Heart-Lung Transplantation Periprocedural Care

Updated: Jun 07, 2017
  • Author: Mary C Mancini, MD, PhD, MMM; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Periprocedural Care

Patient Education and Consent

A careful medical and psychosocial evaluation of the candidate must be performed according to established and published program criteria. These criteria are discussed with the patient and family before the initiation of the evaluation, and a candid discussion of issues that disqualify a patient from candidacy for transplantation must be addressed at the onset.

A written contract is negotiated between the transplant center and the patient, with the stipulation that noncompliance with the guidelines is grounds for removal from the program. Both patient and physician must agree to these stipulations. Candid and frequent discussions concerning guidelines, issues, and waiting time should take place.

Patients are instructed to monitor temperature, blood pressure, and pulse oximetry after the procedure and to be alert for symptoms of rejection (which are carefully discussed with the physician). At the first signs of an alteration in their usual state of health, they are to call the transplant center. Patients are educated in detail about the immunosuppressive medications, their actions, and adverse effects.

Because heart-lung transplant patients are at risk for infection caused by their immunosuppressed state, behavioral modification must be encouraged to prevent exposure to certain conditions. Instruct patients to avoid crowds and ill individuals to the extent possible. If patients cannot avoid being in crowds, they should wear a mask in this situation, particularly during the first year after transplantation. Because the lungs are particularly susceptible to injury, encourage the patient to avoid chemical sprays, noxious conditions, fires, and smoke. Stress good general hygiene, including rigorous housekeeping and monitoring of heating and air conditioning systems.

Careful dietary and rehabilitation education is provided. Because of the adverse effects of immunosuppressant drugs, patients are generally maintained on a low-sodium, low-cholesterol diet. Although the steroid regimen is tapered quickly, patients tend to gain weight as a result of the therapy. Dietary discipline is therefore required.

Before transplantation, patients are encouraged to maintain as much normal activity as physically possible in order to maintain muscle tone. If tolerated, a posttransplant cardiopulmonary rehabilitation program is implemented.

After transplantation, the rehabilitation program is instituted early to assist the patient in regaining normal functional status and good general health. In a cohort of 50 patients, exercise performance as measured by oxygen consumption was found to increase from year 1 to year 2 following cardiac transplantation and was related to increase in body weight. [6]

For patient education resources, see the Heart Center and the Lung and Airway Center, as well as Heart and Lung Transplant.

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Preprocedural Planning

Pulmonologists are consulted to assist with determining the extent of pulmonary disease and the patient’s suitability for heart-lung transplantation. Pulmonologists also help manage patients during the waiting period.

Cardiologists are consulted to help assess the extent of cardiac disease. Right-heart failure may be reversible, in which case a potential heart-lung candidate may be converted into a lung-transplant candidate. Cardiologists also play a key role in evaluating and managing the potential candidate.

Psychiatrists are consulted to determine the patient’s psychosocial fitness to undergo the procedure, as well as to provide rigorous posttransplant follow-up care. Psychiatric assistance is also invaluable in addressing issues of chronic terminal illness and patient compliance.

Nephrologists are consulted to assist with renal management of patients in whom low cardiac output may have altered renal function.

Infectious disease specialists are consulted to assist with evaluation and management in accordance with findings obtained during the evaluation period.

Social services providers are consulted to assist with financial issues, medication availability, family stress, and patient adaptation.

Dietitians are consulted to assist with dietary issues and patient compliance.

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Preprocedural Evaluation

Patients who are being considered for heart-lung transplantation undergo a rigorous screening process to assess their overall physical and psychological health. Because certain disease states recur in the allograft, patients with such conditions may not be suitable candidates for the procedure.

During the waiting period for a potential candidate, carefully monitor for signs of clinical deterioration. Administer standard therapy for congestive heart failure and pulmonary hypertension. Maintain close contact with the transplant center, ensuring that the consultants are informed about the patient’s ongoing medical and social issues.

In the event of deterioration, the transplant center may allow the patient to be admitted and may upgrade their status on the waiting list. Candidates may sometimes deteriorate to the point where transplantation is no longer an option. Thoroughly discuss these issues with the treating physician, patient, and family.

History and physical examination

A thorough history is obtained, which includes inquiries regarding the following factors:

  • Cardiopulmonary disease history
  • Infectious disease exposure
  • Environmental exposure
  • Genetic history
  • Family history
  • Social history, including a substance-abuse profile

A complete physical examination is performed, with particular attention to signs of concomitant disease processes, including gastrointestinal (GI) disturbances, bleeding, vascular insufficiency, and occult carcinoma. All potential candidates are evaluated by social services specialists in order to ensure access to required medications and initiation of appropriate planning.

Laboratory studies

A hepatitis panel can serve as a screen, provided that the patient does not have active antigenicity. Thoracic transplantation in patients with hepatitis C remains controversial and is generally addressed on a center-t-center basis.

HIV positivity remains a contraindication to transplantation.

Testing for other viruses, including Epstein-Barr virus (EBV), cytomegalovirus (CMV), and herpes simplex virus (HSV), is valuable. These tests are used to screen patients for past exposure and currently active disease. Past exposure indicates a risk of reactivity; currently active disease should be treated before transplantation is considered. Recipients who are negative for CMV are generally treated with CMV immune globulin.

Immunizations are administered against any diseases for which vaccines are available (eg, rubella and hepatitis).

Fungal serologic testing and tuberculin (TB) skin testing should be performed, with particular attention to environmental exposure. These tests are used to determine past exposure as a predictor of reactivation. Patients with positive TB results are generally treated before being listed for transplantation.

In males, if prostate-specific antigen (PSA) testing yields positive results, the appropriate workup and therapy are instituted before consideration for transplantation.

In females, Papanicolaou test findings should be negative before listing for transplantation considered. Patients with positive test results should be referred for appropriate evaluation and therapy.

Results from the following tests (except alpha1-antitrypsin) should be within reference ranges, and any abnormalities should be assessed for reversibility:

  • Complete blood count (CBC) with differential
  • Platelet count
  • Prothrombin time (PT)
  • Activated partial thromboplastin time (aPTT)
  • Complete chemistry profile, including liver panel, lipid profile, urinalysis, and tests specific to the pulmonary pathology (eg, alpha 1-antitrypsin levels)

Blood typing and screening, panel-reactive antibody (PRA) testing, and tissue typing are used to determine the patient’s immunologic suitability for transplantation and to enable donor matching.

Imaging studies

Computed tomography (CT) of the thorax should be performed to determine the thoracic size for donor matching and to detect disease processes that prohibit transplantation.

Echocardiography and dynamic magnetic resonance imaging (MRI) may be performed to determine the patient’s right ventricular ejection fraction (RVEF). An RVEF greater than 30% may indicate potential cardiac recovery, suggesting that the patient might benefit from pulmonary transplantation alone.

Bilateral mammograms in females should reveal no abnormalities before listing for transplantation. Patients in whom abnormalities are revealed should be referred for appropriate evaluation and therapy.

Posteroanterior and lateral chest radiographs determine the patient’s chest size, which is needed for assessment of donor suitability and is also used as a screening test for other thoracic pathologies that may preclude transplantation.

Cardiac and pulmonary evaluation

Pulmonary function test results, including diffusion capacity of lung for carbon monoxide (DLCO) and maximal venous oxygen consumption (MVO2), are expected to be abnormal. If the forced expiratory volume in 1 second (FEV1) is greater than 1 L and the MVO2 is greater than 15 mL/dL/min, the condition may be treatable by means other than transplantation.

Right- and left-heart catheterization is used to determine whether the disease process is reversible or treatable by other means.

Careful evaluation of the patient’s pulmonary vascular resistance is valuable. A resistance lower than 4 Wood units indicates that the patient may benefit from cardiac transplantation alone.

Biopsy

Biopsies of appropriate areas are necessary if the patient is manifesting systemic disease (eg, sarcoidosis). Biopsy procedures determine the extent and activity of disease. Systemic involvement and active disease may be contraindications to transplantation.

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Monitoring and Follow-up

Postoperative endomyocardial biopsies are performed at weekly intervals for 2-4 weeks to assess for cardiac rejection.

Chest radiographs and spirograms are routinely obtained to evaluate for the presence of pulmonary rejection or infection. If either entity is considered possible, bronchoalveolar lavage with transbronchial biopsy is performed to streamline the differential diagnosis and direct therapy. [7]

Routine outpatient follow-up care is arranged at prescheduled intervals to monitor for immunosuppression and rejection and to evaluate overall clinical progress. The follow-up interval is determined by the center and may be as frequent as 3 times a week during the first several weeks after discharge. Visits become less frequent as the patient demonstrates stability with the medication regimens and as allograft acceptance (lack of rejection episodes) occurs.

Long-term follow-up care can vary from every 3 months to yearly, depending on the patient’s condition. Each outpatient visit may include the following:

  • Routine tests – These include biochemical screening (including electrolytes, cholesterol, glucose, and liver functions) and immunosuppressant drug levels
  • Pulse oximetry and spirometry – These are performed at each visit
  • Cardiac evaluations – These are obtained at predetermined intervals and include echocardiography to assess the function of the allograft
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