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2016JHLT. 2016 Oct; 35(10): 1149-1205

2%2%

42%

46%2%

3%

4%0%

3%

3%

35%

49%

3%

3%

3%1%

CHD

HCM

ICM

NICM

RCM

Retransplant

VCM

Other

1/2009 – 6/20151/1982 – 6/2015

UNOS, 2017

Adult Heart TransplantsDonor and Recipient Characteristics

1992-2003(N = 48,388)

2004-2008(N = 17,666)

2009-6/2015 (N = 24,474)

p-value

Pre-operative support (multiple items may be reported)

Hospitalized at time of transplant 59.0% 46.4% 44.1% <0.0001

On IV inotropes 54.6%1 44.6% 39.4% <0.0001

Ventilator 3.3% 3.0% 2.1% <0.0001

IABP 6.4% 7.0% 6.4% 0.1497

Mechanical circulatory support 22.2%2 26.0% 44.7% <0.0001

LVAD 20.1%2 22.2% 38.1% <0.0001

RVAD - 4.4%3 3.2% <0.0001

TAH 0.5%2 0.5% 1.4% <0.0001

ECMO 0.3%4 0.9% 1.3% <0.0001

2016JHLT. 2016 Oct; 35(10): 1149-1205

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Indications

Reversible Causes

Addressed

Transplant Evaluation

SHSS 1 year survival <80%

HFSS high/medium riskVO2 Max < 12 ml/kg/min

Yes

Listing

Stage D Heart Failure

Re-Transplants

CHD

Sick enough?

Defer

SHSS 1 year survival >80%

HFSS low riskVO2 Max >14ml/kg/minCandidate?

Medical

Surgical

Psychosocial/financial

No

Palliation

VO2 max

HFSS

SHFM

INTERMACS

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• Donor Specific Antibodies: (DSA)• Antibodies directed against human leukocyte antigens (HLA) are associated with

mortality, graft rejection, dysfunction, organ loss, graft vasculopathy• Why are they there?

• Sensitizing event: blood transfusions, pregnancy, prior Tx, surgery, infection

• Panel reactive antibody (PRA) = percentage of possible donor HLA antigens targeted by the recipient’s circulating antibodies.

**Percentage estimate of the local donor pool that will be incompatible with recipient**

• Cross-match testing: recipient’s serum combined with donor cells to see if compatible

ABSOLUTE CONTRAINDICATIONS

1.Organ transport time > 4 hours2.Confirmed myocardial infarction with systolic dysfunction3.LVEF < 30%4.Severe valvular disease not amenable to repair5.Active infection with transmissible pathogens including, but not limited to HIV, hepatitis B (HBSAg +) or C virus, or highly resistant bacteria6.Bacterial endocarditis7.A history of major extracranial or metastatic malignancy8.Age > 60 years9.Significant penetrating cardiac trauma

RELATIVE CONTRAINDICATIONS

1.Donor recipient mismatch > 6 inches2.Age 50-60 years 3.Male donors > 45 years and female donors > 50 years with cardiovascular risk factors and an inability to perform coronary angiography4.Previous high risk behavior including intravenous drug use or risky sexual activity5.Donor instability manifested by hypoxia, severe acidosis with pH<7.2, hypotension requiring high dose vasoconstrictors6.Organ transport time 3-4 hours

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Biatrial Anastomosis• Shorter ischemic time• Complications

• Atrial dysfunction due to size mismatch of atrial remnants

• Arrhythmia (sinus node dysfunction, bradyarrhythmias, and AV conduction disturbances) that necessitate PPM implantation

Bicaval Anastomosis• Can prolong ischemic times• Decreases incidence of arrhythmias, the need for

a pacemaker, and risk for mitral or tricuspid regurgitation

• Narrowing of the SVC and IVC make biopsy surveillance difficult

Annals of Cardiac Anaesthesia, Vol. 12, No. 1, January-April, 2009, pp. 71-78

• Maintain perfusion

• RV support• Early Diuresis• Pacing

• Inotropic support

• Manage rhythms

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Infection

Rejection

• Mainstay of therapy, inhibits T-cell lymphokine production

• Trough levels monitored

• Tacrolimus (Prograf, FK-506)-most widely used

• Cyclosporine (Gengraf/Neoral)

• Adverse effects• Hyperglycemia• Renal dysfunction• HTN• Tremor• Gingival hyperplasia• Risk of malignancy

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Adverse effects:Short-term

Psychosis, confusion

Fluid retention

GI symptoms

Hyperglycemia

Insomnia

Increased appetite

Long-termOsteoporosis

Diabetes

Impaired wound healing

Hypertension

Glaucoma, cataracts

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Rejection Infection

Cardiac Allograft Vasculopathy(CAV)

Malignancy

Complications

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Adult Heart Transplants Relative Incidence of Leading Causes of Death

0

10

20

30

40

50

0-30 Days

(N=1,474)

31 Days - 1 Year

(N=1,416)

>1-3 Years

(N=986)

>3-5 Years

(N=813)

>5-10 Years

(N=2,091)

>10-15 Years

(N=2,158)

>15 years

(N=2,632)

% o

f D

ea

ths

CAV Acute Rejection

Malignancy (non-Lymph/PTLD) Infection (non-CMV)

Graft Failure Multiple Organ Failure

Renal Failure

2016JHLT. 2016 Oct; 35(10): 1149-1205

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CMVMost common infection after solid organ transplant

Wide range of symptoms:

-Fever (may be blunted because of weakened

immune system)

-Abdominal pain, diarrhea, nausea, vomiting

-GI bleeding

-Pneumonia (lung involvement)

-Neurological changes (altered mental status,

seizures)

-Visual impairment (CMV retinitis)

Test of choice – CMV PCR +/- biopsy of involved

organ

Treatment – high dose ganciclovir or valganciclovir

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Class I Class II

Screen for breast, colon and prostate

cancer

Chronic immunosuppression should be

minimized as possible, particularly in

patients at high risk for malignancy

Skin cancer surveillance

Evaluation for post-transplant

lymphoproliferative disorder (PTLD)

No evidence to support a reduction in

immunosuppression in patients with

solid tumors unrelated to the lymphoid system

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