Heart Transplantation

DR. KEWAL KRISHAN MBBS MS MCH DNB MNAMS FIACS (CTVS)ADVANCED FELLOW, MAYO CLINIC & MOUNT SINAI, USA

PROGRAM HEAD, HEART TRANSPLANT & VENTRICULAR ASSIST DEVICES

SENIOR CONSULTANT CARDIAC SURGEON

MAX SUPERSPECIALITY HOSPITAL, SAKET, NEWDELHI

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Advanced Heart Failure - Definition

Patients have significant cardiac dysfunction and marked symptoms: dyspnea, fatigue end-organ hypoperfusion at rest or with minimal exertion despite maximal medical

therapy AHA Stage D Refractory symptoms requiring specialized

interventions to manage symptoms or prolong lifeGoodlin et al, Journal of Cardiac Failure Vol. 10 No. 3 2004Hunt SA et al JACC 2001;38:2101–13.

INTERMACS Profiles 1-3 Interagency Registry for Mechanical Circulatory Support

‘Frequent Flyer’Stevenson, JHLTX; 09:535

INTERMACS Profiles 4-7

Stevenson, JHLTX; 09:535

‘Housebound’

‘Class IIIb’

Deg

ree

of C

ircul

ator

y Su

ppor

t

IABP

PARTIAL SUPPORTCI* ↑15% CI ↑30-60%

ECMO

+

FULL SUPPORTCI ↑100%

Levitronix CentriMagAbiomed BVS 5000Abiomed AB 5000Abiomed Impella 5.0 LP Abiomed Impella 5.0 LD

TandemHeart pVADAbiomed Impella 2.5 LP

Short-term MCS Devices

*CI – cardiac index

Class I Indications for Cardiac Transplantation

Cardiogenic shock requiring mechanical assistance. Refractory heart failure with continuous inotropic infusion. NYHA functional class 3 and 4 with a poor 12 month

prognosis. Progressive symptoms with maximal therapy. Severe symptomatic hypertrophic or restrictive

cardiomyopathy. Medically refractory angina with unsuitable anatomy for

revascularization. Life-threatening ventricular arrhythmias despite

aggressive medical and device interventions. Cardiac tumors with low likelihood of metastasis. Hypoplastic left heart and complex congenital heart

disease.

When to think of Cardiac Transplantation

Patients should receive maximal medical therapy before being considered for transplantation. They should also be considered for alternative surgical therapies including CABG, valve repair / replacement, cardiac septalplasty, etc.

VO2 has been used as a reproducible way to evaluate potential transplant candidates and their long term risk.

Generally a peak VO2 >14ml/kg/min has been considered “too well” for transplant .

Peak VO2 10 to 14 ml/kg/min had some survival benefit,

Peak VO2 <10 had the greatest survival benefit.

Evaluation of Cardiac Transplantation Recipient

Right and Left Heart Catheterization. Cardiopulmonary testing ( VO2 max). Labs including BMP, CBC, LFT, UA, coags, TSH,

UDS, ETOH level, HIV, Hepatitis panel, PPD, CMV IgG, RPR / VDRL, PRA (panel of reactive antibodies), ABO and Rh blood type, lipids.

CXR, PFT’s including DLCO, EKG. Substance abuse history Mental health evaluation and social support. Financial support. Weight no more than 140% of ideal body weight.

Cardiac Donor

Brain death is necessary for any cadaveric organ donation. This is defined as absent cerebral function and brainstem reflexes with apnea during hypercapnea in the absence of any central nervous system depression.

There should be no hypothermia, hypotension, metabolic abnormalities, or drug intoxication.

If brain death is uncertain, confirmation tests using EEG, cerebral flow imaging, or cerebral angiography are indicated.

Matching Donor and Recipient

ABO blood type (match or compatible),

Donor weight to recipient ratio (must be 75% to 125%), Response to PRA ( Panel Reactive Antibodies) The PRA is a rapid measurement of preformed reactive

anti-HLA antibodies in the transplant recipient. In general PRA < 10 to 20% then no cross-match is necessary. If PRA is > 20% then a T and B-cell cross-match should be performed.

Case Study

A 42 yeears old gentleman with C/O EPIGASTRIC PAIN for the LAST 3 YEARS

Breathlessness for the last 2.5 yrs Orthoponea for the last 10 months ( off & on) DM(+) SINCE LAST 3 YEARS SMOKER SINCE LAST 1O YEARS

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Case Study

FIRST EVALUATED – 1 YR BACK-HOSPITALISED DUE TO ACUTE HEART FAILURE

Due to frequent admissions ( INTERMACS 4) SUGGESTED BY CARDIOLOGIST FOR HEART TRANSPLANT DUE TO DCMP WITH SEVERE LV DYSFUNCTION

The patient first time saw me in Dec.2014.

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Case Study

RIGHT HEART CATH-DONE WITH SWAN-GANZ CATHETER SHOWED- PVR=287

- SVR=1326 AFTER DOBUTAMINE INFUSION FOR 24 HOURS-

PVR=192 PFT-WITHIN NORMAL LIMIT DURING LAST 6 MONTHS-He HAD 3 EPISODES OF

ACUTE HEART FAILURE-HOSPITALISED and -MANAGED CONSERVATIVELY WITH INOTROPES AND DIURETCS

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Case Study

CALL RECEVED FROM B.L. KAPOOR HOSPITAL FOR A+ DONOR AT 10.30PM PATIENT( Recepient) WAS CALLED TO REACH

HOSPITAL PT REACHED MAX HOSPITAL AT AROUND 11 PM AND WAS

IMMEDIATELY ADMITTED FOR HEART TRANSPLANTATION CTVS TEAM REACHED BLK HOSPITAL FOR ASSESSMENT OF

DONOR 57 YEARS MALE PATIENT ADMITTED AFTER ROAD-TRAFFIC ACCIDENT WITH HEAD

INJURY DECLARED BRAIN DEAD ON 31/7/15 AT 11 AM AND

RECONFIRMATION DONE AFTER 6 HOURS at 5.15 PM ACCORDING TO LEGAL REQUIREMENTS ( Human organ Act)

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Case Study

ALL LAB INV. OF DONOR- with in acceptable limits 2-D ECHO- SHOWED NO REGIONAL WALL MOTION

ABNORMALITY, LVEF=50% CORONARY ANGIO=NORMAL DONOR WAS TAKEN TO O.T. AFTER MIDNIGHT AFTER PAINTING AND DRAPING-MEDIAN STERNOTOMY

WAS DONE HEART INSPECTED VISUALLY AFTER CONFIRMATION OF GOOD DONOR HEART-

RECEPIENT WAS WHEELED-IN MAX HOSPITAL O.T.

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Case Study

AT BLK HOSPITAL UROLOGY AND HEPATOBILIARY TEAM STARTED ORGAN DISSECTION OF KIDNEYS AND LIVER

MEANWHILE LINES WERE INSERTED AND PT. WAS BEING PAINTED AND DRAPED FOR SURGERY AT MAX HOSPITAL

ONCE OTHER TEAMS WERE READY FOR ORGAN HARVESTING-HEART WAS TAKEN OUT AFTER CROSS-CLAMPING AND CARDIOPLEGIA

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Case Study

RECEIPIENT CARDIECTOMY WAS DONE AND DONOR HEART WAS SUTURED IN the SEQUENCE OF

LEFT ATRIUM→IVC→PULMONARY ARTERY→AORTA →SVC

DE-AIRING WAS DONE AND CROSS-CLAMP WAS RELEASED AFTER GIVING 500MG METHYLPREDNISOLONE

HEART STARTED BEATING WEANED OFF CPB SLOWLY &DECANNULATION DONE CHEST CLOSED IN LAYERS AFTER PUTTING CHEST

TUBES PT WAS SHIFTED TO ICU AT 7.30 AM ON 1/8/15

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Bicaval Approach

Left atrial anastomosis performed

Separate inferior and superior vena caval anastomosis

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Case Study

PT WAS EXTUBATED ON 1st POD MOBILISED OUT OF BED ON 2nd POD SWAN ,SHEATH AND CHEST TUBES REMOVED ON 2nd POD INOTROPES WEANED IMMUNOSUPPRESSIVE DRUGS STARTED -TACROLIMUS

AND MYCOPHENOLATE MOFETIL METHYLPREDNISOLONE WAS PUT ON WEANING MODE PT RECOVERed DISCHARGED WITHIN A WEEK FROM

HOSPITAL

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HEART TRANSPLANTATION Kaplan-Meier Survival (1/1982-6/2005)

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Years

Surv

ival

(%)

Half-life = 11.0 yearsConditional Half-life = 14.0 years

N=89,006

N at risk at 25 years = 98

HEART TRANSPLANTATION Kaplan-Meier Survival (1/1982-6/2009)

ISHLTISHLTJ Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132

Common Immunosuppressive Regimen

Primary: cyclosporine / tacrolimus(utilized in conjuction with therapeutic drug monitoring)

Adjunctive: mycophenolate mofetil Supportive: prednisone (only 20 to 30% centers

wean prednisone off if possible) Additive: statins (shown to be immunomodulatory

and associated with improved long term survival)

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Major Post Transplant Complications

Rejection Infection Cardiac allograft vasculopathy (CAV) Hypertension Nephrotoxicity Malignancy

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Identifying Allograft RejectionDisease Progression

Alloimmune activation Cellular invasion

Multiple genes and pathways

Cellular inflamationand myocyte necrosis

Graft Dysfunction

Heart failure andarrhythmias

Diagnostic Indicators

Gene Expression ProfilingImmune Function Assays

Endomyocardial Biopsy(intermediate)

Functional Assessment(late)

Rejection

Invasive surveillance biopsies are the best established method for following patients

Typically 13-15 biopsies are done in the first year Each biopsy requires a minimum of 3 samples from

3 different sites to be meaningful

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GRADE 1A

GRADE 2

GRADE 1B

Mild

31GRADE 4

GRADE 3A GRADE 3B

ThresholdMandatory

ForTherapy

Long Term Challenges

Renal failure and metabolic adverse effects

Cardiac allograft vasculopathy

Malignancy

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Cardiac Allograft Vasculopathy

Coronary Angiogram

Intravascular Ultrasound (IVUS)

Histology(autopsy)

Diagnosis: coronary angiogram, IVUS, Dobutamine stressEchocardiography (DSE), myocardial perfusion imaging (MPS)

VAD Components

Inflow cannula

Outflow Graft

Percutaneous drive line

Pump

HEART WARE

• Weigh 145 gms• Pumps 4-5 liter/min• No pocket required• Under clinical trial

Peripherals

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Short-Term Extracorporeal Assist DeviceDevi

Levitronix CentriMag

Magnetically-levitated centrifugal pump Continuous-flow rotary pump Electrical actuation– magnetic coupling of

the motor and impellor Capable of 6 ~ 9 L/min at 5500 RPM Left, Right, or Biventricular support Operative placement requiring sternotomy Bridge to recovery

Courtesy of Levitronix, Inc.

Extra Corporeal Membrane Oxygenation ( ECMO)

www.kewalkrishan.com

Thank you