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HEART TRANSPLANTATION SUGERY
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- 5. DEFINITION CARDIAC TRANSPLANTATION ISA THERAPEUTIC PROCEDURE WHERE BY THE HEART OF A SUITABLE DONOR IS IMPLANTED TO A RECIPIENT
- 6. INDICATIONS Cardiogenic shockrequires mechanical assistance Refractory heart failure with continuous inotropic infusion Progressive symptoms with maximal therapy Severe symptomatic hypertrophic or restrictive cardiomyopathy Medically refractory angina with unsuitable anatomy for revascularisation life-threatening ventricular arrhythmias despite aggressive medical and device intervention Cardiac tumours with low likelihood of metastasis
- 7. Hypoplastic leftheart and complex congenital heart disease Patient should receive max medical therapy before being considered for transplantation i.e. they should be considered for the alternative surgical therapies including CABG valve replacement / repair cardiac septalplasty Peak VO2 (VO2 MAX) less than 10mL/kg/min
- 8. CONTRA-INDICATION ABSOLUTE Systemic illnessthat will limits survival despite heart transplantation 1. Neoplasm other than skin 2. HIV/AIDS 3. SLE/SARCOID that has multistage involvement or is still active 4. Any systemic process that has high probability of recurring in transplanted heart RELATIVE Age over 65 yrs PVD not amenable to surgical / percutaneous therapy Ankle brachial index <0.7 or substantial risk of limb loss with diminished perfusion Asymptomatic carotid stenosis >75% or symptomatic carotid stenosis of less severity DM with end organ damage E.g.:- nephropathy, neuropathy
- 9. ABSOLUTE Fixed pulmonaryhypertension 1. Pulmonary vascular resistance >5 wood units 2. Trans-pulmonary gradient >15mmHg Age >70 years Relative Severe lung disease Uncorrected abdominal aortic aneurysm >4-6cm Systemic infection causing immune suppression risk 1. HIV 2. Hep.B 3. CMV (+ve donor to –ve recipient ) Psychological impairment that jeopardizes the transplanted heart
- 10. EVALUATION OF CARDIAC TRANSPLANTATIONRECIPIENT Right and Left heart catheterization Cardiopulmonary testing Labs including BMP, CBC, LFT, UA, coags, TSH, UDS, ETOH level, HIV, Hepatitis panel, PPD, CMV IgG, RPR/VDRL, PRA(panel reactive antibodies) ABO and Rh blood type, lipid CXR, PFT’s including DLCO, ECG Substance abuse history and evidence of abstinence for at least 6 month and enrolment in formal rehab. Mental health evaluation Financial support Weight no more than 140% of ideal body weight
- 11. Cardiac Donor Braindeath is necessary for any cadaveric organ donation. This is defined as absent cerebral function and brainstem reflexes with apnoea during hypercapnea in the absence of any CNS depression There should not be any hypothermia , hypotension , metabolic abnormality, or drug intoxication If brain death is uncertain confirmation test using EEG, cerebral flow imaging or cerebral angiography are indicated
- 12. Cardiac Donor –Exclusion Criteria Age older than 55 yrs . Serologic test positive for HIV, Hep.B/C Systemic infection Malignant tumours with metastatic potential Systemic comorbidity (DM, collagen vascular disease) Cardiac disease CAD Allograft ischemic time estimated to be >than 4-5 hrs Left ventricular hypertrophy or left ventricular dysfunction on echo. Death of carbon monoxide poisoning IV drug abuse
- 13. Matching Donor &Recipient Because of ischemic time during cardiac transplantation is crucial DONOR – RECIPIENT MATCHING is based primarily not on HLA typing but on the 1. Severity of illness 2. ABO typing 3. Response to PRA 4. Donor wt. to recipient ratio (must be 75%-125%) 5. Geographic location of donor
- 14. SURGICAL TRANSPLANTATION TECH. ORTHOTOPIC IMPLANTATION IT IS THE MOST COMMON IT INVOLVES COMPLETE EXPLANTATION OF THE NATIVE HEART HETEROTOPIC IMPLANTATION IT IS AN ALTERNATIVE TECH. IN WHICH THE DONOR HEART FUNCTIONS IN PARALLEL WITH THE RECIPIENT
- 15. Orthotopic heart transplantation the recipient’s diseased heart is removed the donor allograft is inserted anatomically in its place After the sternotomy, The ascending aorta is cannulated close to the aortic arch, venous return cannulae are inserted into both the superior and inferior cavae, and the patient is placed on CPB. The cavae are encircled with tourniquets to isolate all of the venous return from the heart, the ascending aorta is clamped close to the aortic arch, and the recipient heart is then excised. There are two techniques of orthotopic heart transplantation
- 16. the classicor biatrial method and the bicaval method. In the classic method, the recipient’s right atrium is divided through the body, leaving its posterior aspect in situ In the bicaval method, the recipient’s entire right atrium is removed by dividing both the inferior and superior vena cavae proximal to the atrium the bicaval technique may result in fewer postoperative rhythm problems and less tricuspid regurgitation. The left atrium is divided, leaving its posterior aspect and the pulmonary veins of the recipient in situ and the recipient heart is removed.
- 17. The donorheart is then placed in the pericardial well and attached to the recipient with left atrial and right atrial (or bicaval) suture lines, and then the donor pulmonary artery and donor ascending aorta are anastomosed end-to-end to the recipient’s artery and aorta. When the aortic anastomosis is completed, the aortic cross clamp is removed from the recipient aorta, ending the ischemic time of the donor heart.
- 18. Heterotopic heart transplantation Heterotopic heart transplantation is a rarely performed procedure in which the recipient’s heart remains in place, and the donor heart is attached to its right side so that the flow in each is in parallel, permitting the recipient’s heart to continue to pump blood, particularly through the lungs . This procedure is primarily reserved for patients with pulmonary hypertension as a strategy to avoid acute right heart failure in the unconditioned donor heart and in cases in which there is a marked difference in size of the donor and recipient
- 19. PHYSIOLOGICAL CINCERNS Biatrialconnection means less atrial contribution to stroke vol. Resting HR is faster (95-110 bpm) and acceleration of HR is slower during exercise bcoz. Of denervation Diurnal changes in BP are abolished Diastolic dysfunction is very common bcoz. the myocardium is stiff from some degree of rejection and possibly from denervation
- 20. POST OPERATIVE COMPLICATION SURGICAL Aortic pseudo aneurysm or rupture at cannulation site Haemorrhagic pericardial effusion due to bleeding or coagulopathy MEDICAL Severe tricuspid regurgitation RV. Failure 1. Pulmonary artery compression 2. Pulmonary HNT LV. Failure 1. Ischemia 2. Operative injury 3. Acute rejection
- 21. RHYTHM DISTURBANCES Asystole Complete heart block Sinus node dysfunction with bradyarrythmias Atrial fibrillation Ventricular tachycardia RESP. FAILURE Cardiogenic pulmonary oedema Non cardiogenic pulmonary oedema infection
- 22. COAGULOPATHY INDUCEDBY CARDIOPULMONARY BYPASS RENAL OR HEPATIC INSUFFICIENCY (drugs , CHF )
- 23. POST OPERATIVE MANAGEMENT INITIATION OF MEDICATION, PERTICULARLY IMMUNOSUPRESSIVE AGENTS BEGINS ON THE DAY OF OPERATION 1. CYCLOSPORINE 2. AZATHIOPRINE 3. SOLUMEDROL 4. +/- MUROMONAB-CD3 (OKT3)
- 24. PNEUMOCYSTIS CARINIIPROPHYLAXIS IS STARTED WITHIN THE FIRST WEEK AFTER TRANSPLANTATION IF PATIENT / DONOR IS CMV +VE THEN GANCICLOVIR IS STRATED ANTICOAGULANT IS STARTED IF HETEROTOPIC TECH. HAS BEEN PERFORMED ECG ARE OBTAINED IN EVERY DAY
- 25. LONG-TERM MANAGEMENT Cyclosporinelevels are checked periodically by individual centre protocols Echo. Is useful periodically and as an adjunct to endocardial biopsy Cardiac catheterization is performed annually for early detection of allograft vasculopathy There is no need of routine exercise or nuclear stress testing.