Transplant Team Members
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Transplant surgeons
Transplant surgeons meet with the patients and families during the
evaluation process to perform a medical evaluation, explain the
surgical process, and review patient’s risks and benefits of
transplant. The transplant surgeon performs the transplant surgery
and works with the medical doctors to manage your care after the
transplant.
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Transplant internists, nephrologists, hepatologists
Transplant internists provide medical care to patients once they
have received their transplants. This includes the short and longterm management of immunosuppression and other medical issues.
Nephrologists and Hepatologists are doctors who assess the patient
to decide if a transplant will be of help. They stay involved in the
patient's care while the patient is on the waiting list and long-term
after transplant has been done.
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Pre-transplant nurse coordinators
Pre-transplant coordinators are responsible for coordinating the
patient care before transplant, from the time of the first referral
until the time a transplant is received. They help arrange the testing
required for placing a patient on the waitlist. A pre-transplant
coordinator will assist the patient through the evaluation process by
working closely with the patient and communicating with patient’s
local doctors, dialysis units, other healthcare facilities, and
outpatient clinics.
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Post-transplant nurse coordinators
Post-transplant coordinators assist with coordinating every aspect
of transplant care, from the time of transplant through long-term,
post-transplant care. They serve as the patient’s link to the rest of
the transplant team after the patient goes home after transplant
surgery. Coordinators assist the doctors in the medical management
of the patient, provide ongoing education for the patient and family,
and act as patient advocates. Their follow up care includes contact
with local doctors, other healthcare facilities, and outpatient clinics.
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Clinical social worker
Clinical social workers conduct a psychosocial assessment, discuss
available community resources, assist with financial resources, and
work with other members of the transplant team to support the
patient emotionally throughout the transplant process. The social
worker will provide information and help with completion of advance
directives. They can also assist with finding a support group for
patients and their families.
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Clinical dieticians
Clinical dieticians work with the patient and the patient’s family to
evaluate nutritional status and develop a plan for good nutrition
throughout the transplant process.
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Physician assistants
Physician assistants assist with inpatient and outpatient care and
help organize the patient needs on discharge. Physician assistants
check patient recovery, assist in daily medical management after
transplant surgery, and assist doctors in every aspect of patient
care.
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Surgical residents and transplant fellows
Surgical residents and transplant fellows assist mainly with inpatient
care including preparing the patient for surgery, assisting in the
operating room, and helping to manage post operative
issues. Surgical residents and transplant fellows work with the
surgeons and other team members to prepare the patient for
discharge.
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Nurse practitioner
Nurse practitioners assist with inpatient care and outpatient care
following a transplant. A nurse practitioner assists the transplant
doctor with immunosuppression management as well as long-term
general health management. A nurse practitioner is available to see
patients in clinic on a long-term basis.
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Financial counselors
Financial counselors work with the patient and patient' insurance
company both before and after transplant to facilitate financial
matters concerning transplantation, such as billing, collection,
deductibles, drug coverage, and co-insurances. They are responsible
for patient education about the financial aspects of transplant. They
are best resource for help with any insurance related questions.
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Transplant pharmacists
Transplant pharmacists work closely with doctors, nursing staff, and
the patient to ensure that the transplant medicines are used
correctly. The pharmacists work with the rest of the transplant team
to find the best way to diminish the side effects a patient may have
due to immunosuppression and other medicine used during
transplantation. They also help with managing the medicine schedules.
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Inpatient transplant nurses
Inpatient transplant nurses specialize in the care and treatment of
transplant patients during their hospital stay. Patients are assigned
a primary nurse for their inpatient nursing care that will work with
doctors, coordinators, and other health care disciplines to prepare
the patient for discharge.
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Discharge case manager
Discharge case managers work with patients and families to
prepare them to leave the hospital. Some patients need skilled
nursing care after leaving the hospital, and discharge case
managers assist with arranging these services.
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Transplant clinic nurses
Transplant clinic nurses care for patients during clinic visits and
assist with numerous outpatient procedures. The clinic nurses
provide care and support for patients during the recovery period
after procedures, and assist in setting up required follow-up
care. They also provide ongoing education for patients and their
families.
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Office support staff
Members of the transplant office support staff provide phone
triage to coordinators and other staff and assist in management of
outpatient medical information. They help coordinators with
managing patient lab results and daily patient issues and concerns.
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Pastoral care
Chaplains help many patients and families receive comfort and
meaning from their faith during illness recovery. Chaplains
provide spiritual and emotional support and perform religious
ceremony. Faith and medicine opportunities are provided at the
hospital chapel.
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Other doctor consultations
Other doctor consults may be required either during the
transplant evaluation or at any period after transplant to address
the patient's special needs. Infectious disease, dental, endocrine,
cardiology, hepatology, gastroenterology, dermatology, urology,
and rehabilitation and … are just a few of the teams that are
available to assist patient care.
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Heart transplantation
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Heart transplantation
The treatment of choice for younger patients who have intractable
heart failure despite maximal medical and device therapy who are
otherwise healthy.
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Indications
Refractory heart failure despite maximal medical support,
Refractory ventricular arrhythmias (rare)
Refractory angina (rare)
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Contraindications/ Any medical condition that would
be expected to limit life expectancy after transplantation
Recent or active malignancies, active infections, or other chronic life-threatening
diseases,
Evidence of end-organ damage, including advanced pulmonary disease, renal
insufficiency, hepatic insufficiency, or severe vascular disease,
Age greater than 65 years has become a relative contraindication, because patients
above this age have been shown to have worse outcomes,
Psychosocial factors, including inability to follow a rigorous medical regimen after
transplantation,
Pulmonary hypertension with a pulmonary vascular resistance that cannot be reduced
by medical means or through the placement of a ventricular-assist device (CI for
isolated cardiac transplantation)/ In the setting of fixed pulmonary hypertension, the
donor right ventricle often fails, leading to a high risk of perioperative mortality
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Allocation system
Donor hearts are to be allocated to the sickest patients first to
maximize waiting list survival.
The current acuity system includes three levels. Patients who are at
the greatest risk of death are listed as status 1A; patients who are
status 2 are considered to have a lower risk.
Within an ABO blood group and recipient size range, donor organs are
offered first to the highest priority patients and then to the lower
risk groups until the organs are matched with a recipient.
Hearts are offered geographically using the location of the donor.
Hearts are offered first to local transplant centers and then to
centers outside the region in a series of concentric circles of 500
miles in diameter until an organ is matched. The ischemic time of
approximately 4 hours limits the distance from which a heart can be
harvested.
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Pretransplantation care
Patients awaiting cardiac transplantation are managed with a variety
of heart failure therapies including neurohormonal blocking agents
(angiotensinconverting enzyme inhibitors, beta blockers, aldosterone
antagonists, angiotensin receptor blockers) and diuretics.
In addition, eligible patients may receive a biventricular pacemaker,
and almost all these patients have an implantable defibrillator to
protect against sudden cardiac death before transplantation.
It is important that clinicians re-evaluate patients being considered
for cardiac transplantation, because several of the newer therapies
can promote positive remodeling of the ventricle over time, precluding
or at least delaying the need for transplantation.
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Pretransplantation care
Intravenous inotropic therapy is often initiated for patients who
remain in a low cardiac output state or who have refractory symptoms
of congestion despite maximal medical support and, if appropriate,
biventricular pacing. The most commonly used chronic inotropes
include milrinone and dobutamine.
Inotropes can significantly improve cardiac index, decrease symptoms,
and improve end-organ perfusion. Inotropes also significantly increase
the risk of arrhythmias, including potentially fatal ventricular
arrhythmias.
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Pretransplantation care
In the past, patients receiving continuous inotropes remained
hospitalized until a suitable organ became available. Recent studies
have shown that with the use of an implantable defibrillator to treat
dangerous ventricular arrhythmias, patients awaiting transplantation
can be managed safely as outpatients.
Patients who have acute hemodynamic compromise or have a chronic
low cardiac output state despite inotropic support may be candidates
for placement of a ventricular-assist device.
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Pretransplantation care
These devices can supplement or replace the cardiac output from the
right, left, or both ventricles. Ventricular assist devices have been
used to bridge patients to transplantation, and there is evidence that
in the appropriate population these devices can reverse end-organ
dysfunction and allow improved outcomes after Transplantation.
Certain ventricular-assist devices allow patients to be managed
successfully as outpatients while awaiting transplantation.
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Surgical techniques
Three surgical techniques are commonly in use for cardiac
transplantation: the standard, bicaval, or total technique.
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Surgical techniques/ Biatrial
In the standard or biatrial
technique, cuffs of the recipient
atria, including the orifices of the
pulmonary veins, are left intact
and then are sewn to the donor
atria. Advantages of this
technique include a shorter
surgical time and no need to reimplant the pulmonary veins.
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Surgical techniques/ Biatrial
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Surgical techniques/ Biatrial
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Surgical techniques/ Biatrial
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Surgical techniques/ Biatrial
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Surgical techniques/ Bicaval
During the past several years, the bicaval approach has gained favor,
because it has reduced atrial arrhythmias, sino-atrial nodal
dysfunction, and tricuspid regurgitation.
In this technique, the recipient pulmonary veins are excised in a cuff
of left atrium and then are attached to the donor left atrium. The
entire recipient right atrium is removed. The superior and inferior
vena cavae are attached, as are the aorta and pulmonary arteries.
Several studies have shown that this technique, although it adds
ischemic time, has led to improved short- and long-term outcomes.
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Surgical techniques/ Bicaval
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Surgical techniques/ Bicaval
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Surgical techniques
The total technique involves removal of the entire recipient heart
with the exception of two small ‘‘buttons’’ of left atrial tissue
containing the four pulmonary veins. The remainder of the
anastomoses are identical to the bicaval technique, except that there
are two anastomoses in the left atrium.
Limited studies have suggested that this technique adds significant
ischemic time but does not lead to improved outcomes.
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Surgical techniques/ Total
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Surgical techniques/ Total
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Surgical techniques/ Total
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Surgical techniques/ Total
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Surgical techniques/ Total
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Cardiac transplantation outcomes
The outcomes in cardiac transplantation have improved over time, with
the 1-year survival rate, 86.7%; the 3-year survival rate, 78.6%
At 1 year, approximately 36% return to work.
In the first year, the most common cause of death includes graft
dysfunction.
After the first year, infections and graft dysfunction are the most
common causes.
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Cardiac transplantation outcomes
Late causes of death include graft vasculopathy and malignancies.
Graft vasculopathy is one of the major limitations to long-term
survival after cardiac transplantation.
Graft vasculopathy differs from typical coronary disease in that it is
diffuse in nature and can affect the small vessels first, making it
difficult to detect with coronary angiography. Intravascular
ultrasound has become the criterion standard for detecting and
monitoring graft coronary disease but is not available routinely
outside research protocols.
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Cardiac transplantation outcomes
Most researchers agree that this form of vasculopathy is immune
mediated, and several small studies have shown regression with newer
or augmented immunosuppression.
The routine use of 3-hydroxy-3-methylglutaryl coenzyme A reductase
inhibitors in all cardiac transplant recipients, regardless of lipid
profile, has become the standard of care because of evidence
suggesting that the antiinflammatory property of statins may help
prevent or delay vasculopathy.
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‫تغییرات فیزیولوژیک در پیوند قلب‬
‫‪Denervation‬‬
‫‪(1‬افزایش ضربان قلب در حالت استراحت‪،‬‬
‫‪(2‬افزایش تدریجی ضربان قلب در هنگام ورزش و بازگشت تدریجی به حالت اول‪،‬‬
‫‪(3‬عدم بروز آنژین‬
‫‪(4‬افزایش پاسخ به بعضی داروها نظیر آدرنالین و آدنوزین و کاهش پاسخ به برخی داروها‬
‫نظیر آتروپین و دیجوکسین‪.‬‬
‫ممکن است دو تا موج ‪ P‬در نوار قلب مددجو دیده شود که ناشی از حضور توام گره‬
‫سینوسی دهلیزی قلب دریافت کننده و قلب پیوند شده است‪ .‬ذکر این نکته مهم است که‬
‫تنها گره سینوسی دهلیزی قلب پیوندی جریان الکتریکی قلب را هدایت می کند‪.‬‬
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‫مراقبت پرستاری‬
‫بررسی پرستاری‪/‬‬
‫بررسی فیزیکی‪ /‬سمع صداهای قلبی و ریوی و بررسی نبض های محیطی و سیاهرگ جوگوالر از نظر‬
‫برآمدگی است‪.‬‬
‫بررسی مداوم عملکرد کلیوی و کبدی و پایش سطح داروهای مهارکننده سیستم ایمنی و همچنین‬
‫شمارش کامل گلبول های خون الزم است‪.‬‬
‫در روزهای اول پس از پیوند قلب بروز اریتمی معمول است‪.‬‬
‫همچنین‪ ،‬به دلیل جایگزینی مایعات و درمان با دوز باالی کورتیکواستروئید احتمال هیپرولمی وجود دارد‪.‬‬
‫عوارض پس از پیوند قلب عبارتند از اختالل در عملکرد عضو پیوندی‪ ،‬رد پیوند‪ ،‬عفونت‪ ،‬اشکال در عروق‬
‫کرونر‪ ،‬و بدخیمی‪.‬‬
‫برای پایش مددجو از نظر عفونت ریوی از رادیوگرافی قفسه سینه استفاده می شود‪.‬‬
‫برای تشخیص رد پیوند از اکوکاردیوگرافی و نمونه گیری از بافت قلب کمک گرفته می شود‪.‬‬
‫تظاهرات بالینی رد پیوند عبارتند از تب‪ ،‬وجود صدای ‪ S3‬یا ‪ ،S4‬کاهش فشار خون‪ ،‬کاهش کسر تخلیه ای‪،‬‬
‫و اتساع ورید جوگوالر‬
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