Heart Transplantation Periprocedural Care

Updated: Feb 26, 2016
  • Author: Donald M Botta, Jr, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Periprocedural Care

Preprocedural Evaluation

Evaluation of the heart transplant candidate includes laboratory tests, imaging studies, and other tests as appropriate.

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 (CHF), and offer the patient the alternative of participating in experimental clinical trials; such participation does not preclude listing for transplantation. Maintain close contact with the transplant center, 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 so that he or she can be evaluated for implantation of an artificial cardiac assist device, an upgrade on the waiting list, or both. At times, the candidate may deteriorate to the point where transplantation is no longer an option. Carefully discuss these issues with the treating physicians, the patient, and the family.

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Laboratory Studies

A hepatitis panel can serve as a screen, provided that no active antigenicity exists. Patients who are carriers of the disease or who have active disease are not considered candidates for heart transplantation. Hepatitis C positivity remains controversial with respect to thoracic transplantation and is addressed on a center-to-center basis. A large multicenter cohort study found that pretransplant hepatitis C positivity was associated with decreased survival at a mean follow-up of 5.6 years after transplantation. [21]

The patient must not be infected with HIV. HIV positivity remains a contraindication to transplantation.

Testing for other viruses, including Epstein-Barr virus (EBV), cytomegalovirus (CMV), and herpes simplex virus (HSV), is used to determine past exposure and currently active disease. Past exposure indicates a risk of reactivation; appropriate prophylaxis should be instituted after the procedure. Treat active disease before considering transplantation. Recipients whose test results are negative for CMV are generally given CMV immune globulin. Immunize patients whose test results are negative for other viral agents during the evaluation period.

Perform fungal serologic testing and tuberculosis (TB) skin testing, paying particular attention to environmental exposure. These studies are used to determine past exposure and to predict reactivation. Patients with positive TB skin test results are usually treated before being placed on the transplantation list.

If the prostate-specific antigen (PSA) study results are positive, initiate appropriate evaluation and therapy before completing the evaluation for transplantation.

Papanicolaou test results should be negative before listing for transplantation. If the results are positive, undertake appropriate referral for evaluation and therapy before proceeding with the evaluation for transplantation.

Perform a complete blood count (CBC) with differential, platelet count, prothrombin time (PT), activated partial thromboplastin time (aPTT), and complete chemistry profile (including liver panel, lipid profile, and urinalysis). Results of these tests should be essentially normal. Any abnormalities must be assessed before proceeding with the evaluation.

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

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Imaging Studies

In the case of cardiomyopathy, coronary arteriography is performed to determine if the cause of the cardiac dysfunction may be amenable to conventional therapies such as coronary artery angioplasty, coronary artery bypass grafting (CABG), or valvular repair.

Echocardiography is used to determine the cardiac ejection fraction and to monitor the cardiac function of patients on the transplantation waiting list. Ejection fractions of 25% or less are indicative of poor long-term survival rates.

Posteroanterior and lateral chest radiographs are used to screen for other thoracic pathologies that may preclude transplantation.

Bilateral mammograms should reveal no abnormalities before listing for transplantation. If abnormalities are found, undertake appropriate referral for evaluation and therapy before proceeding further with the evaluation for transplantation.

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Cardiac and Pulmonary Evaluation

Pulmonary function tests are performed to assess overall pulmonary function. Severe untreatable pulmonary disease is a contraindication to the procedure.

Maximal venous oxygen consumption (MVO2) is used to assess overall cardiac function and is used as a predictor of the severity of congestive heart failure and survival. An MVO2 value of less than 15 ml/dl/min is a poor prognostic indicator for 1-year survival in the patient awaiting cardiac transplantation.

Cardiopulmonary evaluation includes right- and left-heart catheterization to determine if the disease process is reversible or treatable by more conventional therapy. Careful evaluation of pulmonary vascular resistance is essential. Patients with fixed resistances above 4 Wood units are not candidates for the procedure.

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Biopsy

Endomyocardial biopsy of the potential candidate is not routinely performed. The procedure may be considered if a systemic process involving the heart is thought to be the cause of the cardiomyopathy.

Perform biopsies of appropriate areas if the patient exhibits symptoms of systemic disease. Biopsies are used to determine the extent and activity of the disease process. Systemic disease processes are a contraindication to cardiac transplantation.

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Monitoring and Follow-up

After transplantation, 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. [22, 23, 24]

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