Nursing implications for ED care of patients who have received heart transplants

February 2001 27:1 JOURNAL OF EMERGENCY NURSING 33

C L I N I C A L A R T I C L E

D uring the past 30 years, since Dr ChristianBarnaard performed the first successful ortho-topic heart transplant in 1967, survival rates for

patients receiving a transplant have increased dramatically,providing people who otherwise would have died fromend-stage heart failure with a second chance for a more ful-filling quality of life. Increasing survival rates of hearttransplant recipients may be attributed to advances in sur-gical techniques, organ preservation, tissue matching, im-munosuppressive agents, and rejection treatments. As aresult, increasing numbers of transplant survivors who areliving longer will be seeking care at emergency depart-ments across the United States.

Historical perspective: Past to present

Heart transplantation began with Dr Barnaard’s successfulorthotopic heart transplant in a 54-year-old man whoseown heart was severely damaged by multiple myocardialinfarctions. The surgery itself was a success; however, thepatient died 18 days later as a result of rejection and infec-tion. Poor survival rates in the late 1960s and 1970s causedmany heart transplantation programs to shut down.However, the use of cyclosporine in the 1980s increasedsurvival rates, more programs were begun, and a largernumber of patients survived.1 In 1997, more than 3000heart transplants were performed all over the world, with a1-year survival rate of 83%. Today more than 45,000 hearttransplants have been performed at more than 300 centersthroughout the world.2

Other factors contributing to the boom in hearttransplant care are refinements in patient selection,

Nursing Implications

for ED Care of Patients Who Have

Received Heart Transplants

Kathleen Evanovich Zavotsky, West Central New Jersey Chapter, isClinical Nurse Specialist, Emergency Department, and Joan Sapienza isHeart Failure/Heart Transplant Nurse Practitioner, Robert WoodJohnson University Hospital, New Brunswick, NJ. Diana Wood waspreviously Assistant Professor of Medicine, Department of Cardiology,Robert Wood Johnson Medical School, New Brunswick, NJ, and iscurrently on the Heart Transplant Team at Hahnaman UniversityHospital, Philadelphia, Pa.For reprints, write: Kathleen Evanovich Zavotsky, MS, RN, CCRN,CS, CNS,C, CEN, Robert Wood Johnson University Hospital, 1Robert Wood Johnson Place, New Brunswick, NJ 08903; E-mail:[email protected] Emerg Nurs 2001;27:33-9.Copyright © 2001 by the Emergency Nurses Association.0099-1767/2001 $35.00 + 0 18/1/111511doi:10.1067/men.2001.111511

Kathleen Evanovich Zavotsky, MS, RN, CCRN, CS, CNS,C, CEN,Joan Sapienza, MSN, RN, CCRN, ACNP, CNS,C, and Diana Wood,MD, New Brunswick, NJ

34 JOURNAL OF EMERGENCY NURSING 27:1 February 2001

CLINICAL ARTICLE/Zavotsky, Sapienza, and Wood

improvements in surgical techniques, new antimicrobialagents, better protection of the myocardium, and use ofendomyocardial biopsies. In addition, life-threateningopportunistic infections consistent with immunosuppres-sion have been reduced over the years. As a result, hearttransplantation is now considered an effective therapy forend-stage heart failure. Heart transplantation has becomeso progressive that not enough donor organs are availableto meet the needs of the number of listed patients waitingfor a transplant. Unfortunately, approximately 15% to20% of patients waiting for a donor heart die before theyreceive a heart.1

The evaluation process

Other medical and surgical modalities have failed for mostpatients referred for heart transplantation. A patient musthave been diagnosed with end-stage heart disease and havea life expectancy of 1 year or less to be eligible for hearttransplantation. In 1996, of the patients receiving hearttransplants, 45% had coronary artery disease (CAD), andapproximately 42% had cardiomyopathy.1,2 Whatever thedisease process, patients must meet one or more criteria(Table 1) to be considered for a transplant.

The evaluation of a patient for a heart transplant can bea long, tedious process for the patient, family members, andhealth care providers. The patient must undergo many lab-oratory and diagnostic studies during the evaluationprocess.1

Psychosocial and financial issues are extensively evalu-ated. The patient must be psychologically and financially

able to undergo the procedure and be able to manage life-long effects of immunosuppression therapy and potentialcomplications.

ABSOLUTE CONTRAINDICATIONS FOR HEARTTRANSPLANTATION

Absolute contraindications for heart transplantation1-4

include being older than 70 years, having ABO incompat-ibility, and having a life expectancy that is limited by coex-isting illnesses, among other contradictions (Table 2).

Being listed for a heart transplant

Once the evaluation process is complete, the patient’s caseis presented at a multidisciplinary meeting, and onceagreement is reached, the patient is listed through theUnited Network for Organ Sharing.

Once the patient is listed as a candidate for a hearttransplant, the waiting period begins. The wait may be sev-eral days to months to even years, depending on the statusthe patient is listed under and organ availability in the area.All persons involved should be prepared for the possibilitythat the patient may not survive until an organ becomesavailable.

TABLE 1 Heart transplant consideration criteria

1. New York Heart Association Classification III, IV conges-tive heart failure refractory to maximal medical therapy

2. Inoperable coronary artery disease with intractableangina symptoms

3. Malignant ventricular dysrhythmias that are unresponsiveto medical/surgical therapy

4. Primary cardiac tumors with no evidence of spread toother body systems

TABLE 2Absolute contraindications for heart transplantation

• ABO incompatibility• Older than 70 years• Life expectancy limited by coexisting illness• Fixed pulmonary hypertension with a pulmonary

vascular resistance >4-6 Wood units• Active malignancy• Active systemic infection including positive HIV status

and hepatitis C (some centers will perform transplantsin patients with hepatitis C)

• Severe renal or hepatic dysfunction• Severe chronic obstructive pulmonary disease (forced

expiratory volume in 1 second <1 L)• Active peptic ulcer disease• Acute psychiatric illness• Active drug or ethyl alcohol abuse

Data from reference 1.

Data from references 1 and 4.



During the waiting process, the patient must beinvolved in a cardiac rehabilitation program. The patient’sphysical condition prior to transplantation will greatlyaffect his or her postoperative recovery. Exercise improvesa patient’s physical state and helps to pass the time.

The phone call

The call that an organ is available generates both excite-ment and fear. Patients and families may have mixed feel-ings, ranging from joy that the recipient has a chance tolive longer to guilt and sadness that another person had tolose a life so the recipient can live. Sometimes the donorheart initially seems to be a match but for some reason isfound to be unsuitable, and the patient experiencesextreme disappointment.

If the donor organ is suitable for transplant, the recip-ient is given oral cyclosporine and intravenous azathioprineimmunosuppressants preoperatively. Intraoperatively, thepatient is given 1 g of methylprednisolone sodium succi-nate (Solu-Medrol) intravenously. Patients with impairedrenal function preoperatively will require other immuno-suppressive agents such as lymphocyte immune globulin(Atgam) or OKT3; they cannot begin taking cyclosporineimmediately because of renal toxicity for several days post-operatively.

The index of suspicion for infectionshould always be high when a patientwith a heart transplant comes to theemergency department with vaguecomplaints. The common signs andsymptoms of infection are low-gradefever, cough, and general malaise.

Preoperative preparation is similar to that done forpatients undergoing general cardiovascular surgery.Interventions specific to the patient receiving a heart trans-plant are as follows: consent for heart transplantation,endomyocardial biopsies, catheterization of the right sideof the heart, and possible use of nitric oxide and adminis-tration of cytomegalovirus negative/leukocyte depleted

blood products. Once the procurement team physicallyexamines the donor heart, the recipient is taken to surgery.

When the donor heart arrives in the operating room,the recipient’s diseased heart is removed and the donorheart is attached to the recipient. Immediate intraoperativecomplications are graft failure resulting from prolongedischemic time (>4 hours), poor myocardial protection,right ventricular failure resulting from pulmonary hyper-tension, or hyperacute rejection.

Postoperative care

The primary goals in the immediate postoperative periodare to promote adequate gas exchange and hemodynamicstability, ensure peripheral blood flow and systemic organperfusion, and deal with issues specific to cardiac trans-plantation.2 These issues include early identification ofbleeding, treatment of dysrhythmias, prevention of rightsided heart failure, early detection of rejection, infection,immunosuppression issues, monitoring for signs of drugtoxicity, and patient education. See Table 3 for drugs usedfor inotropic/vasodilator support in the immediate postop-erative period.1

If no complications occur, the patient usually pro-gresses smoothly. Many patients do not report severe painfrom the incision because of the high doses of steroids thathave been administered.

TABLE 3Inotropic/vasodilator support during the postoperativeperiod

• Isoproterenol• Dobutamine• Epinephrine• Norepinephrine• Milrinone• Prostaglandin E• Nitroglycerin• Nitroprusside• Thyroxine• Intraaortic balloon pump counterpulsation• Ventricular assist devices• Extracorporeal membrane oxygenation



During the postoperative period, the patient andfamily will need extensive instruction about medicationregimens, signs and symptoms of infection, rejection,endomyocardial biopsies, adverse effects of medicaltherapy, when to contact the transplant team, andhealth promotion activities. The patient is usually dis-charged from the hospital within 7 to 10 days aftersurgery and after the first biopsy is completed. A rightsided heart catheterization is performed with the firstbiopsy to determine the hemodynamic status of the newheart. Once the patient is discharged from the hospital,biopsies are done weekly for the first 4 weeks, every 2weeks for the next 4 weeks, then monthly for 3 months,then every 6 months, then finally at 24 months. Oncesteroid doses have been tapered and no major rejectionepisodes have occurred, biopsies are done annually, andthe patient is ready to start his or her new life with anew heart.

Complications

One of the most devastating occurrences for a patient whohas had a heart transplant is a complication that may jeop-ardize the integrity and function of the newly transplantedheart. When patients who have had a heart transplantcome to the emergency department, their fear of having alife-threatening complication is common and should notbe taken lightly. As ED nurses, it is important that we be

aware of the presenting signs and symptoms of patientswith potential serious complications. The following com-plications that sometimes occur in patients who have hada heart transplant are most likely to be seen in the emer-gency department.

REJECTION

The accurate diagnosis and treatment of allograft rejectionremains one of the crucial factors in the survival of patientswho have had a heart transplant. Rejection is divided into3 categories: hyperacute, acute, and chronic.3

Hyperacute rejection generally takes place immediatelyafter surgery from ABO incompatibility and antibodies. Themore common forms of rejection that would be seen in anemergency department are acute and chronic rejection. Acuterejection usually occurs in the first several weeks after thetransplantation when the patient’s body sees the transplantedheart as a foreign body. Chronic rejection is manifested as alow-grade immunologic response; the exact cause is unclear.3

Some presenting signs and symptoms of rejection aregenerally as vague and nonspecific as low-grade fever andfatigue and shortness of breath (Table 4).4-6 Rejection isdefinitively diagnosed with an endomyocardial biopsy.

Treatment of rejection. Patients experiencing rejection aretreated with increased doses of cyclosporin (depending onthe patient’s cyclosporine level), azathioprine, high-dosecorticosteroids, prednisone that is tapered, monoclonalantibodies, or polyclonal antibodies. The aggressiveness ofthe treatment depends on the severity of the rejection.2

One of the most important things for staff in an emer-gency department to do when caring for a patient with aheart transplant who is suspected of experiencing rejectionis to contact a heart transplant team immediately. If thehospital does not have a transplant team, the nearest facil-ity with a team or the patient’s transplant facility must becontacted to obtain expert care for the patient to limit theextent of rejection and prevent death.

INFECTION

Infection resulting from immunosuppressive therapy is theleading cause of morbidity and mortality in the first yearafter transplantation. Lung- and blood-borne pathogensaccount for 50% of serious infections. The highest risk forinfection is 1 week after transplantation; this period

TABLE 4Signs and symptoms of rejection

• Low-grade fever• Fatigue• Shortness of breath• Peripheral edema• Pulmonary crackles• Pericardial friction rub• Arrhythmias• Decreased EKG voltage• Increased jugular venous distention• Hypotension• Cardiac enlargement on radiograph• Vascular degeneration



accounts for 46% of total infections in the first year.Cytomegalovirus is the most common viral infection, withan incidence of 40% in the first year. Fungal infectionsaccount for 7% and protozoal infections for 6% in the firstyear after transplantation.4

The signs and symptoms of infection are usually maskedby the use of immunosuppression. The index of suspicion forinfection should always be high when a patient with a hearttransplant comes to the emergency department with vaguecomplaints. The common signs and symptoms of infectionare low-grade fever, cough, and general malaise. All woundsshould be assessed for erythema, drainage, and pain. Theapproach to infection is largely preventative, that is, stricthand washing and high-calorie, high-protein diets to promotewound healing. If treatment is indicated, use of the appropri-ate antimicrobial agent should be instituted immediately.

CORONARY ARTERY DISEASE

Accelerated CAD is another complication that must betaken into consideration in the patient who has had atransplant. At 2 years, the occurrence of CAD is 20% to30%.6 Some persons suggest that CAD occurs in patientswho received a heart that was older than 35 years, and itmay also be seen in patients who have experienced chron-ic rejection.6,7 The diffuse distribution of the cardiaclesions and rapid progression of the CAD limit the use ofcoronary bypass surgery or interventional angiography formany of these patients. Elective retransplantation is theonly recognized treatment.6

COMPLICATIONS OF LONG-TERM USE OFIMMUNOSUPPRESSIVE AGENTS

All organs in the body are affected by the use of immuno-suppression therapy (Table 5).4-7 Patient education is veryaggressive regarding the importance of compliance with themedication regime because of the adverse effects of the treat-ment, which can be extremely difficult for many patients.

Case study

EJ, a 58-year-old man, came to the emergency departmentbecause of generalized weakness, nausea, and vomiting. Hispresenting vital signs were as follows: temperature, 98.5°F;heart rate, 88; respiratory rate, 18; blood pressure, 110/60;and oxygen saturation in arterial blood, 98% on room air.

He underwent a heart transplant 1 month previously atanother institution and has been progressing well postoper-atively. His other symptoms consisted of visual changes,polyuria, and polydipsia. He denied having shortness ofbreath or chest pains. His son reported that he spent timearound children who had flu-like symptoms during the pastweekend. He is presently taking prednisone, 30 mg bymouth every day. Upon a review of systems, he denied hav-ing fevers, chills, palpitations, orthopnea, paroxysmal noc-turnal dyspnea, edema, cough, or recent upper respiratoryinfections. After undergoing transplantation, his creatininelevel ranged between 1.1 and 1.2, his glucose level was 90during his clinic visit last week, and his last biopsy specimenshowed no sign of rejection. He had a history of non-insulin-dependent diabetes mellitus controlled by dietbefore receiving the transplant. Results of EJ’s initial chem-istry panel revealed the following: sodium, 144; potassium,6.5; chloride, 99; bicarb, 26.9; blood urea nitrogen, 52; cre-atinine, 2.7; and blood glucose, 1126. In the emergencydepartment he was hydrated and an insulin drip was started.Determination of his cyclosporine level was pending, and hewas admitted to the cardiac care unit for further observationand control of his blood sugar.

TABLE 5Some long-term adverse effects of immunosuppressivetherapy

• Malignant disease• Weight gain• Bloating• Hyperglycemia• Peptic/gastric ulcers• Pancreatitis• Mood changes• Gastrointestinal bleeding• Cholecystitis• Anemia• Hypertension• Hyperlipidemia• Impaired wound healing• Osteoporosis• Cataracts• Glaucoma• Dyspepsia



Treatment in the emergency department for unrelated problems

If a patient with a heart transplant seeks emergency care forconditions unrelated to the heart transplant, such as lacer-ations, fractures, or motor vehicle crashes, the heart trans-plant is a critical part of his or her history and will have animpact on the triage acuity assigned. A high index of sus-picion for rejection/infection should always be maintained,regardless of the patient’s clinical presentation.

Patients who undergo transplantation receive atremendous amount of patient education regarding themedication regime they must maintain and potential life-threatening problems that may occur if they are noncom-pliant. It is vitally important that emergency nurses makeevery effort to keep patients on their medication schedule,particularly with their immunosuppressive therapy.

Initial evaluation/triage

To triage patients with heart transplants appropriately, it isimportant to evaluate their presenting signs and symp-toms, vital signs, medication usage, and medical history.Because of the very subtle signs and symptoms and theimmunosuppression that takes place with the transplanta-tion patient, a detailed history must be obtained. Patientswho have fatigue-like symptoms may, in fact, be showingearly signs of rejection/infection as opposed to a simple“flu”; therefore, the triage category assigned to themshould be significantly different than that of a patient whohas not had a heart transplant.

When EJ came to the emergency department, thetriage nurse gave him an emergent classification, eventhough his vital signs were stable. There was a high indexof suspicion for rejection/infection because of his subtle“flu-like” symptoms. Transplant team members were con-tacted; they evaluated EJ and contacted his transplant cen-ter for his history, flow sheets, current status, and medica-tion list. All previous tests showed no signs of rejection.

An accurate medication history is vital to help deter-mine compliance and risk of rejection. The staff must lis-ten to the patient carefully and obtain old medical records,which will help eliminate potentially life-threateningerrors. Ascertaining the time the last dose of immunosup-pression therapy was taken is useful because the mostmeaningful way to determine the level is to draw a trough

10 to 14 hours from the time of ingestion. Many patientswill have lists of medication, doses, and times that shouldbe copied and placed into the patient’s medical record foraccurate and easy reference.

EJ had a card from his transplant institution that list-ed all of his current medications, as well as phone numbersof his transplant team. All of this information was careful-ly obtained and placed in our medical record. The familymembers, as well as the patient, were able to provide accu-rate and precise information.

Many emergency departments are overcrowded, and itis important to use common sense when deciding where toplace patients who have had a heart transplant in a busydepartment. It is not necessary to place such patients in iso-lation, but it is important to keep the patient away fromanyone with an active infection, especially the pediatric pop-ulation. Opportunistic infections can be life threatening.

Treatment/evaluation

If the emergency department has access to a transplantteam, the team must be contacted so that a collaborativemultidisciplinary protocol can be developed for use whena patient with a heart transplant arrives at the department.The protocol must describe signs and symptoms of rejec-tion, which will help to alert the triage nurse to life-threat-ening situations that could occur. A list of resources tocontact with phone numbers and beeper numbers of trans-plant team members will also be helpful in obtainingexpert assistance. Consulting a pharmacist for each patientwith a heart transplant who enters a facility reduces theotherwise high risk for drug-to-drug interactions.

If a transplant team is not available, phone numbers forlocal heart transplant centers must be readily available.Obtaining an accurate history is very important, as are oldrecords. In EJ’s case, the information obtained from histransplant center helped us to get his baseline assessmentdata.

Protocols must be developed that enable the staff torun certain tests prior to evaluation, depending on thepatient’s presentation (ie, blood cultures, urine cultures,complete blood cell count, chemistry panel, cyclosporinetrough 10 to 14 hours after ingestion, prothrombin time,partial thromboplastin time, EKG, echocardiogram, and



chest radiograph), which may expedite the ED stay anddisposition.

The approach to infection is largelypreventative, that is, strict hand wash-ing and high-calorie, high-proteindiets to promote wound healing. Iftreatment is indicated, use of theappropriate antimicrobial agentshould be instituted immediately.

The hospital protocol was activated immediately uponEJ’s arrival. Within 15 minutes, the transplant team was atthe bedside, intravenous lines were initiated, and bloodwas drawn for laboratory tests. Within 30 minutes of hisarrival, a chest radiograph and echocardiogram were per-formed. The echocardiogram revealed normal LV and RVfunction with a mildly hypertrophic LV.

Case study continued

In the cardiac care unit, EJ was adequately hydrated, bloodglucose levels were controlled, and a septic workup wascompleted. During the next 15 hours his renal functionimproved, his creatinine level came down to 0.9, and hiselectrolytes normalized. His vision improved slowly. Theendocrine service assisted the transplant team in determin-ing EJ’s insulin requirements. He received instructionregarding the American Diabetes Association diet and useof a glucometer and did very well. His cyclosporine(Neoral) was titrated to his cyclosporine level, and pred-nisone was slowly tapered as well.

In EJ’s case, insulin-dependent diabetes mellitus haddeveloped in response to the use of steroids postoperative-ly. He did not have any signs of acute rejection or infec-

tion. The transplant team continued to administer hisother medications at the same doses. He was then dis-charged home and followed up by endocrine service staffand his transplant center.

Conclusion

Providing care in the emergency department for patientswho have had a heart transplant is a challenge. Emergencydepartments must have protocols and appropriateresources readily available to provide the patients with theexpert care they need in an efficient manner. If expert carecannot be provided, the patient must be transported to thenearest transplant center. Rejection or infection willbecome life threatening if not diagnosed and treatedimmediately.

AcknowledgmentWe thank Marguerite K. Schlag, MSN, RN, EdD, for her valuable assis-tance with this article.

REFERENCES1. Roarke T, Droogan M, Ohler L. Heart transplantation: state of

the art. AACN Clin Issues 1999;10:185-201.2. UNOS Organ Procurement Transplant Network. Database.

Richmond (VA): The Network; 1998.3. Murdock DK, Collins EG, Lawless CE, Molnar Z, Scanlon PJ,

Pifarre R. Rejection of the transplanted heart. Heart Lung1987;16:237-45.

4. Borge RC. Cardiac transplantation. In: Bennett JC, Plum F, edi-tors. Cecil textbook of medicine. 20th ed. Philadelphia: WBSaunders; 1996. p. 360-7.

5. Gao SZ, Alderman EL, Schroeder JS, Silverman JF, Hunt SA.Accelerated coronary vascular disease in the heart transplantedpatient: coronary arteriographic findings. J Am Coll Cardiol1988;12:334-40.

6. Bieber C, Hunt SA, Schwinn S, Jamieson S, Reitz B, Oyer P, etal. Complications in long term survivors of cardiac transplanta-tion. Transplant Proc 1981;13:207-11.

7. Hosenpund J, Shipley G, Wagner C. Cardiac allograft vascu-lopathy: current concepts, recent developments and future direc-tions. J Heart Lung Transplant 1992;11:9-29.

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Nursing implications for ED care of patients who have received heart transplants