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Transplant/lvad Flashcards

1
Q

Rejection scales

A

1r interstitial or pervasculqr infiltrate with one focus of myocyte damage
2r two or more infiltrates with myocyte damage
3r diffuse infiltrate with multifocal damage

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2
Q

Name 5 drugs that increase prograf levels?

A 
Diltiazem
Erythromycin
Ketoconazole
Cimetidine 
Greatfruit juice
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3
Q

Half life of a transplanted patient
Mean age of donors
Most common indication for transplant

A

10 years
30yo
Myopathy

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4
Q

How often get angiography

A

Annually for 3 to 5 years

Follow up six months after pci

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5
Q

Risk factors for early transplant failure

A 
Recipient age/bmi
Donor age
Center volume
Ischemic time 
Billi, creatinine, pvr
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6
Q

Indications for transplant

A

Absolute: cardiogenic shock, inotrope dependent, vo2 < 10, arrhythmia
Relative:NYHA IV with vo2 < 14, severe Angina, fluid/renal despite maximal therapy and good compliance.

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7
Q

What is anaerobic threshold

A

When rer >1

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8
Q

What are predictors of bad outcomes on cpet

A

Vo2< 11
Ve/VCo2 >35
< predicted vo2 < 5x vo2 + 3L/min

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9
Q

What to do if submax vo2

A

Use ve/vco2 slope>35
In obese can adjust to lean body mass lean vo2< 19 cc/kg/min
Hfss in ambiguous situations.

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10
Q

Worst outcomes on rhc

A

No reduction in pvr worse than pvr reduced but bp dropped

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11
Q

Pvr cutoff

A

4-6 woods unit

320-480 dynes

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12
Q

Absolute contraindications for txp

A 
Life expectancy less than 2 years
  Malignancy within 5
   Aids with frequent oi
   Lupus sarcoid amyloid if axtiv
    Irreversible other organ dysfunction
   Severe copd
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13
Q

Dig effect on transplanted heart

A

No effect on hr

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14
Q

What are the class I mhc

A

Exogenous ( all nuclearwd cells)
a,b cw
Recognized by cd8 cytotoxic cells

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15
Q

Class ii mhcq

A

Exogenous antigen presenting cells b cells.
How dp, dq, dr
Recognized by cd 4 cells

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16
Q

How are T cells activated after transplant

A

By Recognizong donor apc or recipient apc (indirect) with donor antigens.
This Triggers compliment usually thru classical pathway

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17
Q

Two types of antibody identification

A 
Cell based.  Allow for quantification. Need donor cells
Solid phase(elisa or antigen based) 
Can use stores sera
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18
Q

How does cross matching work? How to assess severity?

A

Mix donor lymphocytes with recipient serum. 20-50 weakly pos
>50% positive
>80 strongly postive

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19
Q

Recs for donor/recipient crossmatch

A

Screen pra. Need further eval if > 10%
Need solid phase
Do compliment fixation

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20
Q

What does CDC stand for

A

compliment dependent cytotoxicity

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21
Q

Risk of rejection in first year

A

30%

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22
Q

Rf for rejection (5)

A

Young, female, allosensitized, black, female into male

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23
Q

Two noninvasive ways to detect rejection

A

Evoked potentials and allomap

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24
Q

Rematch

A

Class iv, ef <12 or inotropes

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25
Q

Heart mate 2 dt trial

A

No changes in quality of life or functional capacity in comparison to pulsatile.

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26
Q

Hm2 btt trial

A

Outcomes transplant or alive for 180 days

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27
Q

Hm2 dt trial

A

Compare xve to hm2
Lvef <25
Vo2 less than 14
Class 3b iv inotropes 14 days or iabp x7 days
Outcome: survival, free from stroke or reoperation

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28
Q

Plasma free Hgb of concern

A

if greater than 40

Ldh greater than 1000

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29
Q

Significant rvswi?

4 other factors that predict rv dysfunction post op

A 
>300 
Vasopressors
Ast billi
Creat
Cvp/wedge
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30
Q

Other things besides vo2 max in exercise testing?

A

Young people use predicted 35

If obese use 19 of lean body mass

31
Q

Who should get vasodilator challenge

A

Pa systolic > 50
Tpg > 15
Pvr > 3
BP >85

32
Q

Weight cutoff for transplant

33
Q

What are 5 absolute 1a

A 
Incubated
Mcs 
Mcs greater than 30d with complications
Sgc+ .5 milrinone or 7.5 dobutamine 
Non of the above but life expectancy less than 7 days
34
Q

2 drugs that don’t affect the txp heart

A

Digoxin, atropine

35
Q

Class1 guidelines for histocompatibility

A
  1. Everyone need a PRA. If >10 Work up
  2. use solid phase assays
  3. Use complement fixation
  4. Define specificities
  5. Use virtual crossmatch
36
Q

Emb guidelines (4).

A

Reasonable to do in preop
Standard of care to do during first 6-12 months
Ok to do after first year in high risk, hemodynamic compromise, and African Americans

37
Q

Allomap score cutoff

38
Q

Class I guidelines for asymptomatic rejection (4 things)

A

3R should be treated with iv corticosteroid
2R if asymptomatic can be treated with oral or iv
Maintainance therapy should be adjusted
Restart antimicrobials

39
Q

Guidelines for symptomatic rejection (7 things)

A

Do emb
Hospitalize patients
If hemodynamic compromise need to put in icu
Repeat 1-2 weeks
Serial echoes
Consider ACR in patients who dont look good
No IL2

40
Q

AMR
Classes
What are guidelines
Rx

A

Either 0 or 1
Do CD68 or C4D
When to screen: if AMR is suspected need to do further staining
Check for DSA
Repeat emb 1-4 weeks
Corticosteroids , cytolytics, plasmapheresis, apheresis, maintain cardiac output with inotropes.

41
Q

What are the two major concepts of rejection

A

Activation and Replication of t cells

42
Q

How do steroids work

Rx

A

Bind to specific gr, in lymphocytes inhibits ap1 and nfkb
Use 1-3 mg /kg pred or 3mg
Class I: withdrawal can be achieved within 3 months.

43
Q

How do calcineurins work

A

CNI diffuse into cytoplasm bind immunophilins
Use micro emulsions
Promote IL-2 transcript

44
Q

Side effects of calcineurins

A
  1. Renal failure: acute or chronic
  2. neuro: headaches, tremor, seizure
  3. Endocrine: Htn with cya, dm with prograf
  4. GI: nausea/vomiting
  5. Gout, low mg, hus
    6 hirsute gingival hyperplasia with cya, allopesia and thrombocytopenia with tac
45
Q

Tac vscya

A

Less rejection
Trend toward survival
Fewer drug withdrawals
No long term differences.

46
Q

Class I guidelines with cni

A

You can lower levels when use with mmf

47
Q

Aziothioprine side effects

A

Replace mmf in combo
Dose reduce
Do not use with allopurinol
See pancreatitis, hepatitis, hepatovenoocclusice disease, skin cancer

48
Q

Mmf adverse effects

A

Nausea, vomiting and diarrhea
Anemia thrombocytopenia hyperkalemia
Leukopenia with valcyte

49
Q

What is sirolimis

A

Proliferative signal inhibitor
Binds to fkbp mtor
Prevents proliferation

50
Q

Side effects of rapa

A 
Wound healing
Hepatitis
Renal insufficiency
Gout, triglycerides
Pneumonitis, hepatic vein thrombosis.
51
Q

Guidelines for psi

A

Psi may be substituted for CNI> 6 months for renal nephrotoxicity and cav
Mmf evl or sirolimis should be used as it reduces onset of cav

52
Q

Two systems for drug metabolism

A

Cp450 and p glycoproteins

53
Q

Inhibitors cyp450

Metabolized by?

A

Diltiazem verapamil inhibit cp450

Statins and cni metabolized by cp 450

54
Q

What decrease CNI levels

A 
Ethanol
Phenytoin
Phenobarbital
Rifampin
Cholestyramine
55
Q

Rabdo and cya

A

Avoid fibric acids and statins.

56
Q

Most common problems for death long term

A
  1. Malignancy

2. Cav

57
Q

Guidelines for angiography

A

Annual for 3-5 years
Baseline
6 months after pci
Ivus at Cath

58
Q

2 papers for cav

A

Prava 40 or simva 20

Less cav by Ivus, less rejection, decreased cytokines.

59
Q

Guidelines for cav(6)

A
  1. Control risk factors and prevent cmv
  2. Annual angiography
  3. Six months after pci
  4. Consider psi
  5. Stress echo
  6. Consider retransplantation
60
Q

What to do when statins are not enough in the patient with a heart transplant

A

Bile acid need to be given 4 hours from csa
Zetia increased 12 times by cyclo
Watch out for fibric acids

61
Q

Infections after 1st month in the heart transplant patient

A
  1. First bacteria
  2. Then opportunistic thru first six months
  3. Then community acquired
62
Q

Define cmv

A

DNA or seroconversion
& cmv syndrome or tissue invasion
Rx 900 PO for prophylaxis
Iv gancyclovir 5mg/kg iv bid 3 weeks, then for 3 months after.

63
Q

Rate of malignancy at 10 years after heart transplant

64
Q

Sx of ptld

Risk factors for ptld

A

Malaise and fever, abdominal masses

Ebv, okt3, atg, cmv, rejection

65
Q

What bones are affected by transplanted

A

Axial bone (cancellous, think vertebral) and not appendicular

66
Q

Guidelines for bones post txp

A

Screen with Dexa,
Improve pore transplant if possible
Everyone needs calcium and vitamin d
All heart transplant candidates should be on bis phosphonates for the first year

67
Q

Class I guidelines for insertion of lvad

A 
Class IV despite med therapy 45/60 days.
Life expectancy less than 2 years
Not a candidate for heart transplant
cardiogenic shock 
Failure to respond to medical therapy in last 60 of 90 days.
Ef  < 25
Vo2 < 12
BSA > 1.5
Continuous inotropes
Recurrent vt.
68
Q

Risk factors for death one year after heart transplant?

A

Congenital, mcs, vad, vent, dialysis, female.

69
Q

Indications for surgery for aortic insufficiency

A

Severe with symptoms or ef 75

70
Q

Avr for as

A

Severe with sx or ef %50

71
Q

Who should get mvr

A

Severe with sx
Severe without symptoms but ef >30-60 and or end systolic > 40
HF but ef > 30 or end systolic <55

72
Q

Leitz miller 9

A

Ast, Hct, inr, albumin, platelets, billi
Pulm pressures <25
No Inotropes vasodilators

73
Q

6 absolute contraindications for txp

A
  1. Systemic illness
  2. HIV with oi
  3. Severe copd
  4. Multisystem organ failure
    5 high pvr
  5. Cancer within five years

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