eMedicine Specialties > Transplantation > Surgery
Heart Transplantation: Treatment
Updated: May 1, 2009
Treatment
Medical Therapy
Closely monitor the heart transplant candidate for signs of clinical deterioration during the waiting period for a suitable donor organ.
Administer standard therapy for congestive heart failure, and offer the patient the alternative of participating in experimental clinical trials because this does not preclude listing for transplantation. Close contact with the transplant center must be maintained, keeping the consultants informed of ongoing medical and social issues pertaining to the candidate.
In the event of clinical deterioration, the transplant center may deem it appropriate to admit the patient for evaluation for implantation of an artificial cardiac assist device and/or an upgrade on the waiting list. At times, the candidate may deteriorate to the point that transplantation is no longer an option. Carefully discuss these issues with the treating physicians, the patient, and the family.
Surgical Therapy
The applicability of cardiac transplantation is limited by the availability of suitable donors. All potential donors have succumbed to brain death secondary to some catastrophic event. The underlying pathology of the donor, including cardiac contusion, cocaine use, cardiac pathology, or social history, often precludes donation. Because of the short preservation time tolerated by the heart (4-6 h), procurement distances are limited.
Potential heart donors must meet brain death criteria and be free of cardiac pathology. Examination by echocardiography remains the best initial screening mechanism for potential donors. A normal ejection fraction (>50%) with normal valvular structure and function and an absence of left ventricular hypertrophy (as determined by echocardiography) are indicators of an excellent heart for transplantation. Minimal abnormalities detected by echocardiography, such as trivial tricuspid or mitral regurgitation, marginal left ventricular hypertrophy, or reduced ejection fraction, may also be indicators of an acceptable organ for transplantation, depending on the history of the donor and the condition of the recipient. In instances in which the recipient is in extremis, a less-than-ideal donor heart may be accepted in order to save the patient's life. Donors who have a significant smoking history must be screened for coronary artery disease with cardiac catheterization.
Current donor criteria include age younger than 65 years, normal cardiac function, and no coronary artery disease. Once these criteria are met, donor and potential recipients are matched according to blood group (ABO) compatibility and size.
The final decision regarding the suitability of the donor heart can be made only by direct inspection by an experienced surgeon. A median sternotomy incision is performed to allow for inspection of the heart. Care is taken to assess the organ for potential contusions and overall function. The heart is flushed with cold cardioplegia solution, removed, and placed into cold sterile electrolyte solution for transport.
The recipient operation is performed using cardiopulmonary bypass. The recipient heart is removed, and the donor heart is inserted in its place. The left atrial anastomosis is performed, followed by the right atrium and the great vessels.
Intraoperative Details
While preparing a graft for transplantation, the authors look for a patent foramen ovale. If present, it is closed. Over the last few years, many centers have started to perform tricuspid valve annuloplasty of the graft as prophylaxis against development of tricuspid regurgitation in the postoperative period. In some series, the rate of moderate-to-severe tricuspid regurgitation is reported to be as high as 50% at 5 years.
View of the recipient's chest after the heart is removed, with the patient on cardiopulmonary bypass.
Suturing of the donor heart. Note that the left atrial anastomosis is performed first.
The completed operation. Note the suture lines on the now-implanted heart.
A cardiac allograft can be sewn in a heterotopic or orthotopic position. The authors rarely perform heterotopic heart transplants because of the inherent problems (eg, pulmonary compression of the recipient, difficulty obtaining endomyocardial biopsy, need for anticoagulation); however, it is an excellent technique for patients with severe pulmonary hypertension.
Heterotopic transplantation.
Orthotopic heart transplantation is performed with either the classic Shumway-Lower technique or as a bicaval anastomosis.
View following cardiectomy showing cuffs for bicaval anastomosis.
Completed bicaval transplantation technique.
The former method is simpler and saves perhaps 10-15 minutes of ischemic time. The latter method is advantageous in that, by avoiding a large right atrium, the surgeon is able to maintain better atrial transport. Another claimed advantage is a lower reported incidence of tricuspid regurgitation with the bicaval technique. Additionally, when the ischemic time of the allograft is too long because of transportation or surgical extraction of the recipient heart/ventricular assist device, the donor heart can be better preserved by continuous cold retrograde blood cardioplegia through the coronary sinus. Of course, topical cooling of the graft continues to be the primary means of graft preservation.
The incidence of tricuspid regurgitation is reported to be as high as 47-98% following heart transplantation.8 Some centers have now begun to prophylactically perform tricuspid annuloplasty on donor grafts before performing the transplantation.9
Postoperative Details
The patient is maintained on a combination of pressor agents while the donor heart regains energy stores. The ionized calcium level of the patient is carefully monitored and replaced with calcium chloride because the function of the denervated heart is initially extremely dependent on circulating calcium ions. The acid-base status of the patient is also carefully monitored and corrected.
Immunosuppression is started soon after surgery. Several regimens can be used, including pretransplantation induction therapy or simply postoperative maintenance therapy. The choice of regimen is dependent upon the training and experience of the transplant center.
Once stabilized, the patient is rapidly weaned from the ventilator and the pressors. The posttransplant hospital stay can be as short as 5 days, depending upon the condition of the recipient prior to surgery.
Follow-up
After transplant, endomyocardial biopsies are performed to assess for allograft rejection. These may be performed as frequently as every week for the first month, with the frequency decreasing over time. Follow-up visits are frequent for the first month because regulation of immunosuppression is being adjusted during this time. The frequency of visits gradually diminishes until the patient is generally seen on an annual basis. Certain centers perform coronary angiography annually after transplantation to monitor the patient for the development of allograft vascular disease.10,11,12
For excellent patient education resources, visit eMedicine's Heart Center. Also, see eMedicine's patient education articles Heart and Lung Transplant and Congestive Heart Failure.
Complications
Complications after transplantation include bleeding from the suture lines. This is a rare occurrence but may require reexploration in the early postoperative period.
Hyperacute rejection can occur immediately after blood flow is restored to the allograft and up to 1 week after surgery despite therapeutic immunosuppression.
Infection is the primary concern in transplant patients. Preventive measures should be instituted. During the early posttransplant course, bacterial infections are of primary concern. Fungal infections can appear if the patient is diabetic or overimmunosuppressed. Prophylaxis for Pneumocystis carinii is universally administered, as is therapy for cytomegalovirus (CMV) infection. Maintain vigilance for other uncommon infectious processes including Listeria, Legionella, Chlamydia, and Nocardia infections.13
Psychiatric disturbances from steroid therapy can occur in the immediate posttransplant period. These disturbances may be predicted from the pretransplantation psychiatric evaluation and thus averted.
Cardiac rejection is to be expected and should be detected by endomyocardial biopsy. Depending upon the severity of the incident, the process can be treated with steroid therapy alone, polyclonal antibody therapy, or monoclonal antibody therapy.
Allograft vascular disease is the main cause of late graft failure and death. The coronary arteries develop a progressive concentric myointimal hyperplasia. This hyperplasia can develop as early as 3 months after transplantation. The cause of the process is unclear. However, CMV infection and recurrent rejection episodes are thought to be associated with the cause. Current research indicates that the initial ischemia/reperfusion injury of the allograft coupled with repeated rejection episodes might contribute to the process. The only available therapy is retransplantation. The process can sometimes be treated by stenting of the diseased vessels.14,15,16,17
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References
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Further Reading
Keywords
cardiac replacement, cardiac transplantation, cardiac allograft, cardiopulmonary bypass, cyclosporine, intra-aortic balloon pump, implantable assist devices, coronary artery angioplasty, coronary artery bypass surgery, CABG, valve repair, allografts, xenografts, end-stage congestive heart failure, CHF, ischemic cardiomyopathy, angina, pulmonary disease, malignant cardiac arrhythmias, coronary artery disease, CAD, congenital heart disease, CHD, cytomegalovirus, CMV, rejection, organ donors, organ donation
