Cardiac transplant

Question 1

Prognosis of Cardiac transplantation? (1-year, 5-year survival rate, average survival, for 30s and 60s)

Answer 1

5-year survival 75%

1-year survival 90%

Average 15 years

For 30 years: 20 years

For 60 years: 12 years

Question 2

What are the indications for the Cardiac transplant? (4 must, 2 extra)

Answer 2

NYHA class IV despite maximal medical (and surgical/device) therapy

Intractable severe ischaemia not amenable to revascularisation (neither PCI or surgical) - e.g. severe transplant CAD (aka cardiac allograft vasculopathy)

Intractable life-threatening arrhythmias unresponsive to medical therapy, catheter ablation, surgery or iCDs

Cardiogenic shock - requiring continuous inotropes, IABP, LVAD

Selected patient with restrictive or hypertrophic cardiomyopathies + NYHA III-IV (e.g. Cardiac amyloid)

Congenital Heart Disease - NYHA IV and others: say that those with complex intracardiac congenital abnormalities with significant pulmonary vascular disease, e.g. Eisenmenger’s require Heart + Lung transplant

Question 3

Absolute contraindications for Cardiac Transplant? (6)

Answer 3

Systemic illness with life-expectancy <2 years

Multi-system disease with severe extra-cardiac organ dysfunction

Irreversible pulmonary HTN

Active drug or alcohol abuse

Multiple demonstrations of inability to comply with therapy

Clinically severe cerebrovascular disease

Question 4

What are relative contraindications to cardiac transplantation? (5)

Answer 4

Obesity (BMI >35)

Age (>70)

Poorly controlled diabetes or end-organ damage

Irreversible renal failure

Acute PE (<8 weeks)

Neoplasm / Infection - individualised assessment

Question 5

Cardiac transplant history? (PRIC-MCP)

Answer 5

P: when + why was it done. What was the indication? What medications, device, surgery was tried before considering transplant?

R: risk factors for adverse outcomes

I: TTE, gated pool, EST, angiogram, endomyocardial biopsy (before & recent), RHC before transplant

C: of surgery, HF medications, Anti-arrhythmics (especially amiodarone), transplant medications, Rejections

M: current regime (Tacro…etc), LVAD prior to transplant (40% of patients)

C: current symptoms, LV function, any transplant coronary artery vasculopathy (usually 2 yearly cath), most recent biopsy results, frequency of follow-up, and these investigations.

How is the patient coping? managed to go back to work? any problem with returning to transplant centre?

P: understanding of their prognosis

Question 6

What are indications for LVAD? (1) + and main side effect?

Answer 6

Repeated hospital admissions to hospital with decompensated HF

Main side effects = thrombosis and infection

Need Warfarin + at least one anti-platelet therapy

Question 7

Risk factors for adverse outcome to ask in “R” in history? (5)

Answer 7

Obesity / Exercise / Diet

Alcohol and Drugs

Psychosocial issues

Adherence problems

History of infection / Cancer

Question 8

Pre-cardiac transplant workup?

Answer 8

Categorise!

Cardiac: TTE (LVEF, valve, exclude LV thrombus), gated-pool scan (EF), 24h-Holter, Angiogram, RHC to exclude p-HTN. Don’t forget Carotid USS

Resp: CXR, LFT, sleep study if OSA

Metabolic: HBA1C (OGTT/fasting glucose), lipids, DEXA (baseline)

Infection: HIV, IGRA, Hep B/C, CMV, EBV, VZV, HSV, Toxoplasma, MRSA carriage

Immunology: Igs, protein electrophoresis, Auto-antibodies

Malignancy: CT CAP (if age >60 or >50 if a smoker), otherwise recent FOBT, PSA, mammogram, PAP-smear

Psychosocial: psychiatry consult, SW, dietician, transplant nurse & coordinator

Question 9

Any other workup if the cause of cardiomyopathy is unknown? (3)

Answer 9

Myocardial biopsy

Viral tires (Coxakie, Echo, Adeno, Influenza)

Iron studies (haemochromatosis)

Question 10

What are the symptoms / presentations of Allograft rejection? (5) - cardiac transplant

Answer 10

Heart failure symptoms

Arrhythmia (AF/flutter)

LVEF reduction on TTE/GHPS

ECG - decreased ECG voltage (due to myocardial oedema)

Unexplained fever / flu-like illness / pleuristic chest pain

Question 11

Cardiac transplant patient but on multiple anti-failure medications - does this concern you?

Answer 11

Yes as transplant patients should not require them.

I would be concerned about allograft rejection and investigate for these.

Question 12

What is the frequency of endomyocardial biopsies post-transplant?

Answer 12

Weekly in 1st month

Bi-weekly in 2nd-3rd months

Monthly until 9th month

Once at 12 months

6-12 monthly thereafter (check)

Question 13

Why do you think this patient is on Diltiazem?

Answer 13

Sometimes used as cyclosporin-sparing agent as it dramatically reduces Cyclosporin metabolism

Question 14

How would you investigate this cardiac transplant patient p/w SOB/Leg oedema

Answer 14

ECG to look for decreased voltage (myocardial oedema)

TTE

Question 15

What is the most important problem / rejection phenomenon following cardiac transplant?

Answer 15

Allograft arteriopathy.

Because the heart has been denervated there is usually no pain (not always as some get re-innervated)

Question 16

Prognosis if patient with 40% Coronary stenosis in transplant?

Answer 16

Allograft arteriopathy (Coronary allograft vasculopathy)

2-year survival only 50%

Once MI occured, 2-year survival only 10-20%

Question 17

What are DDx for cardiac transplant patients presenting with SOB? (7)

Answer 17

Acute cellular / humoral rejection (symptoms resemble pericarditis - usually from ischaemia or reperfusion injury)

Arrhythmia - especially SVT is a marker of acute rejection

Coronary Allograft Vasculopathy (=chronic rejection)

Infection (e.g. PJP, pneumonia)

Malignancy (PTLD, Solid organ tumours, Mets)

Renal failure (CNI toxicity)

Psychological (in context of steroids)

Question 18

So how would you investigate this patient? (SOB in transplant patient)

Answer 18

T: Key investigation = ECG (reduced voltage, arrythmia = suggestive of rejection), TTE (LV function), angiogram (CAV), endomyocardial biopsy (lymphocytic infiltrate - rejection).

Confirmatory for CAV = IVUS (intravascular USS) - angiographic technique

E: inflammatory markers, PJP / septic work-up (induced sputum/BAL culture, blood culture, screen for nocardia, toxoplasma, fungal infections), CXR (pneumonia), CTPA, FBC (anemia), EUC (renal failure), CNI levels

Question 19

Management options for CAV? (4)

Answer 19

Statin - reduces incidence of CAV and mortality significantly

Consider Diltiazem if concomitant HTN

Consider Sirolimus (mTOR) - significant reduction in major adverse cardiac events c/w CNI for documented CAV

PCI with stenting for discrete lesions

Surgical grafting

Re-transplantation if a diffuse disease