Heart and Lung Transplant

Question 1

What is the primary indication for a heart or lung transplant?

Answer 1

progressive terminal cardiopulmonary disease with limited life expectancy

Question 2

Majority of heart transplants are due to….?

Answer 2

CAD, which leads to myocardial damage and cardiomyopathy

Question 3

Majority of lung transplants are due to….?

Answer 3

Emphysema
-idiopathic pulmonary fibrosis is the 2nd more common diagnosis

Question 4

Indications for heart transplant

Answer 4

End stage heart disease: hemodynamic compromise, CAD, cardiomyopathy, refractory cardiogenic shock
 NYHA Class III-IV despite maximal therapy
 Poor quality of life: intractable angina, refractory arrhythmia, Vo2 max<10mL/kg/min
 Other: congenital heart disease, cardiac tumors

Question 5

Indications for lung transplant

Answer 5

 COPD: BODE index 7-10 with any of the following – hx of acute hypercapnia, pulmonary HTN or cor pulmonale, FEV1 of 20% and DLCO of 20%
 Idiopathic pulmonary fibrosis and evidence of any of the
following: DLCO of 39%, 10 decrease in FVC, <88% 02 saturation during 6MWT
 Cystic Fibrosis: FEV1 of 30% and any of the following –
increasing 02 requirements, hypercapnia, pulmonary HTN
 Idiopathic pulmonary arterial hypertension
 Sarcoidosis – with hypoxemia at rest, pulmonary H

Question 6

Absolute contraindications for heart tranplant

Answer 6

 Systemic illness with life
expectancy less than 2 years
 AIDS
 Lupus
 Significant obstructive
pulmonary disease
 Fixed pulmonary
hypertension

Question 7

Absolute contraindications for lung transplant

Answer 7

 Active malignancy within the
past 2 years
 Continued abuse of alcohol,
tobacco or narcotics
 HIV
 Significant chest wall or spinal
deformity
 Hepatitis B antigen positivity
 Hepatitis C with liver disease
 Untreatable psychiatric
condition
 Absence of support system

Question 8

Who maintains the list of awaiting transplant candidates?

Answer 8

UNOS- United Network of Organ Sharing
-Candidates on the waiting list are matched with the donor’s characteristics and a computer rank is given to them

Question 9

Which factors does the computer rank consider?

Answer 9

-age
-tissue match
-blood type
-length of time on waiting list
-immune status and distance between recipient and donor

Question 10

What is the Lung Allocation Scale (LAS)?

Answer 10

address the risk of death with and without transplantation and other factors that affect survival
-pts are assigned a score from 0-100 and is reassessed every 6 months
-higher scores receive higher priority for a lung

Question 11

T/F Patients may be referred to cardiac or pulmonary rehab while waiting for a transplant

Answer 11

True- can address chest wall ROM, balance, strength, and gait mobility deficits

Question 12

T/F some patients may need to be hospitalization until transplant

Answer 12

True- Respiratory status of patients can decline and may result in patient’s needing bridging techniques as they wait for a lung transplant – this can include but is not limited to mechanical ventilation

Question 13

What is an LVAD?

Answer 13

an electrically powered, implantable device that provides permanent support of the systemic circulation in those whom a suitable donor has not been found

Question 14

What are alternatives for those with end-stage pulmonary disease who do not qualify for transplant?

Answer 14

Lung volume reduction surgery: reduction pneumoplasty or bilateral pneumonectomy

Question 15

What are alternatives who do not qualify for a heart transplant?

Answer 15

Left, right, biventricular assist devices may be used

Question 16

Allocation times for different transplants

Answer 16

-Lung: 6 hrs
-Heart: 6 hrs
-Liver: 24 hrs
-Pancreas: 24 hrs
-Kidney: 72 hrs

Question 17

What are the 4 heart transplant techniques?

Answer 17

1. Heterotopic
2. Total transplantation
3. Biatrial
4. Bicaval technique

Question 18

What is a heterotopic heart transplant?

Answer 18

Used if there is a mismatched size between the recipient and donor- the native heart is NOT removed
-the donor heart is connected to the patient’s native heart by both R atriums and L atriums
-ascending aortas are connected as are the pulmonary arteries

Question 19

What is a total transplantation heart transplant?

Answer 19

A complete excision of the recipients atria and complete atrioventricular transplantation
-not frequently used

Question 20

What is a biatrial heart transplant?

Answer 20

An orthotopic heart transplant that leaves the recipient’s SA node intact
-where the donor’s SA node is denervated and operates independently of the recipients

Question 21

What is a bicaval heart transplant?

Answer 21

Separate caval anastomoses are sewn which is different than the biatrial technique where donor and recipient atrial cuffs are sewn together
-more frequently used

Question 22

T/F lungs are removed from the donor in 2 separate units

Answer 22

False- they are removed as 1 unit and then divided into R and L for implantation
-the least functional lung is transplanted first and the remaining contralateral lung is ventilated
-by transplanting one lung at a time, the time needed for cardiopulmonary bypass is decreased

Question 23

What are the most common procedures used for lung transplantation?

Answer 23

-mainstem bronchi anastomoses with bilateral thoracotomies
-transsternal bilateral thoracotomy

Question 24

which meds are given post-transplant?

Answer 24

The majority of meds are immunosuppressive agents- necessary to prevent rejection of the donor organ by reducing the normal immune system’s response to foreign tissue

Question 25

What are the 3 stages of immunosuppression?

Answer 25

1. Introduction: strong dose of immunosuppressants at time of transplant
   -thought to reduce acute rejection, but not used everywhere b/c of increased risk of malignancy and infection
2. Maintenance: some meds are continued throughout life
3. Treatment of acute rejection: treated with strong dose of immunosuppressants

Question 26

Risks of transplants

Answer 26

-rejection
-graft vs host disease
-infection
-cancer
-poor wound healing
-recurrence of original disease
-OP
-steroid-induced myopathies
-avascular necrosis

Question 27

Types of Rejection:

Answer 27

1. Hyperacute Rejection: second to minutes after transplant- organ death inevitable**
2. Acute Rejection: days to years after transplant- sudden onset of symptoms and usually reversible**
3. Chronic Rejection: months to years after transplant- slow, progressive organ failure

Question 28

What is graft vs host disease?

Answer 28

When T-cells of the donor recognize the recipient as foreign
-inflammatory response
-recipient tissue damage
-fatal if untreated- increase immunosuppression use

Question 29

Rehab interventions following an acute heart transplant

Answer 29

-optimize pulmonary hygiene and chest wall mechanics
-improve strength and ROM of the UEs and thoracic region
-improve exercise tolerance through ADLs and exercising at low to moderate intensity
-begin exercises in supine and progress to sitting an standing
-patient education

Question 30

S/S of acute rejection following a heart transplant

Answer 30

 Low grade fever
 Increase in resting BP
 Hypotension with activity
 Myalgia
 Fatigue
 Decreased exercise tolerance
 Ventricular dysrhythmias
 Dyspnea
 Weight gain due to water retention
 Decreased urine output

Question 31

What is the most fragile of transplanted organs?

Answer 31

Lungs- more susceptible to damage
-excessive fluid administration
-aspiration
-ventilator-assisted pneumonia