Heart Transplant Patient

CRITERIA FOR CARDIAC TRANSPLANT RECIPIENT

Clinical

  • NYHA class III/IV heart failure refractory to maximal medical therapy
  • severe limiting angina not suitable for revascularization
  • recurrent symptomatic ventricular arrhythmia refractory to treatment
  • estimated life expectancy of < 12 months

Physiological

  • peak O2 consumption less than 10mL/kg/min after reaching anaerobic threshold

EXCLUSION CRITERIA

  • age > 65 yrs
  • pulmonary hypertension (not reversible with nitrates or inhaled NO)
  • IDDM with end-organ damage
  • severe psychiatric disturbance or intellectual retardation
  • current alcohol or drug abuse
  • morbid obesity
  • malignancy
  • severe hepatic or renal disease
  • immunuodeficiency disease
  • active systemic infection

ASSESSMENT

HISTORY

  • cause of cardiac failure and symptoms patients had
  • functional limitations
  • surgery and perioperative course
  • complications: rejection, infection, coronary vascular disease, malignancy, hyperlipidaemia and HT
  • currently exercise tolerance
  • previous anaesthetic history after transplant
  • symptoms of rejection and cardiac performance (symptoms of rejection: unexplained weight gain, or fever, recent cardiac biopsy result – Bilingham grade)
  • symptoms of heart failure seen or arrhythmia
  • donor heart IHD – don’t get pain because heart denervated
  • ability to work

Medications

  • standard + immunosuppressants
  • 3 classes of drugs used:
    1. Immunophilin binding drugs (cyclosporin, tacrolimus) – prevent cytokine-mediated T cell activation and proliferation
    2. Nucleic acid synthesis inhibitors (azathioprine, mycophenolate) – block lymphocyte proliferation
    3. Steroids (prednisone) – block production of inflammatory cytokines, lyse T lymphocytes and alter the function of remaining lymphocytes
  • anaemia, thrombocytopaenia and leukopaenia -> may require treatment
  • all can predispose to: infection, malignancy (SCC of skin, lymphoma), OA, CRF
  • cyclosporine – associated with HT, renal dysfunction, prolonged effect of ND-NMBs, calcium antagonists are used to increase cyclosporine levels
  • tacrolimus – renal dysfunction
  • recent biopsy and angiography results

EXAMINATION

  • weight
  • BP
  • CVS: high HR, no variation, pacemaker, sternotomy, scars over RIJ from biopsies, HS and lungs

INVESTIGATIONS

  • ECG: look for second (native p wave), RBBB
  • angio:
  • ECHO: intramural thrombi and ventricular function
  • FBC
  • U+E
  • drug levels
  • CXR

MANAGEMENT

Bridge to Transplant Therapies

  • ACE-I
  • beta-blockers
  • inotropes
  • intra-aortic balloon pump
  • implantable defibrillators
  • cardiac resynchronisation
  • advanced pacing devices
  • surgical interventions (CABG, anterior ventricular wall remodelling, mitral reconstruction)
  • VAD
  • totally implanted artificial heart

Donor coronary artery disease

  • immune mediated
  • very common
  • will not get angina as heart denervated -> aggressive maintenance of coronary artery perfusion and oxygenation

Rejection

  • look for: weight gain, fluid retention, pyrexia, decreased cardiac function on ECHO
  • don’t cannulate RIJ as this is where cardiac biopsies are taken from

Immunosuppression

  • must be continued perioperatively and in ICU
  • look out for drug interactions
  • drug side effects: chronic renal impairment, HT, DM, bone marrow suppression, hepatotoxicity
  • prone to infections (including atypical and opportunistic): strict asepsis, remove all unnecessary lines/drains early
  • if infections suspected: get cultures and start antimicrobials early, involve ID early, increase steroids
  • monitor for malignancy

Respiratory

  • may have phrenic or recurrent laryngeal nerve palsy -> poor cough
  • if has had lung transplant be aware of tracheal anastomosis on intubation (appropriate tube size and check pressure)

Other common diseases

  • PVD
  • DM
  • sarcoid
  • amyloid
  • epilepsy
  • HT

Altered Physiology

  • 10% have pacemaker
  • 10% have RBBB
  • no autonomic innervation: HR around 90/min, loss of vagal tone, no heart rate changes with stimulation -> wide swings in BP c/o reliant on maintenance of pre and afterload
  • marked hypotension with central neuraxial anaesthetic techniques
  • contractility preserved unless rejection taking place

Altered Pharmacology

  • use direct acting agents: adrenaline, noradrenaline, isoprenaline and beta-blockers, phenylephrine
  • atropine: no effect on HR
  • adenosine: more sensitive -> start with 1mg
  • digoxin: minimal delay in AV conduction -> not a good anti-arryhthmic here
  • adrenaline and noradrenaline: increased contractility and chronotropy
  • beta-blockers: increased antagonistic effect
  • pancuronium: no tachycardia
  • neostigmine: no bradycardia
  • isoprenaline: normal effects
  • GTN: no reflex tachycardia
  • suxamethonium, neostigmine: no bradycardia

References and Links

  • Lindenfeld J et al. Drug therapy in the heart transplant recipient: part I: cardiac rejection and immunosuppressive drugs. Circulation. 2004 Dec 14;110(24):3734-40. [PMID 15596559]
  • Burgess MI. The role of echocardiography in evaluation of the cardiac transplant recipient. Minerva Cardioangiol. 2003 Dec;51(6):677-987. [PMID 14676753]
  • Mancini D, Lietz K. Selection of cardiac transplantation candidates in 2010. Circulation. 2010 Jul 13;122(2):173-83. [PMID 20625142]
  • Ramakrishna H, Jaroszewski DE, Arabia FA. Adult cardiac transplantation: a review of perioperative management Part-I. Ann Card Anaesth. 2009 Jan-Jun;12(1):71-8. [PMID 19136760]
  • Ramakrishna H, Jaroszewski DE, Arabia FA. Adult cardiac transplantation: a review of perioperative management (part-II). Ann Card Anaesth. 2009 Jul-Dec;12(2):155-65. [PMID 19602745]
  • Futterman LG, Lemberg L. Cardiac transplantation: a second chance for extending life. Am J Crit Care. 2008 Mar;17(2):168-72. [PMID 18310657]
  • Deng MC. Cardiac transplantation. Heart. 2002 Feb;87(2):177-84 [PMID 11796563]
  • Knisely BL, Mastey LA, Collins J, Kuhlman JE. Imaging of cardiac transplantation complications. Radiographics. 1999 Mar-Apr;19(2):321-39; discussion 340-1. [PMID 10194782]

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.