Heart and Lung Transplant Flashcards
What is the primary indication for a heart or lung transplant?
progressive terminal cardiopulmonary disease with limited life expectancy
Majority of heart transplants are due to….?
CAD, which leads to myocardial damage and cardiomyopathy
Majority of lung transplants are due to….?
Emphysema
-idiopathic pulmonary fibrosis is the 2nd more common diagnosis
Indications for heart transplant
End stage heart disease: hemodynamic compromise, CAD, cardiomyopathy, refractory cardiogenic shock
NYHA Class III-IV despite maximal therapy
Poor quality of life: intractable angina, refractory arrhythmia, Vo2 max<10mL/kg/min
Other: congenital heart disease, cardiac tumors
Indications for lung transplant
COPD: BODE index 7-10 with any of the following – hx of acute hypercapnia, pulmonary HTN or cor pulmonale, FEV1 of 20% and DLCO of 20%
Idiopathic pulmonary fibrosis and evidence of any of the
following: DLCO of 39%, 10 decrease in FVC, <88% 02 saturation during 6MWT
Cystic Fibrosis: FEV1 of 30% and any of the following –
increasing 02 requirements, hypercapnia, pulmonary HTN
Idiopathic pulmonary arterial hypertension
Sarcoidosis – with hypoxemia at rest, pulmonary H
Absolute contraindications for heart tranplant
Systemic illness with life
expectancy less than 2 years
AIDS
Lupus
Significant obstructive
pulmonary disease
Fixed pulmonary
hypertension
Absolute contraindications for lung transplant
Active malignancy within the
past 2 years
Continued abuse of alcohol,
tobacco or narcotics
HIV
Significant chest wall or spinal
deformity
Hepatitis B antigen positivity
Hepatitis C with liver disease
Untreatable psychiatric
condition
Absence of support system
Who maintains the list of awaiting transplant candidates?
UNOS- United Network of Organ Sharing
-Candidates on the waiting list are matched with the donor’s characteristics and a computer rank is given to them
Which factors does the computer rank consider?
-age
-tissue match
-blood type
-length of time on waiting list
-immune status and distance between recipient and donor
What is the Lung Allocation Scale (LAS)?
address the risk of death with and without transplantation and other factors that affect survival
-pts are assigned a score from 0-100 and is reassessed every 6 months
-higher scores receive higher priority for a lung
T/F Patients may be referred to cardiac or pulmonary rehab while waiting for a transplant
True- can address chest wall ROM, balance, strength, and gait mobility deficits
T/F some patients may need to be hospitalization until transplant
True- Respiratory status of patients can decline and may result in patient’s needing bridging techniques as they wait for a lung transplant – this can include but is not limited to mechanical ventilation
What is an LVAD?
an electrically powered, implantable device that provides permanent support of the systemic circulation in those whom a suitable donor has not been found
What are alternatives for those with end-stage pulmonary disease who do not qualify for transplant?
Lung volume reduction surgery: reduction pneumoplasty or bilateral pneumonectomy
What are alternatives who do not qualify for a heart transplant?
Left, right, biventricular assist devices may be used
Allocation times for different transplants
-Lung: 6 hrs
-Heart: 6 hrs
-Liver: 24 hrs
-Pancreas: 24 hrs
-Kidney: 72 hrs
What are the 4 heart transplant techniques?
- Heterotopic
- Total transplantation
- Biatrial
- Bicaval technique
What is a heterotopic heart transplant?
Used if there is a mismatched size between the recipient and donor- the native heart is NOT removed
-the donor heart is connected to the patient’s native heart by both R atriums and L atriums
-ascending aortas are connected as are the pulmonary arteries
What is a total transplantation heart transplant?
A complete excision of the recipients atria and complete atrioventricular transplantation
-not frequently used
What is a biatrial heart transplant?
An orthotopic heart transplant that leaves the recipient’s SA node intact
-where the donor’s SA node is denervated and operates independently of the recipients
What is a bicaval heart transplant?
Separate caval anastomoses are sewn which is different than the biatrial technique where donor and recipient atrial cuffs are sewn together
-more frequently used
T/F lungs are removed from the donor in 2 separate units
False- they are removed as 1 unit and then divided into R and L for implantation
-the least functional lung is transplanted first and the remaining contralateral lung is ventilated
-by transplanting one lung at a time, the time needed for cardiopulmonary bypass is decreased
What are the most common procedures used for lung transplantation?
-mainstem bronchi anastomoses with bilateral thoracotomies
-transsternal bilateral thoracotomy
which meds are given post-transplant?
The majority of meds are immunosuppressive agents- necessary to prevent rejection of the donor organ by reducing the normal immune system’s response to foreign tissue
What are the 3 stages of immunosuppression?
- Introduction: strong dose of immunosuppressants at time of transplant
-thought to reduce acute rejection, but not used everywhere b/c of increased risk of malignancy and infection - Maintenance: some meds are continued throughout life
- Treatment of acute rejection: treated with strong dose of immunosuppressants
Risks of transplants
-rejection
-graft vs host disease
-infection
-cancer
-poor wound healing
-recurrence of original disease
-OP
-steroid-induced myopathies
-avascular necrosis
Types of Rejection:
- Hyperacute Rejection: second to minutes after transplant- organ death inevitable**
- Acute Rejection: days to years after transplant- sudden onset of symptoms and usually reversible**
- Chronic Rejection: months to years after transplant- slow, progressive organ failure
What is graft vs host disease?
When T-cells of the donor recognize the recipient as foreign
-inflammatory response
-recipient tissue damage
-fatal if untreated- increase immunosuppression use
Rehab interventions following an acute heart transplant
-optimize pulmonary hygiene and chest wall mechanics
-improve strength and ROM of the UEs and thoracic region
-improve exercise tolerance through ADLs and exercising at low to moderate intensity
-begin exercises in supine and progress to sitting an standing
-patient education
S/S of acute rejection following a heart transplant
Low grade fever
Increase in resting BP
Hypotension with activity
Myalgia
Fatigue
Decreased exercise tolerance
Ventricular dysrhythmias
Dyspnea
Weight gain due to water retention
Decreased urine output
What is the most fragile of transplanted organs?
Lungs- more susceptible to damage
-excessive fluid administration
-aspiration
-ventilator-assisted pneumonia
