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HEART TRANSPLANTATION

Dr.Ajeet Jain
(M.S. , M.Ch.(ctvs) FISC , FAPVS , FIEIC , FICC)
HOD, department of CTVS, RGSSH.
NODAL OFFICER, COVIID -19,
Rajiv Gandhi Super Speciality Hospital, Tahirpur, Delhi.

DEFINITION

Cardiac transplantation is a therapeutic procedure whereby the heart of a suitable donor is implanted into a recipient.

Despite advances in pharmacologic and device treatment of chronic heart failure, long term morbidity and mortality remain high and many patients progress to end-stage heart failure. Hence heart transplantation has become the preferred therapy for patients with end-stage heart disease.

HISTORY

  • More than 1,00,000 Heart transplants have been done world wide up to date.
  • The first human cardiac transplantation a Chimpanzee Xenograft done during 1964.
  • Christiaan Neethling Barnard was a South African cardiac surgeon who performed the first human-to-human cardiac transplant on December 3, 1967 at Groote Schuur Hospital in Cape town, south Africa to a 53 year old LOUIS WASHKANSKY a south African grocer who was dying from chronic heart disease received the transplant from Denise Darvall, a 25 year old woman who was fatally injured in a car accident. Published in ‘South African medical journal’ just after three weeks of the event. This first cardiac transplant remains the most published event in the world of medical history.
  • In India, Dr. P. Venugopal and his team performed the first successful heart transplantation on Aug 3, 1994.

Current challenges & Recent advances in Heart transplantation:-

  1. Limited Donor Supply:
  • To expand donor pool.
  • To achieve more donor by DCD(Donate after circulatory death).
  • Ex vivo-heart perfusion.
  1. Increased medical complexity such as:
  • Primary graft dysfunction.
  • Acute Rejection detection:
    • Per blood gene Expression.
    • Cell free DNA.
    • End myocardial Biopsy gene expression.
  • Sensitization:
  • Identify patients:
    • CPRA (calculated panel Reactive Antibody).
    • Compliment fixation Antibody.
  • Desensitization – BORTEZOMIB
  • Post transplantation management – ECULIZUMAB

INDICATIONS FOR HEART TRANSPLANTATION

According to ACC/AHA guidelines:

  • Refractory cardiogenic shock requiring intra-aortic balloon pump counter pulsation or left ventricular assist device (LVAD).
  • Cardiogenic shock requiring continuous intravenous inotropic therapy i.e. Dobutamine, Milrinone etc.
  • Peak VO2 < 10 ml/kg/min (VO2 max).
  • NYHA class of III/IV despite maximized medical and resynchronization therapy.
  • Recurrent life – threatning left ventricular arrythmias despite an implantable cardiac defibrillator, antiarrythmic therapy or catheter- based ablation.
  • End-Stage congenital HF with no evidence of pulmonary HTN.
  • Refractory angina without potential medical or surgical therapeutic options.

ABSOLUTE CONTRAINDICATIONS TO HEART TRANSPLANTATION

  • Systemic illness with life expectancy 2 years, including active or recent solid organ or blood malignancy.
  • AIDS with frequent opportunistic infections.
  • SLE, Sarcoidosis or amyloidosis that has multisystem involvement.
  • Irreversible renal or hepatic dysfunction in patients.
  • Significant obstructive pulmonary disease (FEV1 -1L/min).
  • Fixed pulmonary HTN;
  • PVR>5 wood units.
  • Trans pulmonary gradient > 15mmHg.
  • Age > 70 years.

RELATIVE CONTRAINDICATIONS

  • Age over 65 years.
  • Ankle-brachial index < 0.7.
  • DM with end organ damage:
    • Nephropathy
    • Neuropathy
    • Retinopathy
  • Severe Lung Diseases.

DONOR CRITERIA

  • Brain death is necessary for any cadaveric organ donation. This is defined as absent cerebral function and brain steam reflexes with apnea during hypercapnea in the absence of any CNS depression.
  • Age < 55 years.
  • Absence of significant structural abnormalities – such as LVH; Significant vascular dysfunction; congenital cardiac abnormality; CAD.
  • Adequate physiologic function of donor heart; LVEF > 45%.
  • Serologic results – Negative for HIV, Hepatitis B or C.
  • Absence of active malignancy or overwhelming infection.

EXTEND CRITERIA (MARGINAL) DONOR HEART

The increasing demand for cardiac allografts has led to accept the ECCT to reduce waiting time for transplantation and wait-list mortality.

  • Donor Age> 55 years.
  • Cocaine use.
  • Long – term alcohol abuse.
  • Significant pressor or Inotrope requirement (Dopamine or Dobutamine).
  • ECG abnormalities (left ventricular hypertrophy, regional wall abnormality).
  • Long-Standing diabetes mellitus.
  • Death by poisoning (Carbon monoxide, cyanide).
  • Prolonged ischemic time (>4 hours).
  • Malignant brain tumors.
  • Single vessel coronary artery disease.
  • Undersized organ (mismatch>30%), especially in patients with pulmonary hypertension.

RECIPIENT CRITERIA

  • Patient must be younger than 67 years of age.
  • Pt must have a diagnosis of end-stage heart disease, such as advanced cardiomyopathy, pulmonary HTN, or significant HF.
  • Pt must have a prognosis that indicates significant risk of mortality within one year if a transplant is not performed.
  • Pt may not have an active infection, a cancer diagnosis, Organ impairment Other than impairment in heart.
  • Pt must be psychologically stable.
  • Financial support.
  • Weight no more than 140% of ideal body weight.

MATCHING DONOR AND RECEIPENT

Donor recipient matching is based primarily not on HLA typing but on the:

  • Severity of illness.
  • ABO blood type.
  • Response to panel Reactive Antibody (PRA).
  • Donor weight to Recipient ratio.
  • Geographic location relative to donor.
  • Length of time at current status.

SURGICAL TRANSPLANTATION TECHNIQUES:

HEART TRANSPLANTATION
ORTHOTOPIC HETEROTOPIC
  • Recipient heart replaced with donor heart.
    • Biatrial approach
    • Bicaval approach
  • Also called as piggy back.
  • Leaving the recipient’s heart in place and connecting the donor heart to the right side of the chest.
  • It is important to carefully plan the entire operation to attempt to limit the donor ischemic time to less than 6 hours and preferably less than 4 hours.
  • Orthotopic implantation is most common that involves complete explantation of native heart.
  • Both the bicaval and biatrial techniques can be safely performed with excellent long-term outcomes in patients with end stage HF.
  • Bicaval Technique:
    • Suturing LA.
    • Superior and Inferior vena caval anastomosis.
    • Pulmonary artery and aortic anastomosis.
    • This technique preserves normal atrial morphology, sinus node function and valvular function.
  • Biatrial anastomosis Technique:
    • RA anastomosis is initiated at Superior end of atrial incision.
    • A 3-0 prolene suture is used and suture ends are carried both inferiorly and superiorly to first complete the septal anastomosis and they are joined at lateral wall of septum.

ISHLT (INTERNATIONAL SOCIETY FOR HEART AND LUNG TRANSPLANTATION)

GUIDELINES FOR POST HEART TRANSPLANTATION MONITORING

  • Post operatively 12 lead ECG monitoring.
  • Right atrium / central venous pressure monitoring.
  • Intermittent measure of cardiac output.
  • Intra operatively Transesophageal echocardiogram (TEE).
  • Invasive arterial pressure monitoring.
  • Left atrial of pulmonary of pulmonary artery wedge pressure monitoring.
  • Arterial oxygen saturation monitoring.
  • Continuous assessment of urinary output.

Long Term management

  • End myocardial Biopsy – once a week for first month and then less frequently depending on presence or absence of rejection.
  • Immunosuppressing agents, Cyclosporine levels are checked.
  • ECG is useful periodically and as an adjunct to End myocardial Biopsy.
  • Cardiac catheterization is performed annually for early detection of allograft vasculopathy.

COMPLICATIONS OF HT:

  • Coronary allograft vasculopathy (CAV).
  • Infections – common in organ transplant Recipients.
  • Renal dysfunction- Calcineurin inhibitors induced Nephrotoxicity.
  • Organ rejection.
  • Hypertension -75% of transplant recipients treated with cyclosporine or corticosteroids eventually develop HTN.
  • Malignancy: cutaneous (Squamous cell CA), PTLD(Post Transplantation lymphoproliferative disorder).

RESULTS:

Of all the potential problems are considered, the results of transplantation are remarkably good. The one year mortality rate is 80% overall, 5 years survival in patients with any form of HF < 50%. After heart transplant, 5 years survival averages about 50% - 60%; 1-year survival about 85%-90%. However post-operative care is must and most important.

  • Adopting healthy life style including a heart- healthy diet, regular exercise and stress management.
  • Taking all of medicines correctly and on time.
  • Monitoring for infection/Rejection/other complications.
  • Attend transplant clinic regularly.
*Picture Stat Reference: https://link.springer.com/article/10.1007%2Fs12055-020-00987-0