Cardiac transplantation Flashcards
What agents can you use for vasodilator challenge for assessing PVR before transplant
Milrinone Nitric oxide Nipride Prostaglandin Oxygen
What is the half-life for survival post OHT
10 years is median survival
J Heart Lung transplant 2010; Oct 29 (10) 1083-1141
what are 2001 CCS indications for cardiac transplant
Adavanced function class NHYA III-IV
Poor 1year survival (peak Vo2 < 15 mm/kg/min
Failure to respond to maximal medical therapy
absence of alternative or conventional surgical options
absence of contraindications
potential to undergo rehabilitation post transplant
What are psychosocial issues for transplant
active smoking (3 months stop)
Drug or ETHO (3 months)
Unstable psychiatric conditions
Non-compliance
What body weight contraindications for transplant
Morbid obesity > 140% ideal body weight
Marked Cachexia < 60% of ideal body weight
Osteoporisis-patients with bone mineral density of > 2 SD below normal or at high risk
What are pulmonary pressure indications for not performing transplant
Transpulmonary gradient of > 15
Pulmonary vascular resitanace of > 4
Pulmonary vascular resistance index of > 6
Systolic pulmonary artery pressure > 50 mmhg
What is difference between bi-atrial and b-caval transplant
No difference in mortality
Bicaval—improved exercise tolerance, less need for PPM, less TR, few tachy arrhytmias, slighlty better hemodynamics
complication of bicaval is SVC syndrome
What are risk factors for possible increased mortality in transplant
Older Donors (> 50) Ischemic times; over 4 hours Donor heart dysfunction: regional wall motion abnormalities
Risk factor for mortality with cardiac transplant
A. Previous cardiac transplant
B. Ventricular support/ Mechanical support (VAD) (controversial)
D. Recipient < 5 years of age
E. Recipient > 60 years of age
F. Donor > 40 years of age(controversial)
G. Donor female (some data about gender mismatch outcomes)
H. Ischemic time >3.5 hours (controversial)
What pt will wait the longest for a heart transplant
A type O blood group (can only receive from O)
also a big pt (the size between donor and recipient should be matched at 0.8 to 1.2).
What is the Canadian transplant Status code
Status 4: mechanically assisted (IABP, VAD, ventilation) and in ICU are highest priority
Status 3: High does single or multiple inotropes; pts who have a VAD but are no in ICU
Status 2 Patients requiring hospitalisation
Status 1: pts a home
Why use induction therapy
reduce steroid use and nephrotixicity associated with early and high dose calcineurin inhibitor while minimizing episdoes of rejection
involves short-term use immediately post transplant (day 0 -7) of an intensive anti-T cell regimen.
They are associated with increased risk of infection because the polyclonal antibodies also effect B-cells.
List induction therapy agents
Polyclonal —OKT3; ATG; ATGAM; ALG
OKT3- associated with increased infections and post transplant lymphoproliferative disorder
Monoclonal–Basilizimab and Davlizumab–specially bind the IL-2 reception
Azathioprine (Imuran)
interferes normal purine pathways, inhibiting both DNA and RNA synthesis. Both B and T lymphocyte proliferation is suppressed and secondary antibody synthesis is reduced.
What medication should not be mixed with Azathioprine (Immuran)
Allopurinol
Mycopehnolate Mofetial (Cell Cept)
Purine analogie anitmetabolite that is much more potent and selective then AZA. Both B and T cells are inhibit, leading to a reduction in cell-mediated and humoral immunity.
effective management in acute rejection
has shown increased survival over AZA
Corticosteroids
Primary effect on T lymphocytes
release of cytokines is reduced
IL-2 production is directly and indirectly inhibited
an effect on B-lymphocytes and reducing antibody production
Rapacycin (sirolimus)
ia macrolide antibiotic structurally related to tacrolimus.
Blocking downstream effects of IL-2 and CD28 signaling
Works syndergistic with CyA and MMF
This drug is used only for refractory acute rejection
What are rates of rejection
majority will have at least one rejection in the first year post-transplant
usually detected on routine surveillance
What is the biopsy protocol post transplant
EMBx performed between day 10 to 14
Typically weeks for 4 weeks
After 1st year they do an annual routine until 5 years post-transplant
New rejection classification
Cellular
Grade 0R: none
Grade 1R: 1 focus of interstitial and/or perivascular infiltrate with myocyte damage
Grade 2R: >2 …
Grade 3R: diffuse … With edema, hemorrhage, vasculitis
Humoral
AMR 0: none
AMR 1: presence of histologic feature and immunofluorescence feature ( CD68)
Histologic features are endothelial swelling and immunoglobulins and complement deposition
What is treatment of CMV
Ganciclovir 5mg/kg BID for 14 days followed by 6 mg/kg daily x 5 days per week until day 28