Heart transplantation surgical procedure: Difference between revisions
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'''Editor(s)-in-Chief:''' [[C. Michael Gibson, M.S., M.D.]]; '''Associate Editor-In-Chief:''' {{CZ}}{{IF}} | '''Editor(s)-in-Chief:''' [[C. Michael Gibson, M.S., M.D.]]; '''Associate Editor-In-Chief:''' {{CZ}}{{IF}} | ||
==Overview== | |||
Surgery is usually reserved for patients with advanced, irreversible heart failure with a severely limited life expectancy. Surgery is not the first-line treatment option for patients with heart failure. The mainstay of treatment for heart failure is medical therapy. | |||
==Indications== | |||
*Surgery is the first-line treatment option for patients with either: | |||
===Systolic Heart Failure with a Left Ventricular Ejection Fraction less than 35%=== | |||
<ref name="pmid26776864">{{cite journal| author=Mehra MR, Canter CE, Hannan MM, Semigran MJ, Uber PA, Baran DA | display-authors=etal| title=The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update. | journal=J Heart Lung Transplant | year= 2016 | volume= 35 | issue= 1 | pages= 1-23 | pmid=26776864 | doi=10.1016/j.healun.2015.10.023 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26776864 }} </ref> | |||
*Due to either: | |||
:*Ischemic [[cardiomyopathy]] | |||
:*Dilated [[cardiomyopathy]] | |||
:*[[Valvular heart disease]] | |||
:*[[Hypertensive heart disease]] | |||
:*''Etiologies which are excluded are [[amyloid]], [[HIV]], and cardiac [[sarcoma]]'' | |||
===Ischemic Coronary Artery Disease with Refractory Angina=== | |||
*Ischemia which is not amenable to percutaneous or surgical revascularization ([[coronary artery bypass graft surgery]] CABG) and is refractory to maximally tolerated medical and/or device therapy | |||
===Intractable life-threatening Arrhythmias=== | |||
*[[Ventricular arrhythmias]] which are not controlled by an [[implantable cardioverter-defibrillator]] and are refractory or not amenable to electrophysiologic guided single or combination medical therapy | |||
* Patients that are not a candidate for catheter ablation therapy | |||
===Cardiomyopathies=== | |||
*Restrictive and Hypertrophic Cardiomyopathies with [[New York heart association functional classification|NYHA Class IV]] [[heart failure]] symptoms that persist despite maximal medical therapy, [[myomectomy]], [[alcohol septal ablation]], [[mitral valve replacement]] | |||
*Non-dilated cardiomyopathies such as arrhythmogenic right ventricular cardiomyopathy | |||
===Congenital Heart Disease=== | |||
* CHD resulting in [[New York Heart Association (NYHA) class|New York Heart Association]] functional class IV Heart Failure not amenable to surgery. | |||
* Severe symptomatic [[Congenital heart disease cyanotic|cyanotic congenital heart disease.]] | |||
* Presence of some degree of [[pulmonary hypertension]] with the potential risk of developing fixed and irreversible elevation of [[pulmonary vascular resistance]] (PVR) | |||
==Surgery== | |||
*The feasibility of surgery depends on the patient meeting the criteria for a heart transplant and also the risk-benefit ratio. | |||
==Pre-operative Procedure== | ==Pre-operative Procedure== | ||
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* Doctors made medical history in February 2006, at Bad Oeynhausen Clinic for Thorax and Cardiovascular Surgery, Germany, when they successfully transplanted a 'beating heart' into a patient.<ref>{{cite news | author= | title=Bad Oeynhausen Clinic for Thorax- and Cardiovascular Surgery Announces First Successful Beating Human Heart Transplant | url=http://www.transmedics.com/wt/page/pr_1140714229 | date=23 February 2006 | publisher=TransMedics | accessdate=2007-05-14}}</ref> | * Doctors made medical history in February 2006, at Bad Oeynhausen Clinic for Thorax and Cardiovascular Surgery, Germany, when they successfully transplanted a 'beating heart' into a patient.<ref>{{cite news | author= | title=Bad Oeynhausen Clinic for Thorax- and Cardiovascular Surgery Announces First Successful Beating Human Heart Transplant | url=http://www.transmedics.com/wt/page/pr_1140714229 | date=23 February 2006 | publisher=TransMedics | accessdate=2007-05-14}}</ref> | ||
* Normally, [[potassium chloride]] is injected into the donor's heart (in order to stop it beating, before being removed from the body). It is packed in ice to preserve it. The ice can usually keep the heart fresh for up to four to six hours, depending on its condition to start with. Rather than cooling the heart, this new procedure involves keeping it at [[body temperature]] and hooking it up to a special machine called an [[Organ care system|Organ Care System]] that allows it to continue beating with warm, oxygenated blood flowing through it. This can maintain the heart in a suitable condition for much longer than the traditional method. | * Normally, [[potassium chloride]] is injected into the donor's heart (in order to stop it beating, before being removed from the body). It is packed in ice to preserve it. The ice can usually keep the heart fresh for up to four to six hours, depending on its condition to start with. Rather than cooling the heart, this new procedure involves keeping it at [[body temperature]] and hooking it up to a special machine called an [[Organ care system|Organ Care System]] that allows it to continue beating with warm, oxygenated blood flowing through it. This can maintain the heart in a suitable condition for much longer than the traditional method. | ||
==Contraindications== | |||
===Absolute Contraindications=== | |||
<ref name="ManciniLietz2010">{{cite journal|last1=Mancini|first1=Donna|last2=Lietz|first2=Katherine|title=Selection of Cardiac Transplantation Candidates in 2010|journal=Circulation|volume=122|issue=2|year=2010|pages=173–183|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.109.858076}}</ref> | |||
*Systemic illness with a [[life expectancy]] of less than 2 years ''despite'' HT, including | |||
**Active or recent solid organ or blood [[malignancy]] in the last 5 years | |||
**[[HIV AIDS|AIDS]] complicated by frequent [[opportunistic infection]]<nowiki/>s | |||
**Active diseases with [[Multisystem organ failure|multisystem]] involvement like- [[systemic lupus erythematosus]], [[sarcoidosis]], or [[amyloidosis]] | |||
**Irreversible [[renal]] or [[Hepatic failure|hepatic dysfunction]] | |||
**Significant [[obstructive pulmonary disease]] | |||
*Fixed or irreversible [[pulmonary hypertension]] | |||
**Pulmonary artery systolic pressure >60 mm Hg | |||
**Mean transpulmonary gradient >15 mm Hg | |||
**[[Pulmonary vascular resistance]] >6 Wood units | |||
===Relative Contraindications due to associated [[comorbidities]]=== | |||
<ref name="MehraCanter2016">{{cite journal|last1=Mehra|first1=Mandeep R.|last2=Canter|first2=Charles E.|last3=Hannan|first3=Margaret M.|last4=Semigran|first4=Marc J.|last5=Uber|first5=Patricia A.|last6=Baran|first6=David A.|last7=Danziger-Isakov|first7=Lara|last8=Kirklin|first8=James K.|last9=Kirk|first9=Richard|last10=Kushwaha|first10=Sudhir S.|last11=Lund|first11=Lars H.|last12=Potena|first12=Luciano|last13=Ross|first13=Heather J.|last14=Taylor|first14=David O.|last15=Verschuuren|first15=Erik A.M.|last16=Zuckermann|first16=Andreas|title=The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update|journal=The Journal of Heart and Lung Transplantation|volume=35|issue=1|year=2016|pages=1–23|issn=10532498|doi=10.1016/j.healun.2015.10.023}}</ref> | |||
*'''Age''' - Patients are considered for cardiac transplant if they are < 70 years of age; or carefully selected patients over age 70. | |||
* '''Obesity'''- [[Body mass index|BMI]] > 35 kg/m 2 is associated with a worse outcome. | |||
* '''Cancer'''- Careful assessment of each [[neoplasm]] with a collaboration with oncology specialists to stratify each patient must be done. <ref name="pmid19195521">{{cite journal| author=Kellerman L, Neugut A, Burke B, Mancini D| title=Comparison of the incidence of de novo solid malignancies after heart transplantation to that in the general population. | journal=Am J Cardiol | year= 2009 | volume= 103 | issue= 4 | pages= 562-6 | pmid=19195521 | doi=10.1016/j.amjcard.2008.10.026 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19195521 }} </ref> | |||
* '''Diabetes'''- End-organ damage and persistent poor [[Glycemic Targets in Diabetes|glycemic]] control ([[glycosylated hemoglobin]] [<nowiki/>[[Glycosylated hemoglobin|HbA 1c]]] > 7.5% or 58 mmol/mol) are relative contraindications | |||
* '''Renal dysfunction'''- Irreversible [[renal dysfunction]] ( [[eGFR]] < 30 ml/min/1.73 m 2) is a relative contraindication | |||
* '''Peripheral vascular disease'''- Clinically severe symptomatic [[cerebrovascular disease]] may be considered a contraindication. | |||
* '''Infections'''- Use of [[Immunosuppressive therapy|immunosuppressive]] therapy post-transplantation may cause a flare up of active [[Infection|infections]]. | |||
**[[Human Immunodeficiency Virus (HIV)|Human immunodeficiency viral (HIV) infection]] | |||
**[[Chagas disease]] | |||
**[[Tuberculosis]] | |||
**[[Hepatitis B]] and [[Hepatitis C|C]] viral (HBV and HCV) infections | |||
* '''[[Tobacco Use Disorder|Tobacco]] use'''- Active tobacco smoking is a relative contraindication. | |||
*[[Substance abuse|'''Substance Abuse'''-]] Active substance abusers (including [[Alcohol, Drug Abuse, and Mental Health Services Block Grant|alcohol]]) cannot receive a heart transplant. | |||
* '''[[Psychosocial|Psychosocial evaluation]]'''- Lack of social support of presence of [[Cognitive|cognitive disability]] are relative contraindications. | |||
==References== | ==References== | ||
Revision as of 01:25, 8 July 2020
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Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D.; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [1]Ifrah Fatima, M.B.B.S[2]
Overview
Surgery is usually reserved for patients with advanced, irreversible heart failure with a severely limited life expectancy. Surgery is not the first-line treatment option for patients with heart failure. The mainstay of treatment for heart failure is medical therapy.
Indications
- Surgery is the first-line treatment option for patients with either:
Systolic Heart Failure with a Left Ventricular Ejection Fraction less than 35%
- Due to either:
- Ischemic cardiomyopathy
- Dilated cardiomyopathy
- Valvular heart disease
- Hypertensive heart disease
- Etiologies which are excluded are amyloid, HIV, and cardiac sarcoma
Ischemic Coronary Artery Disease with Refractory Angina
- Ischemia which is not amenable to percutaneous or surgical revascularization (coronary artery bypass graft surgery CABG) and is refractory to maximally tolerated medical and/or device therapy
Intractable life-threatening Arrhythmias
- Ventricular arrhythmias which are not controlled by an implantable cardioverter-defibrillator and are refractory or not amenable to electrophysiologic guided single or combination medical therapy
- Patients that are not a candidate for catheter ablation therapy
Cardiomyopathies
- Restrictive and Hypertrophic Cardiomyopathies with NYHA Class IV heart failure symptoms that persist despite maximal medical therapy, myomectomy, alcohol septal ablation, mitral valve replacement
- Non-dilated cardiomyopathies such as arrhythmogenic right ventricular cardiomyopathy
Congenital Heart Disease
- CHD resulting in New York Heart Association functional class IV Heart Failure not amenable to surgery.
- Severe symptomatic cyanotic congenital heart disease.
- Presence of some degree of pulmonary hypertension with the potential risk of developing fixed and irreversible elevation of pulmonary vascular resistance (PVR)
Surgery
- The feasibility of surgery depends on the patient meeting the criteria for a heart transplant and also the risk-benefit ratio.
Pre-operative Procedure
A typical heart transplantation begins with a suitable donor heart being located from a recently deceased or brain dead donor. The transplant patient is contacted by a nurse coordinator and instructed to attend the hospital in order to be evaluated for the operation and given pre-surgical medication. At the same time, the heart is removed from the donor and inspected by a team of surgeons to see if it is in a suitable condition to be transplanted. Occasionally it will be deemed unsuitable. This can often be a very distressing experience for an already emotionally unstable patient, and they will usually require emotional support before being sent home.
Operative Procedure
Once the donor heart has passed its inspection, the patient is taken into the operating theatre and given a general anesthetic. Either an orthotopic or a heterotopic procedure is followed, depending on the condition of the patient and the donor heart. [2]
Orthotopic Procedure
The orthotopic procedure begins with the surgeons performing a median sternotomy to expose the mediastinum. The pericardium is opened, the great vessels are dissected and patient is attached to cardiopulmonary bypass. The failing heart is removed by transecting the great vessels and a portion of the left atrium. The pulmonary veins are not transected; rather a circular portion of the left atrium containing the pulmonary veins is left in place. The donor heart is trimmed to fit onto the patients remaining left atrium and great vessels and sutured in place. The new heart is restarted, the patient is weaned from cardiopulmonary bypass and the chest cavity is closed.
Heterotopic procedure
In the heterotopic procedure, the patient's own heart is not removed before implanting the donor heart. The new heart is positioned so that the chambers and blood vessels of both hearts can be connected to form what is effectively a 'double heart'. The procedure can give the patients original heart a chance to recover, and if the donor's heart happens to fail (eg. through rejection), it may be removed, allowing the patients original heart to start working again. Heterotopic procedures are only used in cases where the donor heart is not strong enough to function by itself (due to either the patients body being considerably larger than the donor's, the donor having a weak heart, or the patient suffering from pulmonary hypertension).[3]
Post-Operative
The patient is taken into ICU to recover. When they wake up, they are transferred to a special recovery unit in order to be rehabilitated. The duration of hospital stay post-transplant depends on the patient's general health, the status of the new heart, and adherance to post-operative medications and precautions. After discharge, they will have to return to the hospital for regular check-ups and rehabilitation sessions. They may also require emotional support. The number of visits to the hospital will decrease over time, as the patient adjusts to their transplant. The patient will have to remain on lifetime immunosuppressant medication to avoid the possibility of rejection. The importance of immunosuppressive therapy and compliance must be made clear. Since the vagus nerve is severed during the operation, the new heart will beat at around 100 bpm until nerve regrowth occurs.
"Living organ" transplant
- Doctors made medical history in February 2006, at Bad Oeynhausen Clinic for Thorax and Cardiovascular Surgery, Germany, when they successfully transplanted a 'beating heart' into a patient.[4]
- Normally, potassium chloride is injected into the donor's heart (in order to stop it beating, before being removed from the body). It is packed in ice to preserve it. The ice can usually keep the heart fresh for up to four to six hours, depending on its condition to start with. Rather than cooling the heart, this new procedure involves keeping it at body temperature and hooking it up to a special machine called an Organ Care System that allows it to continue beating with warm, oxygenated blood flowing through it. This can maintain the heart in a suitable condition for much longer than the traditional method.
Contraindications
Absolute Contraindications
- Systemic illness with a life expectancy of less than 2 years despite HT, including
- Active or recent solid organ or blood malignancy in the last 5 years
- AIDS complicated by frequent opportunistic infections
- Active diseases with multisystem involvement like- systemic lupus erythematosus, sarcoidosis, or amyloidosis
- Irreversible renal or hepatic dysfunction
- Significant obstructive pulmonary disease
- Fixed or irreversible pulmonary hypertension
- Pulmonary artery systolic pressure >60 mm Hg
- Mean transpulmonary gradient >15 mm Hg
- Pulmonary vascular resistance >6 Wood units
Relative Contraindications due to associated comorbidities
- Age - Patients are considered for cardiac transplant if they are < 70 years of age; or carefully selected patients over age 70.
- Obesity- BMI > 35 kg/m 2 is associated with a worse outcome.
- Cancer- Careful assessment of each neoplasm with a collaboration with oncology specialists to stratify each patient must be done. [7]
- Diabetes- End-organ damage and persistent poor glycemic control (glycosylated hemoglobin [HbA 1c] > 7.5% or 58 mmol/mol) are relative contraindications
- Renal dysfunction- Irreversible renal dysfunction ( eGFR < 30 ml/min/1.73 m 2) is a relative contraindication
- Peripheral vascular disease- Clinically severe symptomatic cerebrovascular disease may be considered a contraindication.
- Infections- Use of immunosuppressive therapy post-transplantation may cause a flare up of active infections.
- Human immunodeficiency viral (HIV) infection
- Chagas disease
- Tuberculosis
- Hepatitis B and C viral (HBV and HCV) infections
- Tobacco use- Active tobacco smoking is a relative contraindication.
- Substance Abuse- Active substance abusers (including alcohol) cannot receive a heart transplant.
- Psychosocial evaluation- Lack of social support of presence of cognitive disability are relative contraindications.
References
- ↑ Mehra MR, Canter CE, Hannan MM, Semigran MJ, Uber PA, Baran DA; et al. (2016). "The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update". J Heart Lung Transplant. 35 (1): 1–23. doi:10.1016/j.healun.2015.10.023. PMID 26776864.
- ↑ Flécher E, Fouquet O, Ruggieri VG, Chabanne C, Lelong B, Leguerrier A (2013). "Heterotopic heart transplantation: where do we stand?". Eur J Cardiothorac Surg. 44 (2): 201–6. doi:10.1093/ejcts/ezt136. PMID 23487534.
- ↑ Konertz W, Sheikhzadeh A, Weyand M, Friedl A, Bernhard A (1988). "Heterotopic heart transplantation: current indications for the procedure, with results in 10 patients". Tex Heart Inst J. 15 (3): 159–62. PMC 324818. PMID 15227245.
- ↑ "Bad Oeynhausen Clinic for Thorax- and Cardiovascular Surgery Announces First Successful Beating Human Heart Transplant". TransMedics. 23 February 2006. Retrieved 2007-05-14.
- ↑ Mancini, Donna; Lietz, Katherine (2010). "Selection of Cardiac Transplantation Candidates in 2010". Circulation. 122 (2): 173–183. doi:10.1161/CIRCULATIONAHA.109.858076. ISSN 0009-7322.
- ↑ Mehra, Mandeep R.; Canter, Charles E.; Hannan, Margaret M.; Semigran, Marc J.; Uber, Patricia A.; Baran, David A.; Danziger-Isakov, Lara; Kirklin, James K.; Kirk, Richard; Kushwaha, Sudhir S.; Lund, Lars H.; Potena, Luciano; Ross, Heather J.; Taylor, David O.; Verschuuren, Erik A.M.; Zuckermann, Andreas (2016). "The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update". The Journal of Heart and Lung Transplantation. 35 (1): 1–23. doi:10.1016/j.healun.2015.10.023. ISSN 1053-2498.
- ↑ Kellerman L, Neugut A, Burke B, Mancini D (2009). "Comparison of the incidence of de novo solid malignancies after heart transplantation to that in the general population". Am J Cardiol. 103 (4): 562–6. doi:10.1016/j.amjcard.2008.10.026. PMID 19195521.