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Flashcards in Cardiac transplantation Deck (56):
1

What agents can you use for vasodilator challenge for assessing PVR before transplant

Milrinone
Nitric oxide
Nipride
Prostaglandin
Oxygen

2

What is the half-life for survival post OHT

10 years is median survival

J Heart Lung transplant 2010; Oct 29 (10) 1083-1141

3

what are 2001 CCS indications for cardiac transplant

Adavanced function class NHYA III-IV
Poor 1year survival (peak Vo2 < 15 mm/kg/min
Failure to respond to maximal medical therapy
absence of alternative or conventional surgical options
absence of contraindications
potential to undergo rehabilitation post transplant

4

What are psychosocial issues for transplant

active smoking (3 months stop)
Drug or ETHO (3 months)
Unstable psychiatric conditions
Non-compliance

5

What body weight contraindications for transplant

Morbid obesity > 140% ideal body weight
Marked Cachexia < 60% of ideal body weight
Osteoporisis-patients with bone mineral density of > 2 SD below normal or at high risk

6

What are pulmonary pressure indications for not performing transplant

Transpulmonary gradient of > 15
Pulmonary vascular resitanace of > 4
Pulmonary vascular resistance index of > 6
Systolic pulmonary artery pressure > 50 mmhg

7

What is difference between bi-atrial and b-caval transplant

No difference in mortality
Bicaval---improved exercise tolerance, less need for PPM, less TR, few tachy arrhytmias, slighlty better hemodynamics
complication of bicaval is SVC syndrome

8

What are risk factors for possible increased mortality in transplant

Older Donors (> 50)
Ischemic times; over 4 hours
Donor heart dysfunction: regional wall motion abnormalities

9

Risk factor for mortality with cardiac transplant

A. Previous cardiac transplant
B. Ventricular support/ Mechanical support (VAD) (controversial)
D. Recipient < 5 years of age
E. Recipient > 60 years of age
F. Donor > 40 years of age(controversial)
G. Donor female (some data about gender mismatch outcomes)
H. Ischemic time >3.5 hours (controversial)

10

What pt will wait the longest for a heart transplant

A type O blood group (can only receive from O)
also a big pt (the size between donor and recipient should be matched at 0.8 to 1.2).

11

What is the Canadian transplant Status code

Status 4: mechanically assisted (IABP, VAD, ventilation) and in ICU are highest priority
Status 3: High does single or multiple inotropes; pts who have a VAD but are no in ICU
Status 2 Patients requiring hospitalisation
Status 1: pts a home

12

Why use induction therapy

reduce steroid use and nephrotixicity associated with early and high dose calcineurin inhibitor while minimizing episdoes of rejection

involves short-term use immediately post transplant (day 0 -7) of an intensive anti-T cell regimen.

They are associated with increased risk of infection because the polyclonal antibodies also effect B-cells.

13

List induction therapy agents

Polyclonal ---OKT3; ATG; ATGAM; ALG

OKT3- associated with increased infections and post transplant lymphoproliferative disorder

Monoclonal--Basilizimab and Davlizumab--specially bind the IL-2 reception

14

Azathioprine (Imuran)

interferes normal purine pathways, inhibiting both DNA and RNA synthesis. Both B and T lymphocyte proliferation is suppressed and secondary antibody synthesis is reduced.

15

What medication should not be mixed with Azathioprine (Immuran)

Allopurinol

16

Mycopehnolate Mofetial (Cell Cept)

Purine analogie anitmetabolite that is much more potent and selective then AZA. Both B and T cells are inhibit, leading to a reduction in cell-mediated and humoral immunity.

effective management in acute rejection

has shown increased survival over AZA

17

Corticosteroids

Primary effect on T lymphocytes
release of cytokines is reduced
IL-2 production is directly and indirectly inhibited
an effect on B-lymphocytes and reducing antibody production

18

Rapacycin (sirolimus)

ia macrolide antibiotic structurally related to tacrolimus.
Blocking downstream effects of IL-2 and CD28 signaling
Works syndergistic with CyA and MMF

This drug is used only for refractory acute rejection

19

What are rates of rejection

majority will have at least one rejection in the first year post-transplant
usually detected on routine surveillance

20

What is the biopsy protocol post transplant

EMBx performed between day 10 to 14
Typically weeks for 4 weeks
After 1st year they do an annual routine until 5 years post-transplant

21

New rejection classification

Cellular
Grade 0R: none
Grade 1R: 1 focus of interstitial and/or perivascular infiltrate with myocyte damage
Grade 2R: >2 ...
Grade 3R: diffuse ... With edema, hemorrhage, vasculitis

Humoral
AMR 0: none
AMR 1: presence of histologic feature and immunofluorescence feature ( CD68)

Histologic features are endothelial swelling and immunoglobulins and complement deposition

22

What is treatment of CMV

Ganciclovir 5mg/kg BID for 14 days followed by 6 mg/kg daily x 5 days per week until day 28

23

What are best ways to assess for Transplant coronary artery disease

intravascular ultrasound
Coronary angiography
Screening can involve dobutamine stress echo or myocardial perfusion imaging

remember that TCAD is independent of cholesterol levels
Some benefit of Diltiazem in decreased TCAD

24

What is Post-transplant Lymphoproliferative disorder (PTLD)

refers to all clinical syndromes association with lymphoproliferative post-transplant from mono to malignancies
Ebstein-Bar virus
Primary EBV infection conveys highest risk

25

More details on PTLD


1) Frequency: Most common tumor in cyclosporine-based immunosuppression
2) Timing: 12-18 months post transplant/also think Peds transplants
3) Location: Intraabdominal most common
4) Etiology: B cell origin induced by Epstein-Barr virus
5) Treatment: Reduce immunosuppression
6) Acyclovir/ Chemotherapy/radiation

26

What are common skin malignancies

Squamous cell carcinoma
Basal Cell Carcinoman
Kaposi's sarcoma
Cervical
Vulvar

27

What is UNOs classification

Status 1A. Patients that are hospitalized with either IV inotropes, heart assist devices, mechanical ventilation, or have a life expectancy of less than 1 week.
Status 1B. Patients that are not hospitalized but have IV inotropes or a heart assist device.
Status 2. All other active patients, usually seen by a cardiologist every month, with a right-sided heart catheterization performed every 3 months”

Excerpt From: Carlos M. Mery & Joseph W. Turek. “TSRA Review of Cardiothoracic Surgery.” Feedbooks, 2011. iBooks.
This material may be protected by copyright.

28

List diagnosis for Heart-Lung transplant

Congenital heart disease
Idiopathic pulmonary artery HTN
Cystic fibrosis
COPD/Fibrosis
Acquired heart disease
Idiopathic pulmonary fibrosis
AAT deficiency emphysema
Sarcoidosis
Re-transplant

29

Indication for heart transplant (pathology)

Systolic heart failure
Ischemic
Dilated

Valvular
Systolic heart failure
Ischemic
Dilated
Hypertensive
Not amyloid, HIV, sarcoma

Intractable ischemia or arrhythmia
Hypertrophic CMP
Not responding to other treatment

CHD without Pulmonary hypertension

Cardiac tumour without metastasis

30

PVR vs TPG

PVR is depend on cardiac output and is calculated by the following equation

MPAP - PCWP /CO

TPG independent of CO

TPG mmHg = PAP mmHg - PCWP mmHg

31

What is adequate decline when testing reversibility of pulmonary resistance

2.5 Woods or 50% while maintaining an adequate systemic systolic pressure

32

Hormonal management of cardiac donor

If LVEF < 45

Vasopressin 1u bolus
T3 4mcg bolus
Methylprednisolone 15 mg/kg
Insulin 1u/hr and titrate

Preferential use of dobu or dopa

Monitor with a swan ganz

33

Preservation solution for cardiac donor

Intracellular ( low sodium, reduce cellular edema)

Wisconsin
Bretschneider

Extracellular ( low potassium, reduce hyperkalemic cell damage and vascular resistance)

St-Thomas
Clesior

34

Meds with no effect on heart rate in the transplant recipient

Atropine
Digoxin

35

Complications vs timing of transplant

< 30 d: primary graft dysfunction, MOF, infection
30d to 1yr: infection, PGD, rejection
>1yr: CAV, cancer

36

NYHA and survival at 1 yr

I : > 95%
II: 80-90%
III: 55-65%
IV: 5-15%

37

Rates of malignancy post transplant

A. Incidence 1-2 %/year
B. Cutaneous Malignancy
1) Squamous cell carcinoma
2) Basal cell carcinoma

38

How much does each 1 Wood unit increase the mortality (especially in 1st year)

15%

39

What agents can be used for assessing pulmonary hypertension reversibility

Nitroprusside
Adenosine
Prostaglandin E1
Milrinone
Inhaled nitric oxide
prostacyclin (Aerosolized Iloprost)

40

Is transplant contraindicated in Amyloid? or DM? in extreme BMI?

Amyloid-controversial. The amyloid deposits will return and 1 year survival reduced

Contraindicated in DM if there is significant end-organ damage

if BMI < 20 or > 35 the results are poor

41

What effect to Calcium channel blockers have on transplant

Accentuated slowing of SA and AV nodes and may alter cyclosporine levels

42

What is leading cause of mortality in transplant population? What is most common bacterial agent? What is most common viral? What fungus is most universally fatal? What is rate of P.Carinii?

CMV (greatest risk is in the first 3 months)

Gram-negative (E.Coli and Pseudomonas)

Aspergillus has highest mortality

P.Carinii--occurs in 1 to 10 % and needs a BAL for diasnosis.

43

Risk factors for developing cardiac allograft vasculopathy

1. acute rejection
2. Anti-HLA antibodies
3. donor age, HTN, Hyperlipidemia, and preexisting DM (all in the donor)
4. The side effects of immunosuppresion agent--steroids/calcineurin inhibitor/--
5. CMV infection, new on-set diabetes- nephrotoxicity

44

What is pathophysiology of CAD

subclinical endothelial injury in the coronary artery allograft---immunological processes involving cytokines, inflammatory mediators, complement activation, and leukocyte adhesion molecules---these changes produce inflammation and thrombosis.

may begin several weeks post transplant.

Silent ischemia, ventricular arrhythmias, congestive heart failure, sudden death are presenting features.

45

What are rates of increased malignancy post transplant

Increased malignancy of 4 to 18%

which is 100 fold greater then general population

lymphoproliferative disorders and carcinoma of the skin are the most common

Risks are higher when monoclonal and polyclonal antibody therapy are added.

46

What is pathophysiology of lymphoproliferative disorders

Loss of T-Lymphocyte control over Epstein-Barr virus stimulated B-Lymphocyte proliferation is primary mechanism

47

How often does retransplantation occur and what are indications

Fewer then 3%

early graft failure, allograft coronary artery disease, and refractory acute rejection

48

What 4 factors are indicated for LVAD based on clinical trials

1. Class 4 Heart failure and failed OMT for at least 60 to 90 days
2. Left ventricular ejection fraction of < 25%
3. Functional limitation with a peak oxygen consumptions of < 12 ml/kg/min or
4. Continued need for intravenous inotropic therapy owing to symptomatic hypotension, decreasing renal funtion, or worsening pulmonary congestion
5. Appropriate body sise (BSA > 1.5)

1/3 of BTT pts are lose transplant candiancy
17% of DT receive transplant

49

What is hyper-acute rejection

Most often when a major blood group incompatiability occurs between donor and recipient,

50

Most common indication for OHT

idiopathic cardiomyopathy
end-stage ischemic heart disease
congenital
valvular heart disease

51

What is Hyperacute rejection

occurs when major blood group incompatibility exists between donor and recipient.

Acute rejection is unusually earlier than 2 to 4 weeks

52

What is acute rejection characterized by

inflammatory state of cell infiltrate, with or without damage to cardiac myocyctes

53

Since 2004 the classification of acute rejection has been changed to what classification

Grade0R--no rejection
Grade 1R-mild rejection
Grade 2R-moderate rejection
Grade 3R-severe rejection

54

What is mechanism of hyperacute rejection

preexisting IgM alloantibodies

virtually eliminated because of blood checks

55

Describe Cell-Mediated rejection

Primarily mediated by CD4 T cells

56

Contraindications to cardiac transplant

Irreversible PVR > 4 woods units
Transpulmonary gradient > 15 mmHg
Create > 200 (irreversible)
Diabetic with end organ damage
Recent malignancy (< 5 years)
severe PVD
Active infection
psychosocial issues
Marked obestity (> 140% ideal body weight
Severe Osteoporsis

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