HEART TRANSPLANTATION
MARTIN SUSSMAN
MILPARK HOSPITAL
ISSUES
• Improvements in survival with medical
therapy impacted on old indications for HT.
• Remain survival and QOL benefits for HF pts
despite this
• Exercise testing strongly recommended, not
routinely performed in JHB
– Peak VO2 <12
INDICATIONS
• End stage heart failure of any cause – on
maximal medical therapy, no alternative
therapy, eg revascularisation, valve
repair/replacement
– ICD 10 codes I 40, I 41, I 42, and I 43 (acute
myocarditis of any cause and associated with any
other illness or disease, chronic cardiomyopathy
of any cause or associated disease or illness)
INDICATIONS 2
• A definitive list, incorporating every possible
condition is complex, of necessity incomplete,
and potentially inappropriately limiting.
• The 3 important “safety nets” are
– All patients are screened by a multidisciplinary
team before being listed
– Exclusion criteria are more important
– Sickest patients get operated first – majority in
ADHF, or multiple recent admissions in HF
EXCLUSION CRITERIA
• Pulmonary hypertension
• Severe co-morbidity not expected to improve
with heart transplant –heart/lung, heart
kidney/liver?
• Malignancy
• Malnutrition
• Advanced age
EXCLUSIONS 2
• Interplay between donor quality and following
relative contra-indications to ensure optimal
utilisation of scarce resource
– Age, DM, PVD, obesity, cancer, renal function
– Negative factors are cumulative, but no weighting
for each
– Role for alternate listing system
PULMONARY HYPERTENSION
• Right heart catheterisation for all HT
candidates
– Repeat 3-6 monthly while on waiting list
– If PAP >50mm Hg, PVR > 3 Wood units, or TPG >
15 mm Hg, trial of vasodilators, inotropes for 2448 hours, MCS. Irreversible PHT if non responder.
– NO ABSOLUTE CUT-OFF, but if PVR remains > 5,
TPG > 16, with PAP > 60, mortality is increased
– If PVR drops <2.5, but SBP also drops below 85mm
Hg, risk is increased
MALIGNANCY
• Type, curability, recurrence risk.
• Ensure no metastatic disease.
• No absolute time line, but 5 years is
mentioned as arbitrary cut-off
DIABETES
• Duration
• No end-organ damage - NOT C/I, but still
worse outcome
• With end organ damage – relative to absolute
C/I
• Hypoglycamia unawareness and autonomic
dysfunction increase concern
MALNUTRITION
• Obesity – BMI > 30 is C/I
• Undernutrition – BMI < 21 males, 19 females
RENAL FUNCTION
• Must decide role of HF – reversibility
• Irreversible, with creat > 300, is a strong C/I
URGENCY
• Acute decompensated heart failure – if BP <
115 mm Hg, urea and creatinine elevated, on
inotropes
Recommended Schedule for Heart
Transplant Evaluation
Test
Baseline
3 months
6 months
9 months
12 months (and
yearly)
X
X
X
X
X
X
X
X
Complete H & P X
Follow-up
assessment
Weight/BMI
X
Immunocompat
ibility
ABO
X
Repeat ABO
X
HLA tissue
typing
Only at transplant
PRA and flow
cytometry
X
• >10%
• VAD
Every 1–2 months
Every 1–2 months
• Transfusion
2 weeks after transfusion and then 9 month × 6 months
Evaluation of multi-organ function
Routine lab
work (BMP,
CBC, LFT)
X
X
X
X
PT/INR More
frequent per
protocol if on
VAD or
coumadin
X
X
X
X
X
Urinalysis
X
X
X
X
X
GFR (MDRD
quadratic
equation)
X
X
X
X
X
Unlimed urine
sample for
protein
excretion
X
X
X
X
X
Preventive and malignancy
Stool for occult
blood × 3
X
Colonoscopy (if
indicated or >50
y)
X
X
Mammography (if
indicated or >40
X
y)
X
Gyn/Pap (if
indicated ≥18 y
sexually active)
X
X
PSA and digital
rectal exam (men
> 50 y)
X
X
Infectious serology and vaccination
Hep B surface Ag
X
Hep B surface Ab
X
Hep B core Ab
X
Hep C Ab
X
HIV
X
RPR
X
HSV lgG
X
CMV lgG
X
Toxoplasmosis lgG
X
EBV lgG
X
Varicella lgG
X
PPD
X
Flu shot (q 1 year)
X
Pneumovax (q 5
years)
X
Hep B
immunizations:
1_2_3_
X
Hep B surface Ab
(immunity)
6 weeks after third immunization
F/U EMB, ANGIOGRAPHY
• EMB
Biopsy 1, 2, 3, 4, and 5:
Biopsy 6, 7, and 8:
Biopsy 9 and 10:
Biopsy 11, 12, and 13:
Subsequent biopsies during
the 1st year after HT:
• ANGIOGRAM + IVUS
Weekly
Every 14 days
Every 3 weeks
Every 4 weeks
Every 5 to 6 weeks
1-2 YEARLY
NEW DEVELOPMENTS
• Harvesting
• Organ transport
• MCS
– Centres of excellence
FEES
• Harvesting heart – 75 units.
– Insertion IC drain under local – 86 units.
– Tonsillectomy and adenoids – 115 units
– Diagnostic coronary angiogram – 140 units
Estimated U.S. Average 2008 FirstYear Billed Charges Per Transplant
Transplant
30 Days
Procurement
Pre-transplant
Hospital
Transplant
Admission
Physician
During
Transplant
180 Days
ImmunoPost-transplant
suppressants
Admission
Total
Heart Only
$34,200
$94,300
$486,400
$50,800
$99,700
$22,300
$787,700
Single Lung
Only
$7,500
$53,600
$256,600
$27,900
$84,300
$20,500
$450,400
Double Lung
Only
$20,700
$96,500
$344,700
$59,300
$113,800
$22,800
$657,800
Heart-Lung
$49,100
$151,900
$682,500
$73,000
$143,300
$24,700
$1,123,800
Liver Only
$21,200
$73,600
$286,100
$44,100
$77,800
$20,600
$523,400
Kidney Only
$16,700
$67,500
$92,700
$17,500
$47,400
$17,200
$259,000
Pancreas Only $16,500
$68,400
$93,400
$16,300
$58,700
$22,200
$275,200
FEES 2
• Heart transplant – 875 units
• Lung transplant – 600 units
Generic Drug Immunosuppression in Thoracic Transplantation:
An ISHLT Educational Advisory
Patricia A. Uber, PharmD,a Heather J. Ross, MD,b Andreas O. Zuckermann, MD,c Stuart C. Sweet, MD,d
Paul A. Corris, MD,e Keith McNeil, MD,f and Mandeep R. Mehra, MBBSa
1. Clinicians should educate their patients to inform
the coordinating center if a change in either the
labeling or appearance of their immunosuppressive
medications suggests that a generic drug substitution
has occurred.
2. Clinical care coordinating centers must develop
structured approaches for the education of all personnel
with regard to use of generic immunosuppressants.
3. In unique clinical situations, where critical drug
dosing represents a fine balance, caution should be
exercised in the use of generic immunosuppression.
4. Heightened vigilance to adverse sequelae and closer
therapeutic drug monitoring is indicated until a
stable immunosuppression milieu can be established