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CV Perf Tech III > Transplants- Exam 2 > Flashcards

Transplants- Exam 2 Flashcards

1
Q

What are the 3 types of transplants that perfusion is involvedin?

A

Heart transplants
Lung transplants
Liver transplants

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2
Q

Transplants can be performed individually or in combination often with what organ?

A

Kidney

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3
Q

Who described the first heterotropic transplant of a donor heart into the neck of a dog? When?

A

1905; Carrel and Guthrie

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4
Q

Describe the first heterotropic transplant of a donor heart into the neck of a dog.

A

Not a functional model, functioned together with the recipients heart; heart was not capable of supporting circulation, lasted 2 hours before the chambers clotted

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5
Q

Who won the Nobel Prize in Medicine and Physiology for work in this area? What year?

A

Carrell, 1912

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6
Q

What institution did Carrel and Guthrie create innovative surgical technique for vascular anastomoses?

A

University of Chicago

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7
Q

Describe the “Working Model” of the heterotopic transplant with circulatory unloading of the RV.

A

1933- Mann, et al. at Mayo Clinic
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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8
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

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9
Q

When was Pharmcologic immunosuppression introduced?

A

1960s

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10
Q

What happened not long after pharmacologic immunosuppresion was introduced?

A

first clinical transplantation occured (kidney)

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11
Q

When was the first human heart transplant? Where?

A

1967, South Africa; followed shortly by Shumway and colleagues at Stanford in 1968

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12
Q

Many centers initially rushed to perform transplants. How come this didn’t continue?

A

Realized post operative survival was limited
lots of opportunistic infections
graft rejections

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13
Q

When did most center discontinue doing transplants ?

A

in the 1970’s

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14
Q

When did cyclosporine based immunosuppresion get introduced?

A

1980’s; interest in transplantation re-emerged around this time

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15
Q

What patients are selected to get transplants?

A

Have to be in end stage CHF

Must be able to benefit from a transplant

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16
Q

How to determine end stage CHF?

A

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, acute myocarditis)
ischemic heart disease

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17
Q

Contraindications of transplants?

A

Advanced age (should be less than 65 y/o)
Irreversible pulmonary hypertension
Active infection and malignancy
Obesity
Diabetes
Pulmonary fibrosis, emphysema, hepatic and renal dysfunction, cerebral vascular disease, peripheral vascular disease (relative)

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18
Q

Contrainidications of transplants: Age

A

Should be less than 65 y/o
Can be done in older patients
physiologic age is a better indicator than chronologic age

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19
Q

Contraindications of transplants: Pulmonary HTN

A

complication of CHF with elevated LVEDP
Can create irreversible changes to pulmonary vasculature
could cause RV failure in new organ
PA systolic above 50-60 mmHg is not good
Give inhaled nitric oxide to prevent pulmonary htn

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20
Q

Contraindications of transplants: Active Infection and malignancy

A

infections are exacerbated by immunosuppression required after transplanation
Hepatits B, C, HIV not usually done
Non-melanoma cutaneous cancers, primary cardiac tumors restricted to the heart, low grade prostate cancers

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21
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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22
Q

Contraindication: Diabetes

A

Relative contraindication
Control of blood sugars on steroids and immunosuppressants
Wound healing

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23
Q

Contraindications: Psychosocial

A

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

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24
Q

What is done prior to performing a transplant?

A

Lots of tests/ workups are done prior to transplantation

Must be approved by several committees and departments prior to listing the patient

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25
What is looked at for organ matching?
``` ABO Blood Compatibility Overall body size (must be within 20% of body weight) HLA Cross match Priority on UNOS Registry Geographic distance from donor ```
26
HLA Cross match
some patients are sensitized to antigen due to pregnancy, prior transplant, or blood transfusion
27
Waiting List Criteria
Status code and time within the status code | Highest medical urgency and lowest short term survival are assigned higher codes
28
How Wait List 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.
29
Going out for Procurement
Donor heart is arrested with 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
30
What is the ischemic time?
3-4 hours!! can do up for 5-6 hours- not idea
31
Recipient: 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
32
Recipient: Bi-atrial tehcnique modified lately
Leave donor atria in tact and make the anastomosis at the SVC and iVV and pulmonary veins (Bicaval techniques) notice less distortion of the aortic valve improved atrial and ventricular function Less AI less arrhythmias/heart block
33
Bicaval technique
Leave donor atria in tact and make the anastomosis at the SVC and IVC and pulmonary veins
34
Post operative course
Same as normal cardiac course: 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"
35
Physiology of Transplanted Heart
Completely denervated Faster resting heart rate (95-100 bpm) intrinsic rate of SA node no parasympathetic down regulation slower to increase HR in response to exercise slower to recover after exercise no angina with ischemia; will have silent MIs. Will present with CHF, Silent MI, or sudden death dont respond to drugs that work via the parasympathetic pathway
36
Perfusion Perspective
Donor heart is located patient will be in room about the time the harvest team is at the donor site harvest team will be able to view heart; once they vew a TEE and visualize, they call OR patient will be induced harvest team will call saying heart is out write down donor XC time. This is the start of the ischemic period of the donor organ. Patient will be draped. If its a redo, incision will be made with the "heart out" call. (median sternotomy; if its a redo you'll go on fem-fem"
37
What do you do once the heart is in the room?
Go on bypass. Usually drift, or cool to about 32. XC almost immediately
38
Recipients diseases heart is removed. iS cardioplegia used?
not usually given
39
What happnes when the sutures are complete?
Some institutions give a "hot shot" type of dose of "cardioplegia." Use glutamate aspartate solution. full of nutrients for that ischemic heart. other places don't.
40
When was the first beating heart transplant?
May 2007
41
Being heart transplant maintianed at what temp?
Maintained at normal body temperature and hooked up to the Transmedics ORgan Care system beats with warm, oxygenated blood inside a sterile box
42
When was the first human lung transplant done? What was the outcome?
over 35 years ago at the University of MS Patient with severe emphysema and carcinoma of L. Bronchus Died 18 days later of renal failure
43
What happened with lung transplants in 1986?
Stanford- first heart-lung transplant | Toronto- first single lung transplant
44
Today, how many lung transports are performed?
More than 1000 lung transplants
45
What's the wait time for single lung?
24 months
46
What's the wait time for double lung?
36 months
47
Indications for a Lung Transplant
Irreversible progressively disabling, end-stage pulmonary disease
48
What is the life expectancy for those needing lung transplant?
18 months or less - oxygen dependent - exercise intolerance - less than 65 years old - poor quality of life
49
Patient is evaluated for lung transplnat in the following areas?
``` Hx respiratory exam PMH family hx psychosocial and cultural hx ```
50
Things affecting lung transplant eligibility
Osteoporosis Musculoskeletal disease use of corticosteroids (>20 mg/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.
51
Types of lung Transplants
Single Lung Transplant (R/L- left side easier) Double lung transplant (En Bloc; bilateral sequential) Heart-lung block Ex-Vivo Lung Transplant
52
Single Lung Transplant
COPD/Emphysema Idiopathic Interstitial Pulmonary Fibrosis Sarcoidosis Eosinophilic Granuloma Lymphangiolymyomatosis Primary Pulmonary HTN Eisenmengers Syndrome with Cardiac repair
53
Is CPB necessary with single lung transplants?
Not usually; depends on patient's tolerance to unilateral support during XC
54
What type of thoracotomy used in single lung transplant?
through bed of excised 5th rib
55
What is done to the main PA during single lung transplant?
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
56
Single Lung Transplant: Temp
usually stay warm
57
Single lung transplant: native lung is....
excised
58
Single lung transplant: What is clamped
LA
59
Singel lungs trnasplant: pulmonary veins attached where?
LA Cuff; PA anastomosed. end to end anastomosis of the donor recipient bronchus, atrial clamp then removed
60
Bilateral Seuqnetial Double Lung
``` cystic fibrosis bronchiectasis emphysema primary pulmonary htn eisenmenger's syndrome with cardiac repair ```
61
Double lung transplant- gives patients better what?
Pulmonary reserve
62
Double Lung transplant: used to be done .....
En bloc where each lung was implanted seprately through a pleural-pericardial window while on CPB; utilized clamshell incision, big pain from a perfusion standpoint
63
Now, common to do ________ (2) double lung transplant
bilateral sequential; like 2 single lung transplants, ventilate the native lung while the first goes in. Then ventilate the new lung wile the second goes in
64
Ex Vivo Lung Perfusion
therapy applied to donor lungs outside the body before transplantation; improves organ quality; expands donor pool
65
Why does ex vivo lung perfusion improve organ quality?
Allows lungs that were previously unsuitable for transplantation- safe for transplanation
66
How long is ex vivo lung perfusion procedure?
3-4 hours procedure
67
How does ex vivo lung perfusion work?
donor lungs placed into plastic dome attached to ventilator, pump and filters maintained at normal body temp treated with a bloodless solution that contains nutrients proteins, oxygen (to reverse lung injury remove excess water) once suitable- transplanted into waiting patinet
68
When was the first humna liver transplant done? By Who?
1963, but Thomas Starz in Denver
69
What happend in 1967?
markes the first time a liver transplant patient lives to 1 year post surgery
70
Liver Transplants: General Guidelines
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
71
Liver Transplants: Evaluation of Severity
``` Encephalopathy Ascites Recurrent Gi bleeding Severe fatigue early stage primary liver tumor others.... ```
72
Liver Transplants: Selection Questions?
Do they need the transplants? can they sustain the operation? Is there a risk of recurrence? commitee meeting ot decide eligibility
73
When does the liver donor organ usually arrive?
Prior to incision; organ is prepped at the back table
74
How to determine in liver transplant patients if V-V bypass will be done?
Test Clamp is performed. If patient remains stable, can do it without V-V bypass. If not, V-V bypass is initiated
75
New Liver is sewn in
``` suprahepatic IVC infrahepatic IVC portal vein hepatic artery clamps are removed- bypass is discontinued bile duct ```
76
WHat percent of liver transplants use V-V bypass?
less than 5%
77
Liver Transplants: what parameters do you monitor?
``` EKG HR Core temp Pulse ox arterial BP PA catheter SvO2 cardiac output ```
78
Liver Transplant- V-V bypass first used by who? When?
Marshall et all 1970; managed a patient with renal cell carcinoma extending into the IVC and RA
79
1960's liver transplant
realized 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. anticoagulation increased bleeding too much.
80
When did V-V bypass come into practice with the use of heparin bonded circuits and a centrifugal pump?
1980's
81
Whats the most common flows in liver transplants?
1-2 L most common. No oxygenator, less flows than on CPB
82
What is cannulated in liver transplants?
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.

CV Perf Tech III (16 decks)

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