

21. 21

22. Case Study
 PT WAS EXTUBATED ON 1st
POD
 MOBILISED OUT OF BED ON 2nd
POD
 SWAN ,SHEATH AND CHEST TUBES REMOVED ON 2nd
POD
 INOTROPES WEANED
 IMMUNOSUPPRESSIVE DRUGS STARTED -TACROLIMUS AND
MYCOPHENOLATE MOFETIL
 METHYLPREDNISOLONE WAS PUT ON WEANING MODE
 PT RECOVERed DISCHARGED WITHIN A WEEK FROM HOSPITAL
22

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24. 24

25. HEART TRANSPLANTATION
Kaplan-Meier Survival (1/1982-6/2005)
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Years
Survival(%)
Half-life = 11.0 years
Conditional Half-life = 14.0 years
N=89,006
N at risk at 25 years = 98
HEART TRANSPLANTATION
Kaplan-Meier Survival (1/1982-6/2009)
ISHLTISHLT
J Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132

26. Common Immunosuppressive
Regimen
 Primary: cyclosporine / tacrolimus
(utilized in conjuction with therapeutic drug monitoring)
 Adjunctive: mycophenolate mofetil
 Supportive: prednisone (only 20 to 30% centers wean
prednisone off if possible)
 Additive: statins (shown to be immunomodulatory and
associated with improved long term survival)
26

27. Major Post Transplant Complications
 Rejection
 Infection
 Cardiac allograft vasculopathy (CAV)
 Hypertension
 Nephrotoxicity
 Malignancy
27

28. Identifying Allograft Rejection
Disease Progression
Alloimmune activation Cellular invasion
Multiple genes
and pathways
Cellular inflamation
and myocyte necrosis
Graft Dysfunction
Heart failure and
arrhythmias
Diagnostic Indicators
Gene Expression Profiling
Immune Function Assays
Endomyocardial Biopsy
(intermediate)
Functional Assessment
(late)

29. 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
29

30. 30
GRADE 1A
GRADE 2
GRADE 1B
Mild

31. 31GRADE 4
GRADE 3A GRADE 3B
Threshold
Mandatory
For
Therapy

32. Long Term Challenges
 Renal failure and metabolic
adverse effects
 Cardiac allograft vasculopathy
 Malignancy
32

33. Cardiac Allograft Vasculopathy
Coronary Angiogram
Intravascular Ultrasound (IVUS)
Histology
(autopsy)
Diagnosis: coronary angiogram, IVUS, Dobutamine stress
Echocardiography (DSE), myocardial perfusion imaging (MPS)

34. VAD Components
Inflow cannula
Outflow Graft
Percutaneous drive line
Pump

35. HEART WARE
• Weigh 145 gms
• Pumps 4-5 liter/min
• No pocket required
• Under clinical trial

36. Peripherals

37. 37

38. Short-Term Extracorporeal Assist DeviceDevi
 Levitronix CentriMag
 Magnetically-levitated centrifugal pump
 Continuous-flow rotary pump
 Electrical actuation– magnetic coupling of
the motor and impellor
 Capable of 6 ~ 9 L/min at 5500 RPM
 Left, Right, or Biventricular support
 Operative placement requiring sternotomy
 Bridge to recovery
Courtesy of Levitronix, Inc.

39. Extra Corporeal Membrane
Oxygenation ( ECMO)

40. www.kewalkrishan.com

41. Thank you