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]