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Utah / kirklin > Transplant > Flashcards

Transplant Flashcards

1
Q

Indications for a heart transplant (3)

A
  1. Absence of reversible or surgically amenable heart disease
  2. NYHA class III-IV symptoms despite maximal medical management
  3. Peak O2 consumption
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2
Q

Recipient risk factors for OHT

A
  1. Neuro: cerebrovascular disease
  2. CV: peripheral vascular disease
  3. Pulm:
    • infection
    • Pulm HTn (>5-6wu)
    • other intrinsic lung disease
  4. GI: irreversable liver disease
  5. GU: kidney disease
  6. FEN: Diabetes / obesity
  7. ID: Infection
  8. Malignancy
  9. psy: confounding psych disease
  10. PSA >
  11. increasing age
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3
Q

Conditions which preclude a donor heart

A
  1. HIV +
  2. significant ventricular arrhythmia
  3. Echo abnormalities
  4. global hypokinesis
  5. significant valvular disease - except ?bicuspid valve
  6. significant coronary disease
  7. Acute malignancy - except primary brain
  8. inadequately treated systemic infection
  9. HBsAg + - unless recip also pos
  10. Hep C - unless recip also pos
  11. Death from CO poisoning with COHb>20%
  12. Significant cardiac contusion
  13. significant LVH
  14. IVDA
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4
Q

Heart Donor criteria

primairy cardiac contraindications

A
  1. significant ventricular arrhymia
  2. significant coronary disease
  3. Echo: “abnormalities” :
    • global hypokinesis
    • significant valvular abnormalities
    • significant cardiac contusion
    • significant LVH
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5
Q

Heart Donor criteria - who should be cath’ed

A
  1. anyone older than 45
  2. hx of smoking
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6
Q

Heart donor - infectious causes for exclusion

A
  1. HIV +
  2. inadequately treated systemic infection
  3. HbSAg + , unless recipient is +
  4. Hep C +, unless recipient is +
  5. Hx of IVDA
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7
Q

Heart donor - issues with carbon monoxide

A

if COHb > 20% - should be concerned in pts with MVA

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8
Q

heart txp PRA - what level is of concern? what is done?

A

if PRA > 10% a prospective cross match is performed

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9
Q

heart txp prospective crossmatch -

A

performed if the PRA > 10%

PRA > 25% very high risk ==> tests recipient sera for anti - HLA ab against donor lymphocytes > + if lymphocyte lysis (prob of hyperacute rejection high)

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10
Q

treatment of high PRA

A
  1. Plasmapharesis
  2. IVIG
  3. cyclophosphamide
  4. Rituximab - specific to CD-20
  5. Photophaeresis
  6. Totoal bone marrow irridation
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11
Q

OHT:

Recipient pulmonary HTN that is associated with increased M&M

A

Pulmonary hypertension:

  • >6 Wood units & responsive to vasodilators
  • not decreasing to 70 mmHg
  • transpulmonary gradient > 15 mmHg
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12
Q

Obesity contraindication to heart transplant

A

Morbid obesity (>140% of predicted ideal body weight)

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13
Q

Criteria for renal function contraindication to heart transplant

A

Creatinine clearance

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14
Q

Hepatic function contraindicating heart transplant

A

Bilirubin > 2.5 mg · dL−1 when not due to reversible hepatic congestion,

transaminases > 2 × normal

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15
Q

PVR that puts donor heart RV graft at risk

A

The critical feature of elevated pulmonary vascular resistance (Rp) is:

pulmonary systolic pressure at completion of CPB during the transplantoperation.

  • Donor right ventricle generally poorly tolerates a systolic afterload of more than about 50 mmHg
  • overt right ventricular dysfunction above a pressure of 55 to 60 mmHg,
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16
Q

what factors dictate the donor heart’s ability to tolerate pulmonary HTN

A

Tolerance of the donor right ventricle to elevated afterload conditions (secondary to increased Rp) is partly a function of: 1. donor right ventricular reserves 2. schemic/reperfusion injury 3. possibly donor/recipient size ratio.

17
Q

Favorable RHC pre OHT

A

If Rp is elevated, a sustained favorable hemodynamic response (Rp

18
Q

Persistent PHTN following in OHT candidate

A

When Rp remains elevated and medical therapy (sometimes over days to several weeks on continuous intravenous [IV] infusions) fails to reduce pulmonary artery systolic pressure below about 60 mmHg, secure conclusions about pulmonary reactivity cannot be made.

In that instance:

implanting a LVAD may be warranted to force reduction of left atrial pressure and promote reversal of the reactive component.

19
Q

Calcineurin - mechanism of action

A
  • Transcription of NFAT
20
Q

Immunosuppressive regimine

A

1 Calcineurin inhibitor 2. Anti proliferation (mTOR) 3. Corticosteroid Monoclonal ab- delay used in Calcineurin inhibitor or treat rejection

21
Q

Calcineurin inhibitors

A
  1. Cyclosporine - binds to cyclophylin
  2. Tacrolimus - binds to fk binding protein
22
Q

Side effects of Calcineurin inhibitors

A
  1. Nephrotic Syndrome
  2. Htn
  3. Hirsuitism
  4. Gingival hyperplasia (cyclo only)
  5. Neurotox
  6. Hepatotox
  7. Hyperglycemia
23
Q

Cyclosporine vs Tacrolimus

A

Calcineurin inhibitors

A. Similar rejection freq

B. Rejection on cyc may reverse w tac

C. Similar nephrotox

D. Dec lipids and htn with tac

E. More hi gluc and and htn w tac

24
Q

Antiproliferative agents

A
  1. MMF
  2. Azathioprine
25
Q

MMF mechanism

A

Antiproliferarive drug:

  • MMF metabolized to Mycophenolic acid (MPA)
  • inhibits purine dependent cell cycling
26
Q

Azathioprine

A

Metabolized to 6-mp

  • Inhibits cell cycle growth by providing a false purine
27
Q

Factors that predict death while on lung txp wait list

A
  • FVC
  • PAs
  • O2 sat at rest
  • Age
  • body mass index
  • Diabetes
  • Functional status
  • Six minute walk distance
  • continuous mechanical ventilation
28
Q

Factors that predict survival after lung transplantation

A
  1. diagnosis
  2. continued mechanical ventilation
  3. forced vital capacity
  4. pulmonary capillary wedge pressure greater than 20
  5. creatinine
  6. functional status
29
Q

Survival 1 year following HM2 implant

A

85%

30
Q

Incidence of drive line infection following LVAD

A

13-27%

31
Q

Survival Following LVAD and OHT at 2 and 5 years (compare with Survival HF model survival at 2 years)

A

Survival (LVAD, OHT):

2 year: 80%, 80% - (SHF - OMM: 40%)

5 year: 40%, 70%

Utah / kirklin (12 decks)

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