Heart transplantation: Difference between revisions
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Ischemia which is not amenable to [[coronary artery bypass graft surgery]] (CABG) and is refractory to maximally tolerated medical therapy | Ischemia which is not amenable to [[coronary artery bypass graft surgery]] (CABG) and is refractory to maximally tolerated medical therapy | ||
===Intractable life-threatening arrhythmias=== | ===Intractable life-threatening arrhythmias=== | ||
:*Arrhythmias which are not controlled by an implantable cardioverter-defibrillator | :*Arrhythmias which are not controlled by an implantable cardioverter-defibrillator | ||
:*Arrhythmias that are refractory or not amenable to electrophysiologic guided single or combination medical therapy | :*Arrhythmias that are refractory or not amenable to electrophysiologic guided single or combination medical therapy | ||
:* Patients that are not a candidate for ablative therapy | :* Patients that are not a candidate for ablative therapy | ||
===Hypertrophic obstructive cardiomyopathy (HOCM)=== | ===Hypertrophic obstructive cardiomyopathy (HOCM)=== | ||
[[Class IV heart failure]] symptoms persist despite maximal therapy, myomectomy, alcohol septal ablation, mitral valve replacement | [[Class IV heart failure]] symptoms persist despite maximal therapy, myomectomy, alcohol septal ablation, mitral valve replacement | ||
===Congenital heart disease=== | ===Congenital heart disease=== | ||
Revision as of 22:05, 25 May 2010
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Editors-in-Chief: Juan A. Sanchez MD MPA [1], Chairman, The Stanley J. Dudrick Department of Surgery, Saint Mary's Hospital, Waterbury, CT; C. Michael Gibson, M.S., M.D.
Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Please Join in Editing This Page and Apply to be an Editor-In-Chief for this topic: There can be one or more than one Editor-In-Chief. You may also apply to be an Associate Editor-In-Chief of one of the subtopics below. Please mail us [3] to indicate your interest in serving either as an Editor-In-Chief of the entire topic or as an Associate Editor-In-Chief for a subtopic. Please be sure to attach your CV and or biographical sketch.
Overview
Heart transplantation or cardiac transplantation, is a surgical transplant procedure performed on patients with end-stage heart failure or severe coronary artery disease. The most common procedure is to take a working heart from a recently deceased organ donor (allograft) and implant it into the patient. The patient's own heart may either be removed (orthotopic procedure) or, less commonly, left in to support the donor heart (heterotopic procedure). It is also possible to take a heart from another species (xenograft), or implant a man-made artificial one, although the outcome of these two procedures has been less successful in comparison to the far more commonly performed allografts.
History
The first heart transplanted into a human occurred in 1964 at the University of Mississippi Medical Center in Jackson, Mississippi when a team led by Dr. James Hardy transplanted a chimpanzee heart into a dying patient. The heart beat 90 minutes before stopping. Dr. James Hardy had performed the first human lung transplant the previous year. [1]
The first human to human heart transplant was performed by Professor Christiaan Barnard at Groote Schuur Hospital in December 1967. The patient was a Louis Washkansky of Cape Town, South Africa, who lived for 18 days after the procedure before dying of pneumonia. The donor was Denise Darvall, who was rendered brain dead in a car accident.
The first successful United States heart transplant was done at St. Lukes hospital in Houston Texas by Denton Cooley, M. D. in June 1968. The donor was a teenage suicide victim (who had had an aortic coarctation repaired as a young child, also by Dr. Cooley) and the recipient, Mr. Thomas, had terminal severe cardiomyopathy. He survived 8 months before dying of rejection of the transplanted heart.
A series of five subsequent heart transplants was done that month by Dr. Cooley followed by a number of transplants in Houston that year before the program was canceled leaving only Norman Shumway at Stanford University at San Francisco doing heart transplants and research on the rejection phenomenon.
1970 - Recipient selection criteria standardized
1973 - Surveillance endocardial biopsy
1977 - Distant donor heart procurement
1980 - Cyclosporine A
Statistics
Reporting of transplant statistics to the Registry of the International Society for Heart and Lung Transplantation (ISHLT) is required in the US, but not other countries. According to ISHLT:
- 5000 heart transplants are performed per year worldwide
- 10-20 heart transplants per year are performed at each center
- 50-59 years is the average age of heart transplant recipients
- 10:1 is the ratio of awaiting recipients to donors
- 207 hospitals performed heart transplants in 207
- 51% of heart transplants are performed for non-ischemic cardiomyopathy and 38% are performed for ischemic heart disease [2]
Indications
In order for a patient to be recommended for a heart transplant they will generally have advanced, irreversible heart failure with a severely limited life expectancy. Other possible treatments, including medication, for their condition should have been considered or attempted prior to recommendation. Generally, the following causes of heart failure can be treated with a heart transplant:
Systolic heart failure with a left ventricular ejection fraction < 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 coronary artery bypass graft surgery (CABG) and is refractory to maximally tolerated medical therapy
Intractable life-threatening arrhythmias
- Arrhythmias which are not controlled by an implantable cardioverter-defibrillator
- Arrhythmias that are refractory or not amenable to electrophysiologic guided single or combination medical therapy
- Patients that are not a candidate for ablative therapy
Hypertrophic obstructive cardiomyopathy (HOCM)
Class IV heart failure symptoms persist despite maximal therapy, myomectomy, alcohol septal ablation, mitral valve replacement
Congenital heart disease
- Fixed pulmonary hypertension must not be present
Contraindications
Some patients are less suitable for a heart transplant, especially if they suffer from other circulatory conditions unrelated to the heart. The following conditions in a patient would increase the chances of complications occurring during the operation:
- Kidney, lung, or liver disease
- Insulin-dependent diabetes with other organ dysfunction
- Life-threatening diseases unrelated to heart failure
- Vascular disease of the neck and leg arteries.
Equitable Distribution of Donor Hearts to those Awaiting Transplantation
In order to assure that access to donor hearts is equitably distributed, the United Network for Organ Sharing (UNOS), was created. In general, patients who are on in patient parenteral inotropic agents are at highest risk of death, and are at the highest priority on the list of recipients. THe following factors are used in assigning the priority for transplantation:
- The level of acuity of the patient's condition (sicker patients are higher on the list)
- The time the patient has waited on the list (patients who have waited longer are higher on the list)
- Duration of ischemic time anticipated when a donor heart does become available (assessed in increments of 500 miles between donor and recipient hospitals)(patients who are located closer to the donor heart are higher on the list)
Some patients may be moved down the list or taken off of the list (delisted). Rarely, about 5% of patients are removed from the list because they improve with medical therapy. The prognosis of patients who have been delisted is controversial. The largest study to date of 100 patients indicates that delisted patients may have a slightly poorer long term prognosis than those patients who are transplanted. [3] While early survival was better among those patients who were delisted, survival after 30 months tended to be better among patients who were transplanted. Although data is lacking, it has been hypothesized that survival could be further improved among delisted patients to 45% at 10 years if a defibrillator or AICD was implanted.
Procedures
Pre-operative
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
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.
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).
Post-operative
The patient is taken into ICU to recover. When they wake up, they will be transferred to a special recovery unit in order to be rehabilitated. How long they remain in hospital post-transplant depends on the patient's general health, how well the new heart is working, and their ability to look after their new heart. Once the patient is released, 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. 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 injected donor's heart (in order to stop it beating, before being removed from the body) packed in ice in 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.
Immunosuppressive Therapy
A. Cyclosporine A
B. Adrenocortical steroids
C. Azathioprine
D. OKT3
E. Anti-thymocyte globulin (ATG)
Prognosis
The prognosis for heart transplant patients following the orthotopic procedure has greatly increased over the past 20 years, and as of Aug. 11, 2006, the survival rates were as follows.[5]
- 1 year: 86.1% (males), 83.9% (females)
- 3 years: 78.3% (males), 74.9% (females)
- 5 years: 71.2% (males), 66.9% (females)
As of 2006, Tony Huesman is the world's longest living heart transplant patient, having survived for 28 years with a transplanted heart. Huesman received a heart in 1978 at the age of 20 after viral pneumonia severely weakened his heart. The operation was performed at Stanford University under American heart transplant pioneer Dr. Norman Shumway, who continued to perform the operation in the U.S. after others abandoned it due to poor results. [6]
Causes of Death after Transplantation
A. Rejection
B. Infection
C. Technical problems
D. CNS events
E. Malignancy
Essentials for Heart Transplantation
Recipient Criteria
A. Terminal heart disease
B. Reasonable physiological
C. No renal or hepatic dysfunction
D. No acute infections
E. No recurrent pulmonary infections
F. Psychosocial stability
G. No alcohol, tobacco or drug abuse
Contradictions
A. Fixed pulmonary vascular resistance
B. Peripheral vascular disease
C. Acute malignancy
D. COPD of chronic bronchitis
E. Morbid obesity
F. ABO incompatibility
Donor Criteria
A. Brain death declared
B. Age <45 (special exceptions)
C. No re-existent heart disease
D. Few CAD risk factors
E. No untreated acute infections
F. No systemic malignancy
G. No cardiac trauma
H. Normal ECG
I. Normal echocardiogram
J. Negative HIV and Hepatitis screen
ACC / AHA Guidelines- Recommendations for Pacing After Cardiac Transplantation (DO NOT EDIT) [7]
| “ |
Class I1. Permanent pacing is indicated for persistent inappropriate or symptomatic bradycardia not expected to resolve and for other Class I indications for permanent pacing. (Level of Evidence: C) Class IIb1. Permanent pacing may be considered when relative bradycardia is prolonged or recurrent, which limits rehabilitation or discharge after postoperative recovery from cardiac transplantation. (Level of Evidence: C) 2. Permanent pacing may be considered for syncope after cardiac transplantation even when bradyarrhythmia has not been documented. (Level of Evidence: C) |
” |
Sources
- The ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities [7]
References
- ↑ http://www.umc.edu/hardy/
- ↑ Taylor, DO, Stehlik, J, Edwards, LB, et al. Registry of the international society for heart and lung transplantation: twenty-sixth official adult heart transplant report-2009. J Heart Lung Transplant 2009; 28:1007.
- ↑ Hoercher KJ, Nowicki ER, Blackstone EH, Singh G, Alster JM, Gonzalez-Stawinski GV, Starling RC, Young JB, Smedira NG (2008). "Prognosis of patients removed from a transplant waiting list for medical improvement: implications for organ allocation and transplantation for status 2 patients". The Journal of Thoracic and Cardiovascular Surgery. 135 (5): 1159–66. doi:10.1016/j.jtcvs.2008.01.017. PMID 18455599. Unknown parameter
|month=ignored (help) - ↑ "Bad Oeynhausen Clinic for Thorax- and Cardiovascular Surgery Announces First Successful Beating Human Heart Transplant". TransMedics. 23 February 2006. Retrieved 2007-05-14.
- ↑ Heart Transplants: Statistics The American Heart Association. Retrieved February 1, 2007.
- ↑ Heart Transplant Patient OK After 28 Yrs (September 14, 2006) CBS News. Retrieved December 29, 2006.
- ↑ 7.0 7.1 Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM III, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices). Circulation. 2008; 117: 2820–2840. PMID 18483207
Additional Resources
- Western Cape Government Website, South Africa (21 February 2005). "Chris Barnard Performs World's First Heart Transplant". Cape Gateway. Retrieved 2007-01-10.
- Department of Cardiothoracic Surgery. "Patient's Guide to Heart Transplant Surgery". University of Southern California. Retrieved 2007-01-10.
- Nancy Reid (September 22, 2005). "Heart transplant: How is it performed?". Healthwise. Retrieved 2007-01-10.
- Jeffrey Everett (10/29/2003). "Heart Transplant: Indications". AllRefer.com. Retrieved 2007-01-10. Check date values in:
|date=(help) - "Hartford Hospital Heart Transplant Program". Hartford Hospital, Connecticut, United States. Retrieved 2007-01-10.
External links
Official Heart Transplant Museum - Heart Of Cape Town
EKG Findings
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