Cardiac Transplant

Question 1

What is the first criteria you look at to determine eligibility for transplant

Answer 1

Transpulmonary gradient

Question 2

How do you calculate transpulmonary gradient?

How do you calculate Woods units?

Answer 2

TPG = mean PAP - PCWP

TPG in Woods = mean PAP - PCWP/CO

Question 3

What % of transplants have previously had LVAD?

Answer 3

up to 50%

Question 4

What are the absolute contraindications to transplant?

Answer 4

Liver disease
Pulmonary Hypertension
Malignancy - 5 years of remission
Pulmonary Disease - FEV1/FVC of less than 40-50% of predicted or FEV1 less than 50% on OMT
Consent
Systemic Disease - that limits long term survival
Infections - active AIDS is a contraindication but HIV is okay if treated or dormant
Psychosocial considerations - Drug or alcohol abuse (3 months of abstinence is required and willingness to enter a structured rehab program), sever congnitive behavioural disabilities or dementia, psychiatric condition, documented life threatening non-compliance or active smoking (3 month abstinence)

Question 5

What are the relative contraindications to transplant?

Answer 5

Age
Pulmonary Hypertension - >5 woods units
Osteoporosis - > 2 SD below normal 
Obesity >35 BMI
Diabetes - with end organ damage
GI disease - active peptic ulcer disease until treated, active diverticulitis
Technical issues - difficulties with surgery
Peripheral and cerebral vascular disease
Renal dysfunction Cr > 200
Amyloidosis
Cardiac disease

Question 6

Name 4 heart transplant techniques

Answer 6

Biatrial (Lower-Shumway) - issue is TR
Bicaval technique
Total orthotopic technique
Domino technique (heterotopic)

Question 7

What are the absolute and relative indications for VO2max in transplant?

Answer 7

relative <14 (12 if on BB)

absolute <10

Question 8

What is the sequence of anastomosis in heart transplant?

Answer 8

Usually from posterior to anterior structures

Left atrium -> IVC -> SVC -> PA -> Aorta

To reduce ischemic time
do Left atrium then Aorta and take cross clamp off
But can get coronary sinus blood during sowing of right sided anastomoses

Left atrium -> IVC -> PA - > Aorta -> cross clamp off -> SVC if you feel that IVC will be challenging with cross clamp off

Question 9

Where is the donor cardiac transplant cut?

Answer 9

IVC - cut at the confluence between the RA and IVC. To identify it, make an anterior cut on the IVC and find the pink of the RA and the white of the IVC. There is no reason to take IVC

PA - must leave 5mm cuff between the posterior commissure of the PA and the bifurcation of the PA. Sometimes there is very little distance between the two, as little as 1cm

LA - lung surgeons need cuff around pulmonary veins, make sure to leave 5mm cuff around pulmonary veins. The most critical part is leaving the right pulmonary vein cuff at least 5mm for the lung team. When cutting the left side, you cut half way between the coronary sinus and the left pulmonary veins.