Thoracic Organ Transplantation Flashcards
Types of cardiopulmonary transplants:
heart
heart-lung
lung
Candidate for heart transplant:
majority due to CAD, myocardial damage, cardiomyopathy
Majority of lung transplant due to:
emphysema
Majority of repeat transplant due to:
failure/rejection
Indications for heart transplant:
end stage heart disease
CAD
cardiomyopathy
congenital heart disease
Indications for lung transplant:
Chronic obstructive pulmonary disease BODE index of 7-10 and any of the following: hx of hypercapnia pulmonary hypertension cor pulmonale FEV1 of 20%
Indications for repeated transplant:
severe acute rejection transplant CAD graft failure intractable airway problems brochiolitis obliterans
Absolute contraindications for cardiac transplant:
systemic illness with left expectancy less than 2 years
active/recent solid organ or blood malignancy within 5 years
AIDS
Lupus, sacroid, amyloidosis
fixed pulmonary hypertension
pulmonary artery systolic pressure greater than 60mmHg
Relative contraindications for cardiac transplant:
age over 72 active infections active peptic ulcer disease severe diabetes w/organ damage server peripheral vascular or cerebrovascular disease ABI less than 0.7
Absolute contraindications for lung transplant:
active malignancy within last 2 years Alcohol or narcotic abuse HIV Hep B and C compliance absence of support chest wall or spinal deformity
Relative contraindication for lung transplant:
symptomatic osteoporosis
65 or older
poor rehab potential
Obesity
Factors affecting UNOS ranking:
tissue match, blood type, length of time on list, immune status, distance between potential recipient and donor
1A status for adults:
Has one of the following:
total artificial heart
intraaortic balloon pump
extracorporeal membran oxygenator
1A status for children:
mechanical ventilator mechanical assist device extracorporeal membrane oxygenation balloon pump congenital/acquired heart disease life expectancy less than 14 days w/out transplant
1A (re-certified every 7 days) status for adults:
continuous infusion of single high dose IV inotrope or multiple IV inotropes and required continuous hemodynamic monitoring of left ventricular filling pressure
1A (only 30 days)
One of following:
lVAD
RVAD
BiVAD
1A (every 14 days)
mechanical and circulatory support and device elated complications
1B for adults
LVAD or RVAD
BiVAD
continuous infusion of intravenous inotropes
1B for children
infusion of low dose single inotrope
6 months or younger
2
Does not met higher criteria but suitable for transplant
Inactive
Temporarily unsuitable for transplant
Components of lung allocation score:
DOB height and weight lung diagnosis functional status diabetes assisted ventilation supplemental O2 MAP 6 minute walk distance
Pulmonary Rehab recommendation:
minimum of 20 sessions three times/week or two times/week plus home high intensity when possible interval training UE and LE training endurance and strength inspiratory muscle training
Goal of preoperative rehab:
improve or prevent deteriorations of candidate’s physical condition
Endurance activities – limited to minimal levels of exertion or ADLs
30-40 min, 3-5x/wk
Why Alternative Therapies
Transplant Unsuitability
Did not meet criteria for organ system failure
Contraindications limits potential for success
Dec overall benefits for the pt
Pt opted for more conservative surgical or medical management
Alternatives for Lung Transplant:
LVRS – Lung Volume Reduction Surgery
20-30% of volume of each lung is removed
Goal improve thoracic distention & chest wall mechanics
Alternatives for Lung Transplant:
Noninvasive ventilation or BiPAP
Tightly fitting nasal mask
Deliver positive airway pressure during inspiration & exhalation
Who is noninvasive ventilation or BiPAP indicated for?
pts with signs of respiratory failure despite max drug & O2 therapy
Alternative Therapies to Heart Transplant
VAD
Home IV pharmacological mangement
cardiomyoplasty
Most common VAD until transplant?
LVAD
Harvest of Donor Lungs
Pulmonary veins are detached from heart with cuff of left atrium
Pulmonary arteries are transected
Lungs removed en bloc, divided into separate right and left lungs
Heterotopic heart transplantation (HHT) – “piggyback”
Pt heart is not removed
Donor heart is connected via R/L atria
Orthotopic/biatrial technique
Recipient’s SA node is left intact,
Donor & recipient’s atrial cuffs are sewn together
2 P-waves on ECG
Signs and Symptoms of acute rejection:
low grade fever increase in resting BP hypotension with activity myalgia fatigue decrease exercise tolerance ventricular dyshythmias
