Transplants Flashcards
First working model of heterotrophic transplant
Mann at Mayo clinic 1933
Lasted 4 days
Discovered acute allograft rejection
First heterotrophic transplant of donor heart into neck of a dog
1905 Carrel and Guthrie at university of Chicago
Lasted two hours
First heart transplant in dogs with topical hypothermia
Lower and Shumway 1960
Survived 6-21 days
Died of rejection
First human heart transplant
1967 in South Africa
Postoperative survival of transplants was limited due to what two factors?
Lots of opportunistic infection
Graft rejections
Patient parameters for heart transplant
End stage CHF (NYHA class 3 or 4)
Unable to manage symptoms with medications, electrophysiology devices, and surgical intervention
LVEF<35%
Cardiogenic shock (acute MI, acute myocarditis)
Ischemic heart disease
Must be able to benefit from transplant
Contraindications to recieving a heart transplant
- Advanced age (physiologic age should be less than 65)
- Irreversible pulmonary hypertension (can cause RV failure in new organ, do not let PA systolic get above 50-60)
- Active infection and malignancy
- Hepatitis B, C, HIV
- Non melanoma cutaneous cancers, primary cardiac rumors restricted to heart, low grade prostate cancers are ok to transplant
- Obesity (BMI need be less than 30kg/m2)
Relative contraindications to transplant
Diabetes
Pulmonary fibrosis, emphysema, hepatic and renal dysfunction, cerebral vascular disease, peripheral vascular disease
Psychosocial contraindications
Substance abuse
Compliance with medications
Social support
5 variables to look at for organ matching
- ABO blood compatibility
- Must be within 20% of body weight
- HLA cross match
- Priority on UNOS registry
- Geographic distance from donor
Status 1a prioritization
Mechanical circulatory support (VAD, total artificial heart, IABP, ECMO)
Mechanical ventilation
Continuous infusion of inotropes with continuous monitoring of LV filling pressures
Exceptional Medical urgency
Status 1b prioritization
VAD >30 days
Continuous inotrope infusion
Status 2 prioritization
Any candidate not meeting 1a or 1b
Order of patients offered organs by status
1a–>1b–>status 1 within 500miles–>status 2–> repeat at 1000 mile radius and 1500 mile radius
Technique for procurement
Donor heart arrested CPG/preservation
Atria transacted at midatrial level (multiple pulmonary venous connections to LA intact)
Transect aorta and PA just above semilunar valves
Heart cooled topically
Ischemic time: 3-4 hours
Recipient preparation for organ
Reanastamosis of midatrial level: start at atrial septum, generous cuff of donor RA included, great vessels connected above semilunar valves
Bicaval technique: donor atria left in tact and anastamosis at SVC, IVC, and pulmonary veins
Benefits of bicaval technique
Less distortion of aortic valve
Improved atrial and ventricular function
Less AI
Less arrhythmias/heart block
Physiology of transplanted heart
Completely denervated Faster resting heart rate Slower to increase HR after exercise, slower to recover No angina with ischemia No response to parasympathetic drugs
First beating heart transplant
2007
Use Transmedics Organ Care System
Indications for lung transplant
Irreversible, progressively disabling, end stage pulmonary disease
Life expectancy less than 18 months
5 Evaluation areas for lung transplant
History Respiratory exam Past medical history Family history Psychosocial and cultural history
Relative contraindications
Osteoporosis Musculoskeletal disease Corticosteroid use (>20mg/day) Malnutrition (130% ideal body weight) Substance abuse Smoking Psychosocial problems Mechanical ventilation Fungi Previous thoracotomy, sternotomy, scarring
4 categories of lung transplants
Single lung
Double lung (En Bloc or Bilateral sequential)
Heart lung block
Ex-vivo lung transplant
Indications for single lung transplant
Emphysema
Idiopathic interstitial pulmonary fibrosis
Sarcoidosis
Eosinophilia granuloma
Lymphangiolyomyomatosis
Primary pulmonary hypertension
Eisenmengers syndrome with cardiac repair
Single lung transplant procedure
No CPB usually
Poster plateau thoracotomy through bed of 5th rib
Main PA encircled and clamped (if can’t tolerate, use femoral bypass)
Stay warm
LA clamped, pulmonary veins attached to LA cuff
PA anastamosed
End to end anastamosis of donor and recipient bronchus
Atrial clamp removed
Indications for bicaval double lung transplant
Cystic fibrosis Bronchiectasis Emphysema Primary pulmonary hypertension Eisenmengers syndrome
En Bloc double lung transplant
Each lung implanted separately through pleural pericardial window
Use clamshell incision
Bilateral sequential double lung transplant
Like 2 single lung transplants
Ventilate native lung while first one goes in
Ventilate new lung while second goes in
First liver transplant
1963 Thomas Starz in Denver
Variables to evaluate severity of liver disease
Encephalopathy Ascites Recurrent GI bleeding Severe fatigue Early stage primary liver tumor
4 sites where new liver is sewn in
Supra hepatic IVC
Infra hepatic IVC
Portal vein
Hepatic artery
Patient parameters that must be measured during liver transplant
EKG HR Core temp Pulse Ox Arterial BP PA catheter SvO2 Cardiac output
V-V bypass
No oxygenator
Flow 1-2LPM
Femoral vein cannulated and advanced to bifurcation of IVC
2nd cannula on portal vein
Centrifugal pump
Return to Axillary vein or internal jugular vein
