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Perf tech 3 > transplants > Flashcards

transplants Flashcards

1
Q

Perfusion is involved in 3 types of transplants:

A

 Heart Transplants  Lung Transplants  Liver Transplants

 Can be performed individually or in combination  Often along with a kidney

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2
Q

1905 – Carrel and Guthrie

A

 Described first heterotopic transplant of a donor heart
into the neck of a dog
 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 won the Nobel Prize in Medicine and Physiology in 1912 for his work in this area.

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3
Q

1933 – Mann, et al. at Mayo Clinic

A

 Heterotopic transplant with circulatory unloading of the
RV  Working model
 Lasted 4 days
 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

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4
Q

1960 – Lower and Shumway

A

Orthotopic heart transplant in dogs with CPB and topical
hypothermia for donor heart preservation  Survived 6-21 days  Died of rejection
 1960s – Pharmacologic immunosuppression introduced.
Not long after – First clinical transplantation occurred  Kidney

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5
Q

1967

A

First human heart transplant was performed in South Africa

 Followed shortly by Shumway and colleagues at Stanford in 1968.

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6
Q

1970s.

A

Most centers discontinued doing transplants in the

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7
Q

1980s

A

cyclosporine-based immunosuppression introduced

 Interest in transplantation re-emerged.

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8
Q

Patient Selection

A 
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.
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9
Q

patients for transplants have to have EF <

A

35%

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10
Q

patients that have cardiogenic shock like _________ may benefit from a transplant

A

 Acute MI
 Acute Myocarditis  Ischemic heart disease
 Must be able to benefit from a transplant

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11
Q

Contraindications advanced age

A

Should be less than 65 years old  Can be done in older patients  Physiologic age is a better indicator than chronologic age.

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12
Q

Contraindications Irreversible pulmonary hypertension

A

 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.

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13
Q

Contraindications

 Active Infection and malignancy

A

Infections are exacerbated by immunosuppression required

after transplantation.  Need to be fever free for 72 hours  Normal white cell count  Negative blood cultures

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14
Q

Contraindications Hepatitis B, C, HIV

A

not usually done  HIV is becoming more acceptable to transplant due to
improvement in drug therapy.

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15
Q

contraindications Non-melanoma cutaneous cancers

A

primary cardiac tumors restricted to the heart, low grade prostate cancers
 Ok to transplant

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16
Q

contraindications obesity

A

 Impacts infection rates, wound healing, and have an increased incidence of acute rejection.
 BMI less than 30 kg/m2

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17
Q

contraidications

A

Diabetes  Relative contraindication  Control of blood sugars on steroids and immunosuppressant’s  Wound healing

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18
Q

relative contraindications

A

Pulmonary Fibrosis, Emphysema, Hepatic and renal dysfunction, Cerebral vascular disease, Peripheral vascular disease

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19
Q

Contraindications

 Psychosocial

A

 Substance abuse (tobacco, alcohol)  Compliance with medications  Frequency of social support

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20
Q

Organ Matching

A

 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

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21
Q

Organ Matching

 Waiting List Criteria

A

Status code and time within the status code

 Highest medical urgency and lowest short term survival are assigned higher codes.

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22
Q

Organ matching how it works

A

 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.

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23
Q

transplant technique

A

Go out for procurement  Donor heart is arrested with a cardioplegia/ preservation
solution.  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  Heart is cooled topically.
 Ischemic time – 3-4 hours!! (can do up to 5-6 hours – not ideal!!)

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24
Q

Technique

 Recipient: bi atrial technique

A

Re-anastomosis of midatrial level
 Start at atrial septum
 Generous “cuff” of donor RA, so SA node will be included in transplant
 Great vessels connected above the Semilunar valves.

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25
Q

Recently, bi-atrial technique has been modified

A

Leave donor atria in tact and make the anastomosis at the SVC and IVC and Pulmonary Veins
 Called Bicaval technique

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26
Q

bicaval technique advantages

A

Notice less distortion of the aortic valve  Improved atrial and ventricular function  Less AI  Less arrhythmias/ heart block.

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27
Q

Post operative course

A

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

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28
Q

Physiology of Transplanted Heart

A

Completely denervated
 Faster resting heart rate (95-100 beats per min)  Intrinsic rate of SA node  No parasympathetic down regulation
 Slower to increase HR in response to exercise
 Slower to recover after exercise

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29
Q

transplanted heart response to injury

A

No angina with ischemia  Will have silent MIs. Will present with CHF, Silent MI or
Sudden death.
 Don’t respond to drugs that work via the parasympathetic pathway.

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30
Q

donor heart iscemic time

A

Write down donor cross clamp time. This is the start of the ischemic period of the donor organ. to cross clamp off after sutures or hot shot

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31
Q

type of incision for heart transplant

A

median sternotomy. if its a redo you will go fem-fem

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32
Q

drift or cool to _____ when transplanting

A

32 C and cross clamp immediately

33
Q

cardioplegia during transplant

A

not usually given

34
Q

after sutures are complete some institutions will give

A

“hot shot” type dose of “cardioplegia”. Use Glutamate Aspartate Solution. Full of nutrients for that ischemic heart. Other places don’t.

35
Q

after hot shot is in or suture are done

A

Cross Clamp off  Pacing wires placed  Fill up heart  Wean from CPB.  Close

36
Q

First beating heart transplant

A

May 2007

37
Q

system that kept first beating heart alive

A

Maintained at normal body temperature and hooked up to

the Transmedics Organ Care System.

38
Q

Transmedics Organ Care System advantages

A

Beats with warm, oxygenated blood inside a sterile box
 Can monitor parameters of the heart and blood.
 Prolongs time between removal of the heart and transplantation.
 Decreases injury while ischemic.
 Can allow for the right patient to get the right organ, despite distance.

39
Q

irst human lung transplant

A

was done over 35 years ago at the University of Mississippi Patient with severe emphysema and carcinoma of L. Bronchus
 Died 18 days later of renal failure

40
Q

First heart-lung transplant

A

1986 Stanford

41
Q

first single lung transplant

A

1986 toronto

42
Q

amount of lung transplants annually

A

1000

43
Q

wait time for a single and double lung transplant

A

24,36

44
Q

Indications for a lung transplant

A

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.

45
Q

lung transplant Patient is evaluated in the following areas:

A

 History

 Respiratory exam  Past medical history  Family history  Psychosocial and cultural history

46
Q

Things affecting eligibility lung transplant

A 
Osteoporosis
 Musculoskeletal disease
 Use of corticosteroids (>20mg/day)
 Malnutrition  130% ideal body weight
 Substance abuse/ addiction  Smoking within 4 months of activation on the transplant list  Psychosocial problems – high risk of poor outcome  Mechanical ventilation  Colonization of fungi  Previous thoracotomy, sternotomy, scarring, etc.
47
Q

Types of Transplants lung

A

Single Lung Transplant : Right,
Left
 Double lung transplant : En Bloc, Bilateral sequential  Heart-lung block  Ex-Vivo Lung Transplant

48
Q

reasons for single lung transplant

A

 COPD/ Emphysema  Idiopathic Interstitial Pulmonary Fibrosis  Sarcoidosis  Eosinophilic Granuloma  Lymphangiolyomyomatosis  Primary Pulmonary Hypertension  Eisenmengers Syndrome with cardiac repair

49
Q

which side is easier for single lung transplant

A

Left side is easier

50
Q

is cpb necessary for single lung

A

No CPB is necessary – usually  Depends on patient’s tolerance to unilateral support during
cross clamp.

51
Q

incision type for single lung

A

Posterolateral thoracotomy through bed of excised 5th rib.

52
Q

how to asses stability of patient for single lung transplant

A

Main PA is encircled and temporarily clamped  Assess the impact on hemodynamic stability and gas
exchange
 If not tolerated, femoral cannulation is used, and patient placed on CPB

53
Q

cooling for single lung

A

stay warm

54
Q

single native lung is excised then …

A

Left Atrium is clamped
 Pulmonary veins are attached to LA Cuff.
 PA is anastomosed
 End to end anastomosis of the donor and recipient bronchus
 Atrial clamp is remove

55
Q

reasons for Bilateral Sequential Double Lung

A

 Cystic Fibrosis  Bronchiectasis  Emphysema  Primary Pulmonary Hypertension  Eisenmenger’s Syndrome with cardiac repair

56
Q

Double lung transplant – gives patients

A

a better pulmonary reserve

57
Q

Double Lung Transplant

 Used to be done

A

en bloc where each lung was implanted separately through a pleural-pericardial window while on CPB.

58
Q

en bloc utilizes

A

Clamshell incision  BIG PAIN from a perfusion standpoint!!

59
Q

Now, common to do

A

bilateral sequential.
 Like 2 single lung transplants.
 Ventilate the native lung, while the first goes in. Then ventilate the new lung while the second goes in.

60
Q

Ex Vivo Lung Perfusion

A

Therapy applied to donor lungs outside the body before transplantation
 Improves organ quality  Allows lungs that were previously unsuitable for
transplantation – safe for transplantation.  Expands donor pool

61
Q

Ex Vivo Lung Perfusion lasts for

A

3-4 hour

62
Q

ex vivo maintained at

A

normal body temps.

63
Q

EX VIVO treated with

A

a bloodless solution that contains nutrients, proteins, oxygen
 Reverse lung injury  Remove excess water

64
Q

First human liver transplant was done in

A

1963 by Thomas Starz in Denver, CO.

65
Q

But 1967, marked

A

the first time a liver transplant patient lived to 1 year post surgery.

66
Q

Liver Transplants

 General Guidelines

A

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.

67
Q

liver transplants evaluation of severity

A

 Encephalopathy  Ascites  Recurrent GI Bleeding  Severe Fatigue
 Early stage primary liver tumor  Others.

68
Q

liver transplant questions before transplant

A

 Do they need the
transplant?
 Can they sustain the operation?
 Is there a risk of recurrence?

69
Q

test clamp for liver

A

est Clamp is performed. If patient remains stable – can do it
without V-V bypass. If not, V-V bypass is initiated.

70
Q

New Liver is sewn in:

A

 Suprahepatic IVC  Infrahepatic IVC  Portal Vein

 Hepatic Artery  Clamps are removed – Bypass is discontinued  Bile Duct

71
Q

Less than 5% of liver transplants use

A

V-V Bypass.

72
Q

liver can use a partial occlusion

A

clamp on the IVC without cross clamping the entire IVC

73
Q

liver Need to monitor lots of parameters:

A

 EKG

 HR  Core Temp  Pulse Ox  Arterial BP  PA Catheter  SvO2  Cardiac Output

74
Q

Liver Transplant – V-V bypass

 First used by

A

Marshall, Et al in 1970.  Managed a patient with renal cell carcinoma extending into
the IVC and RA

75
Q

Liver Transplant – V-V bypass 1960s – realized

A

that they needed a shunt that could train blood from the lower extremities and portal system
 First looked at utilizing bypass without a pump  Unsuccessful – circuit clotted, and created embolism
 Tried anticoagulation  Increased bleeding too much

76
Q

liver transplant 1980s

A

V-V Bypass came into practice with the use of heparin bonded circuits and a centrifugal pump.

77
Q

Liver Transplant – V-V Bypass perfusion

A

No oxygenator
 Less flows than on CPB
 Flows from 1-2 liters most common  Flow what you can get
 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.  Centrifugal pump  Return to axillary vein or internal jugular vein.

78
Q

Liver Transplant – V-V Bypass

 No heparin

A

is used  Flows adequate unless less than 1 liter per minute
and cardiac preload is maintained  Need to maintain flow to prevent clot  Preload dependent.
 Closed system, so no volume can be added.

79
Q

To avoid pulmonary hypertension give

A

Inhaled NO

Perf tech 3 (14 decks)

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