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Flashcards in mechanical assist device # 2 Deck (24):
1

Relative VAD contraindications

Age > 70
Congenital heart disease
chronic renal failure
symptomatic cerebrovascular disease
COPD
Blood/bleeding disorders
bacterial endocarditis
malignancy or other disease causing an expected survival < 2 years
any contraindication to transplant

2

List possible VAD candidates

Transplant candidates
Corrected metabolic abnormalities (temp, pH, and electrolytes)
Good Neurological function
absence on infection
absence of coagulopathy or GI bleed
absence of signficant lung disease

3

What 3 lesions do you need to fix when implanting a VAD

PFO--closed to prevent R-L shunting and cyanosis

Mitral stenosis---might need to do a valvotomy to improve LVAD inflow. If MVR use a bioprosthesis

Aortic insufficiency/either replace or oversew. Mechanical valve has to be replaced or oversewn.

4

List absolute contraindications to cardiac transplant

Pulmonary hypertension
Transpulmonayr gradient > 15mmHg
systolic pulmonary artery pressure > 50
Pulmonary vascular resistance > 4
Pulmonary vascular resistance index > 4
Renal dysfunction
Active infection
DM with end order dysfunction

5

What are characteristics of brain death

Absence of Brain stem reflexes
Cough +/- pharyngeal reflexes
Corneal reflexes
Occulocephalic reflex (Doll's eyes)
Occulovestibular reflex
Apnea test for minimum of 8mins showing no resp movements and pco2 60
Absence of response to pain
Ensure no metabolic disturbances, pharmacoogic agents, and hypothermia
Clinical evidence of CNS catastrophe compatible with brain death

6

What are advantages of Bicaval anastomosis in transplant

decreased incidence of atrial arrhythmias and conduction
decreased incidence of MR and TR
improved preservation of atrial geometry
decreased dependence on diuretics
decreased post operative RV failure
decreased length of stay
better 1 year survival

7

What is CMV

Member of herpes virus family
Can be a new infection or a reactivation of latent infection

8

What are effects of CMV infection

It has both direct and indirect effects on recipient resulting in increased morbidity and mortality

Direct
Heptatitis
gastroenteritis
colitis
Pneumonia
Indirect
Allograft injury-lead to acute rejection and cardiac allograft vasculpathy
PTLD

9

What are effects of CMV infection

It has both direct and indirect effects on recipient resulting in increased morbidity and mortality

Direct
Heptatitis
gastroenteritis
colitis
Pneumonia
Indirect
Allograft injury-lead to acute rejection and cardiac allograft vasculpathy
PTLD

10

What is treatment for CMV prevention and active infection

If pt seropositive then treat with gancyclovir for about 30 days

If pt seronegative pts do no benefit from treatment but some people still give it

If active infection then 2-4 weeks of gancyclovir + hyperimmune globulin

11

Indication for LVAD as bridge to transplant

Potential transplant candidate + absence of major contraindications (Sepsis or Columbia score > 5).
acute, failure of maximal medical therapy (IABO + inotropes)
Cardiogenic shock
post-cariotomy
post MI
myocarditis
peripartum cardiomyopathy
Chronic
acute decompensated heart failure
chronic heart failure
intractable ventricular arrhythmias despite maximal medical therapy

12

4 indications for LVAD as bridge to transplant

Indications
patient is a transplant candidate
CI < 2.0
u/o < 20 ml/hr
PCWP > 20 mmHG
Systolic BP < 80 mmHg

13

List contraindications to LVAD

sepsis
anuria
CVP < 16
Revised Columbia score > 5 (mortality 47% if score > 5)

14

What is Columbia scoring of risk for LVAD insertion

Ventilated ---4 points
Redo surgery --- 2
Lrevious LVAD --2 points
CVP > 16 1
PT > 16 seconds

15

Absolute contraindications to accepting a donor heart

Viral infection: HIV, HTVL, Hep B, systemic viral illness (measles, adenovirus, rabies, enterovirus
Active malignancy or recent malignancy (excluding supretentorial lesions)
Prior MI
Intractable or recurrent ventricular arrhythmias
Significant structural heart disease
myocardial contusions
valvular heart disease
severe LVH
Coronary artery disease

16

What is mechanism of FK506

This is TACROLMIS!!!

binds specifically and competitively to and inhibits Calcineurin

This inhibits transciption and production of IL-2

Inhibits lymphocytem proliferation and activation (T-helper subsets)

17

What is actions of Azathioprine (Imuran)

Purine analogue (anti-metabolite)

reduction in purine intracellular purine synthesis
inhibit T and B cell proliferation (reduction in number of circulating T and B cells)
Decreased immunoglobulin and Il-2 production

18

What is action of Steroids

Steroids do basically everything

Slow reduction in immunoglobulin production
Inhibit proinflammatory pathways
have a major role in cytokine production (stop it!)

19

Two drugs used in induction therapy

Anit-thymocyte globulin
binds to lyphocytes resulting to cytolysis or oposinization
decreases circulating T-Cells

OKT3
This is mono-clonal antibody that binds and modulates the CD3 receptor on cytotoxic T lymphocytes

20

What is technique for Heterotopic heart transplant

Donor IVC and RPVs ligated

Common pulmonary valve orifice create with donoe left pulmonary vein orifice to recipient left atrium, donor SCV to to recipient LA end to side of aortic to aortic anastomosis

end to side anastomsis joining the pulmonary arteries of donor and recipient

21

Why would a pt develop tremor and a low blood count post transplant

Calcineurin inhibitor can really cause tremor

Azathioprine causes the low white blood cell count

22

What are post transplant biopsy factors

density and pattern of lymphocyte accumulation
number of focal infiltrates (one or more)
presence or absence of myocyte necrosis
presence of hemorrhage and cellular edema

For diagnosis of acute rejection look for IgG or complement (CD4)

23

What are indications for LVAD

EF < 25%
NHYA IV on OMT
Inotrope dependence
peak oxygen < 14 ml/kg/min
possible already on IABP

24

Name 6 complications of VAD implantation

Perioperative bleeding (25-30% major bleeding)
Infection
Thormboembolism
Mechanical failure
Right heart failure
Danger of diastolic vacuum
Multi-organ failure

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