Topic 9: Transplants Flashcards
Perfusion is involved in what 3 types of transplants?
Heart Transplants
Lung Transplants
Liver Transplants
Can be performed individually or in combo
Often along with a kidney
Who described first heterotopic transplant of a donor heart into the neck of a dog?
1905–Carrel and Guthrie
Not a functional model, functioned together with the recipient’s heart
Heart was not capable of supporting circulation
Lasted 2 hours before the chambers clotted
Created innovative surgical technique for vascular anastomoses?
Carrel and Guthrie
Heterotopic transplant with circulatory unloading of the RV
Working model
1933–Mann, et al. at Mayo Clinic
Observed–failure of the transplanted heart was not always caused by faulty surgical technique, but to “some biologic factor which is probably identical to that which prevents survival of other homotransplanted tissues and organs”
Described acute allograft rejection
Described acute allograft rejection?
1933–Mann, et al. at Mayo Clinic
Orthotopic heart transplant in dogs with CPB
and topical hypothermia for donor heart preservation?
1960–Lower and Shumway
Survived 6-21 days
Died of rejection
1967–First human heart transplant was performed where?
South Africa
in the 1980s –Interest in transplantation re-emerged?
cyclosporine-based immunosuppression introduced
Patient selection for a heart transplant criteria?
Patients have to be in end stage CHF
NYHA function class III or IV
Symptomatic refractory to management with medications, electrophysiology devices (pacemakers/AICD) and surgical intervention.
LVEF < 35%
Cardiogenic shock (Acute MI or Myocarditis)
Ischemic heart disease
Must be able to benefit from a transplant
Patient selection for a heart transplant criteria, must be what NYHA functional class?
NYHA function class III or IV
Patient selection for a heart transplant criteria, LVEF % has to be what?
LVEF < 35%
Contraindications for transplant?
Advanced age Irreversible pulmonary hypertension Active Infection and malignancy Obesity Diabetes Pulmonary Fibrosis, Emphysema, Hepatic and renal dysfunction, Cerebral vascular disease, Peripheral vascular disease Psychosocial
Contraindications for transplant?
Advanced age:
Should be less than 65 years old
Can be done in older patients
Physiologic age is a better indicator than chronologic age.
Contraindications for transplant?
Irreversible pulmonary HTN
complication of what? PA mmHg? give what?
Pulmonary htn is a complication of CHF with elevated LVEDP.
Can create irreversible changes to pulmonary vasculature
Could cause RV failure in new organ
PA systolic above 50-60mmHg is not good!
Give inhaled nitric oxide to prevent pulmonary htn.
Contraindications for transplant?
Active Infection and malignancy
fever free?
Infections are exacerbated by immunosuppression required after transplantation.
-Need to be fever free for 72 hours
-Normal white cell count
-Negative blood cultures
Hepatitis B, C, HIV not usually done
-HIV is becoming more acceptable to transplant due to improvement in drug therapy.
Non-melanoma cutaneous cancers, primary cardiac tumors restricted to the heart, low grade prostate cancers
-Ok to transplant
Contraindications for transplant?
Obesity?
why, BMI
Impacts infection rates, wound healing, and have an increased incidence of acute rejection.
BMI less than 30 kg/m2
Contraindications for transplant?
Psychosocial - what and why?
Substance abuse (tobacco, alcohol) Compliance with medications Frequency of social support Lots of tests/ workups are done prior to transplantation. Must be approved my several committees and departments prior to listing the patient
Organ matching - what do they look at?
- ABO Blood Compatibility
- Overall body size
- Match must be within 20% of body weight
- HLA Cross match
- Some patients are sensitized to antigens due to pregnancy, prior transplant, or blood transfusion.
- Priority on UNOS Registry
- Geographic distance from donor
Organ matching -Waiting List Criteria
Status code and time within the status code
Highest medical urgency and lowest short term survival are assigned higher codes
Organ matching - how it works?
Offered to local status 1 patients first, Status 1A before Status 1B.
No match? Offered to Status 1 patients within 500 mile radius.
No match? Offered to Status 2 local patients.
Repeat at 1000 mile radius, and 1500 mile radius.
Organ transplant -
how is heart arrested
Donor heart is arrested with a cardioplegia/ preservation solution.
Heart is cooled topically.
Organ transplant - how is it transected?
Atria are transected at the midatrial level
Leave multiple pulmonary venous connections to the LA intact.
Transect the aorta and PA just above the semilunar valves
Organ Transplant – Ischemic time?
–3-4 hours!! (can do up to 5-6 hours–not ideal!!)
Organ Transplant - Re-anastomosis of midatrial level – how is it done?
Start at atrial septum
Generous “cuff” of donor RA, so SA node will be included in transplant
Great vessels connected above the Semilunar valves.
Organ Transplant – Recently, bi-atrial technique has been modified
how is it done? Less what found?
(Called Bicaval technique)
Leave donor atria in tact and make the anastomosis at the SVC and IVC and Pulmonary Veins
Notice less distortion of the aortic valve
Improved atrial and ventricular function
Less AI
Less arrhythmias/ heart block.
Heart/Organ transplant – post op course?
Same as a normal cardiac case
Patient will be on immunosuppression drugs
Will require pacing for a few days
Takes 2-3 days for the SA node to come back and “reset”
Transplanted Heart - response to drugs?
Don’t respond to drugs that work via the
parasympathetic pathway.
Transplanted Heart HR?
Faster resting heart rate (95-100 beats per min)
Intrinsic rate of SA node
Transplanted Heart slower to do what?
Slower to increase HR in response to exercise
Slower to recover after exercise
Transplanted Heart feeling?
Completely denervated
No angina with ischemia
Will have silent MIs. Will present with CHF, Silent MI or Sudden death.
Transplanted Heart parasympathetic effect?
No parasympathetic down regulation
heart transplant - Harvest team will call saying heart is out - what do you do?
Write down donor cross clamp time. This is the start of the ischemic period of the donor organ.
heart transplant - Patient will be draped. If it’s a redo, incision will be made with the “heart out” call – what kind of incision, bypass type?
Median sternotomy
If it’s a redo, you’ll go on Fem-fem
heart transplant - Heart is in the room – temp of the patient? Aox
Go on bypass. Usually drift, or cool to about 32*C.
Cross clamp almost immediately.
heart transplant - Sutures complete - what do you give next?
Some institutions give a “hot shot” type dose of “cardioplegia”. Use Glutamate Aspartate Solution. Full of nutrients for that ischemic heart. Other places don’t.
heart transplant Sutures complete. Cross Clamp off Pacing wires placed \_\_\_\_\_\_\_\_? Wean from CPB. Close
Fill up heart
Wait time for a single lung and a double lung.
more than24 months
36 months - double
Indications for a lung transplant
–Irreversible, progressively disabling, end-stage pulmonary disease
–Usually life expectancy is less than 18 months
Oxygen dependent
Exercise intolerance
Less than 65 years old
Poor quality of life.
Patient is evaluated in what areas for a lung transplant?
History Respiratory exam Past medical history Family history Psychosocial and cultural history
Lung transplant that affects eligibility - how much corticosteriods?
Use of corticosteroids (>20mg/day)
Lung transplant that affects eligibility - Malnutrition restrictions?
Malnutrition 130% ideal body weight
Lung transplant that affects eligibility -
Smoking within how much time of activation on the transplant list?
4 months of activation on the transplant list
Single Lung Transplant – risk factors to get you on the list?
COPD/ Emphysema
Idiopathic Interstitial Pulmonary Fibrosis
Sarcoidosis
Eosinophilic Granuloma
Lymphangiolyomyomatosis
Primary Pulmonary Hypertension
Eisenmengers Syndrome with cardiac repair
Which side is easier for single lung transplant
Left
Single lung transplant – bypass??
No CPB is necessary–usually
Depends on patient’s tolerance to unilateral support during cross clamp.
single lung transplant – Posterolateral thoracotomy through bed of which excised rib?
5th
Single Lung Transplant
When the main PA is encircled and temporarily clamped assess what?
Assess the impact on hemodynamic stability and gas exchange
If not tolerated, femoral cannulation is used, and patient placed on CPB
Single Lung Transplant Usually stay warm Native lung is excised \_\_\_\_\_ is clamped Pulmonary veins are attached to LA Cuff. PA is anastomosed End to end anastomosis of the donor and recipient bronchus \_\_\_\_\_ is removed.
Left Atrium
Atrial clamp
Bilateral Sequential Double Lung Transplant
Cystic Fibrosis Bronchiectasis Emphysema Primary Pulmonary Hypertension Eisenmenger’s Syndrome with cardiac repair
Double lung transplant–gives patients a better pulmonary reserve
En bloc – is what?
Used to be done en bloc where each lung was
implanted separately through a pleural-pericardial window while on CPB.
BIG PAIN from a perfusion standpoint
En bloc - what kind of incision?
Utilized Clamshell incision
bilateral sequential lung transplant
Ventilate the native lung, while the first goes in. Then ventilate the new lung while the second goes in
Ex vivo lung perfusion - how long is procedure?
attached to what? Temps?
3-4 hour procedure Donor lungs placed inside plastic dome Attached to ventilator, pump and filters Maintained at normal body temperatures Once suitable–transplanted into waiting patient
Ex vivo lung perfusion - what are lungs perfused/treated with?
Treated with a bloodless solution that contains
nutrients, proteins, oxygen
Reverse lung injury
Remove excess water
First human liver transplant was done in 1963 by? where?
Thomas Starz in Denver, CO.
But 1967, marked the first time a liver transplant
patient lived to 1 year post surgery.
General guidelines for a liver transplant?
Any patient with a chronic or acute liver disease who is unable to sustain normal quality of life or patients with serious complications related to the underlying liver pathology should be considered
Liver Transplants - Evaluation of Safety
Encephalopathy Ascites Recurrent GI Bleeding Severe Fatigue Early stage primary liver tumor Others...
Donor Liver Organ usually arrives when? Organ is prepped at the back table.
prior to incision
Incision is made, liver is mobilized
For liver transplant - A Test Clamp is performed for what?
If patient remains stable–can do it without V-V bypass. If not, V-V bypass is initiated.
Liver is excised and removed.
New liver is sewn in – what connections need to be made?
Suprahepatic IVC Infrahepatic IVC Portal Vein Hepatic Artery Clamps are removed–Bypass is discontinued Bile Duct
What percents of liver transplants are V-V bypass?
less than 5%
Parameters that need to be monitored during a liver transplant (8)
EKG HR Core Temp Pulse Ox Arterial BP PA Catheter SvO2 Cardiac Output
Most common way to clamp for a liver transplant ?
Now they can use a partial occlusion clamp on the IVC without cross clamping the entire IVC
1980s–V-V Bypass for liver transplant came into practice with the use of what?
heparin bonded circuits and a centrifugal pump
V-V bypass for liver transplant
Flow?
Less flows than on CPB Flows from 1-2 liters most common Flow what you can get Flows adequate unless less than 1 liter per minute and cardiac preload is maintained -Need to maintain flow to prevent clot -Preload dependent.
V-V bypass for liver transplant
Cannulation?
Femoral vein is cannulated and advanced to the bifurcation of the IVC
2nd cannula placed in the portal vein to drain the portal system.
Wyed into the venous line.
Return to axillary vein or internal jugular vein.
V-V bypass for liver transplant
Oxygenator?
Pump?
No oxygenator
Centrifugal pump
V-V bypass for liver transplant
anitcoagulation?
Volume - closed system
No heparin used
Closed system, so no volume can be added
