Cardiac Transplantation - Clinical Tree

I

History

1.
The techniques for heart transplantation were developed by Norm Shumway and Richard Lower at Stanford University in the 1960s.
2.
James Hardy performed the first heart transplant into a human with a chimpanzee xenograft in 1964 at the University of Mississippi.
- a.
  The patient died immediately of acute rejection.
3.
Christiaan Barnard performed the first allograft human heart transplant in December 1967 in Durbin, South Africa.
- a.
  The patient, a 54-year-old man, received the heart of a 25-year-old woman and survived 18 days until he died of pneumonia.
4.
Three days later, Adrian Kantrowitz performed the first transplant in the United States at Maimonides Medical Center in Brooklyn, New York.
- a.
  He transplanted the heart of a 2-day-old anencephalic male into an 18-day-old male infant, who survived 6.5 hours before dying of acidosis.
5.
Initial results continued to be poor, and the procedure fell from favor.
6.
Shumway and the team at Stanford continued their research, and with the availability of cyclosporine in 1981, heart transplantation subsequently became widely accepted.
7.
A total of 2804 heart transplants were performed in the United States in 2016. This number is relatively unchanged in the previous 15 years.

II

Indications

1.
Heart failure due to ischemic disease, dilated cardiomyopathy, valvular heart disease, hypertensive cardiomyopathy, etc.
2.
Intractable angina despite revascularization attempts and maximal medical therapy, or in a patient who is not a candidate for revascularization
3.
Intractable arrhythmia uncontrolled with medical therapy, pacemaker, and ablative therapies, or in a patient who is not a candidate for ablative therapy
4.
Hypertrophic cardiomyopathy with New York Heart Association (NYHA) class IV heart failure symptoms despite therapeutic interventions and maximal medical therapy
5.
Congenital heart disease
6.
Primary cardiac malignancy confined to the myocardium and without evidence of metastatic disease

III

Contraindications

A

Absolute Contraindications

1.
Older than 70 years (specific age limit is institution specific)
2.
Fixed pulmonary hypertension evidenced by pulmonary vascular resistance greater than 5 Wood units or transpulmonary gradient greater than 15 mm Hg
3.
Systemic illness limiting life expectancy regardless of heart transplant; examples include:
- a.
  Malignancy (with the exception of primary cardiac tumors as mentioned previously) other than skin cancer, with a disease-free survival of less than 5 years
- b.
  Irreversible organ dysfunction (may be considered for heart-kidney, or heart-liver transplant)

B

Relative Contraindications

1.
Diabetes mellitus with end-organ damage
2.
Severe chronic obstructive pulmonary disease (COPD)
3.
Recent pulmonary embolism
4.
Severe peripheral and cerebrovascular disease
5.
Obesity (body mass index [BMI] >35 kg/m ² )
6.
Alcohol or drug abuse
7.
Active tobacco use or within the past 6 months
8.
Lack of social support
9.
Proven record of noncompliance with medical therapies
10.
Psychiatric illness preventing adequate compliance with medical therapies
11.
Amyloidosis and human immunodeficiency virus (HIV): previously considered absolute contraindications but now listing is considered at some specialized institutions with multidisciplinary teams and protocols to guide therapy in the appropriately selected patient

IV

Preoperative Evaluation

1.
Thorough evaluation by a multidisciplinary heart failure and transplant team must be performed prior to listing.
2.
Preoperative work-up should include at minimum the following:
- a.
  Complete laboratory profile: complete blood count (CBC), comprehensive medical panel (CMP), liver function tests (LFTs), coagulation studies, thyroid panel, iron panel, blood type, etc.
- b.
  Infectious work-up, including blood and urine cultures and evaluation for cytomegalovirus (CMV), herpes simplex virus (HSV), HIV, varicella, viral hepatitis, toxoplasmosis, tuberculosis
- c.
  Urinalysis and 24-hour urine studies
- d.
  Cardiac studies, including electrocardiogram (EKG), Holter monitor, echocardiogram, viability studies, cardiopulmonary exercise testing (CPET), right and left heart catheterization, myocardial biopsy if indicated to determine etiology of heart failure
- e.
  Pulmonary function tests, chest x-ray (CXR), and computed tomography (CT) chest
- f.
  Carotid duplex, additional vascular studies, such as ABIs or angiography if indicated
- g.
  Renal ultrasound
- h.
  Esophagogastroduodenoscopy (EGD), colonoscopy
- i.
  Liver biopsy if indicated
- j.
  Dual energy x-ray absorptiometry (DEXA) scan to assess for osteoporosis
- k.
  Neurologic and psychiatric evaluation including dementia and depression screening
- l.
  Dental evaluation
- m.
  Assessment of social support system, prior history of medical compliance, financial resources, and evaluation of literacy and educational needs

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