cardiac transplantation; heart transplant

Indications

• refractory cardiogenic shock
• dependence on intravenous inotropic support
• VO2max < 10-14 mL/kg/min (severely limited functional capacity)*
• severe ischemia (limiting functional capacity) despite optimal medical therapy not amenable to reperfusion (CABG, PCI)
• recurrent significant ventricular arrhythmia refractory to therapy
• insufficient indication alone
  • low LV ejection fraction
  • history of NYHA HF class 3 or 4
• other criteria considered (may be center-dependent)
  • < 60 years of age; < 70 years of age
  • strong psychosocial support system
  • free of extra-cardiac organ dysfunction that would complicate recovery
  • exhausted all other therapeutic options

* despite optimal medical therapy

Contraindications

(may be center-dependent)

• diabetes with end-organ damage, nephropathy, retinopathy
• major chronic disabling illness
• severe pulmonary hypertension
• severe peripheral vascular disease
• active infection
• significant chronic & likely functional impairment of other vital organs (renal failure, cirrhosis, COPD ...)
• active substance abuse (including smoking)
• obesity
• current mental or psychosocial instability
• active or recent malignancy

Clinical manifestations

• due to absence of normal vagal tone, resting heart rate is typically 90-110/min

Laboratory

• cardiac transplantation 20 mRNA expression analysis (CPT)
  • routine within 1st 6 months to assess asymptomatic rejection
  • endomyocardial biopsy is alternative

Complications

• acute cellular rejection
  • most recipients experience 2-3 rejections during the 1st 6 months
  • rejection after 12-24 months is uncommon unless immunosuppression has been decreased
  • patients > 55 years of age experience less rejection
  • manifests as left ventricula dysfinction resulting in acute heart failure
    • atrial flutter & atrial fibrillation common
  • rejection severity is graded by histopathologic changes on endomyocardial biopsy
    • lymphocytic infiltration
    • myocyte necrosis
• acute humoral rejection
  • interstitial edema with deposition of immunoglobulin & complement
  • rarely observed > 6 weeks after transplantation
  • presents with severe left ventricular dysfunction
• infection secondary to immunosuppression
  • effects of immunosuppression are maximal 6-12 weeks after transplantaion
  • most frequent cause of death in the 1st year following transplantation
  • bacterial infections are common in the 1st month
  • viral & opportunistic infections occur later
  • pneumonitis is the most common early & late infection
  • 30% of patients experience at least 1 major infection after transplantation
  • cytomegalovirus within the 1st year
    • most important infectious cause of morbidity
    • generally occurs 6-12 weeks following transplantation
• infection from donor organ (hepatitis C)
  • HCV seropositive donor confers survival disadvantage
• cardiac allograft vasculopathy
  • post-transplant coronary artery disease (CAD) is the primary cause of death >1 year after transplant
  • occurs in > 32-50% of patients within 5 years
  • most common cause of heart failure
  • uncommon to present as chest pain (transplanted heart lacks innervation)
  • represents diffuse intimal hyperplasia rather than focal coronary artery stenosis
  • revascularization generally not beneficial
• cyclosporine-induced hypertension
• obesity & hyperlipidemia
• increased risk of malignancy
  • skin cancer
  • B-cell lymphoma associated with Epstein-Barr virus- induced B-cell proliferation
  • lung cancer
  • substantial radiation exposure (children)
    • increased risk of cancer later in life, especially
      • breast cancer
      • thyroid cancer

Management

• transplant rejection
  • endomyocardial biopsy is used to assess rejection
    • absence of or non-specific signs/symptoms of mild to moderate rejection
      • low grade fever, exertional dyspnea, malaise, abdominal pain, mild hypotension & tachycardia
    • weekly for 1st pre-operative month
    • biweekly for next 2 months
    • then reduce to 2-4 times/year
  • clinical manifestations of severe rejection
    • hypotension
    • 3rd heart sound
    • atrial & ventricular arrhythmias
  • immunosuppressive therapy:
    • cyclosporine
    • glucocorticoids
    • azathioprine
    • severe rejection
      • antithymocyte globulin (ATG)
      • monoclonal antibody OKT3 (Muromonab-CD3)
  • plasmapheresis for acute humoral rejection
• treatment of cyclosporine-induced hypertension
  • Ca+2 channel blockers are 1st line agents
  • addition of 2nd agent often required
    • diuretic
    • beta blocker
    • ACE inhibitor
• treatment of hyperlipidemia
  • HMG CoA reductase inhibitor
• assessment of coronary artery disease (CAD)
  • angina pectoris does not occur because of lack of innervation
    • CAD may present as dyspnea on exertion
  • routine ECG to assess silent ischemia/infarction
  • thallium-201/MIBI scintigraphy generally unreliable
  • dobutamine echocardiography generally unreliable
  • coronary angiography is generally method of choice
  • intracoronary vascular ultrasonography may be better than angiography
  • retransplantation is only treatment for multivessel disease
• lymphoma often regresses following reduction in immunosuppression
• survival:
  • 90% at 1 year
  • 65-70% at 5 years

More general terms

• organ transplantation

More specific terms

• heart/lung transplantation

Additional terms

• post cardiac transplant coronary artery disease

Patient information

cardiac transplantation patient information