transplants

Question 1

Perfusion is involved in 3 types of transplants:

Answer 1

 Heart Transplants  Lung Transplants  Liver Transplants

 Can be performed individually or in combination  Often along with a kidney

Question 2

1905 – Carrel and Guthrie

Answer 2

 Described first heterotopic transplant of a donor heart
into the neck of a dog
 Not a functional model, functioned together with the recipient’s heart
 Heart was not capable of supporting circulation Lasted 2 hours before the chambers clotted.
 Created innovative surgical technique for vascular
anastomoses.
 Carrel won the Nobel Prize in Medicine and Physiology in 1912 for his work in this area.

Question 3

1933 – Mann, et al. at Mayo Clinic

Answer 3

 Heterotopic transplant with circulatory unloading of the
RV  Working model
 Lasted 4 days
 Observed – failure of the transplanted heart was not always caused by faulty surgical technique, but to “some biologic factor which is probably identical to that which prevents survival of other homotransplanted tissues and organs”
 Described acute allograft rejection

Question 4

1960 – Lower and Shumway

Answer 4

Orthotopic heart transplant in dogs with CPB and topical
hypothermia for donor heart preservation  Survived 6-21 days  Died of rejection
 1960s – Pharmacologic immunosuppression introduced.
Not long after – First clinical transplantation occurred  Kidney

Question 5

1967

Answer 5

First human heart transplant was performed in South Africa

 Followed shortly by Shumway and colleagues at Stanford in 1968.

Question 6

1970s.

Answer 6

Most centers discontinued doing transplants in the

Question 7

1980s

Answer 7

cyclosporine-based immunosuppression introduced

 Interest in transplantation re-emerged.

Question 8

Patient Selection

Answer 8

Patients have to be in end stage CHF
 NYHA function class III or IV
 Symptomatic refractory to management with medications, electrophysiology devices (pacemakers/AICD) and surgical intervention.

Question 9

patients for transplants have to have EF <

Answer 9

35%

Question 10

patients that have cardiogenic shock like _________ may benefit from a transplant

Answer 10

 Acute MI
 Acute Myocarditis  Ischemic heart disease
 Must be able to benefit from a transplant

Question 11

Contraindications advanced age

Answer 11

Should be less than 65 years old  Can be done in older patients  Physiologic age is a better indicator than chronologic age.

Question 12

Contraindications Irreversible pulmonary hypertension

Answer 12

 Pulmonary htn is a complication of CHF with elevated LVEDP.  Can create irreversible changes to pulmonary vasculature  Could cause RV failure in new organ
 PA systolic above 50-60mmHg is not good!  Give inhaled nitric oxide to prevent pulmonary htn.

Question 13

Contraindications

 Active Infection and malignancy

Answer 13

Infections are exacerbated by immunosuppression required

after transplantation.  Need to be fever free for 72 hours  Normal white cell count  Negative blood cultures

Question 14

Contraindications Hepatitis B, C, HIV

Answer 14

not usually done  HIV is becoming more acceptable to transplant due to
improvement in drug therapy.

Question 15

contraindications Non-melanoma cutaneous cancers

Answer 15

primary cardiac tumors restricted to the heart, low grade prostate cancers
 Ok to transplant

Question 16

contraindications obesity

Answer 16

 Impacts infection rates, wound healing, and have an increased incidence of acute rejection.
 BMI less than 30 kg/m2

Question 17

contraidications

Answer 17

Diabetes  Relative contraindication  Control of blood sugars on steroids and immunosuppressant’s  Wound healing

Question 18

relative contraindications

Answer 18

Pulmonary Fibrosis, Emphysema, Hepatic and renal dysfunction, Cerebral vascular disease, Peripheral vascular disease

Question 19

Contraindications

 Psychosocial

Answer 19

 Substance abuse (tobacco, alcohol)  Compliance with medications  Frequency of social support

Question 20

Organ Matching

Answer 20

 ABO Blood Compatibility
 Overall body size Match must be within 20% of body weight
 HLA Cross match  Some patients are sensitized to antigens due to pregnancy,
prior transplant, or blood transfusion.  Priority on UNOS Registry  Geographic distance from donor

Question 21

Organ Matching

 Waiting List Criteria

Answer 21

Status code and time within the status code

 Highest medical urgency and lowest short term survival are assigned higher codes.

Question 22

Organ matching how it works

Answer 22

 Offered to local status 1 patients first, Status 1A before
Status 1B.
 No match? Offered to Status 1 patients within 500 mile radius.
 No match? Offered to Status 2 local patients.  Repeat at 1000 mile radius, and 1500 mile radius.

Question 23

transplant technique

Answer 23

Go out for procurement  Donor heart is arrested with a cardioplegia/ preservation
solution.  Atria are transected at the midatrial level
 Leave multiple pulmonary venous connections to the LA intact.  Transect the aorta and PA just above the semilunar valves  Heart is cooled topically.
 Ischemic time – 3-4 hours!! (can do up to 5-6 hours – not ideal!!)

Question 24

Technique

 Recipient: bi atrial technique

Answer 24

Re-anastomosis of midatrial level
 Start at atrial septum
 Generous “cuff” of donor RA, so SA node will be included in transplant
 Great vessels connected above the Semilunar valves.

Question 25

Recently, bi-atrial technique has been modified

Answer 25

Leave donor atria in tact and make the anastomosis at the SVC and IVC and Pulmonary Veins  Called Bicaval technique

Question 26

bicaval technique advantages

Answer 26

Notice less distortion of the aortic valve  Improved atrial and ventricular function  Less AI  Less arrhythmias/ heart block.

Question 27

Post operative course

Answer 27

Same as a normal cardiac case  Patient will be on immunosuppression drugs  Will require pacing for a few days  Takes 2-3 days for the SA node to come back and “reset

Question 28

Physiology of Transplanted Heart

Answer 28

Completely denervated  Faster resting heart rate (95-100 beats per min)  Intrinsic rate of SA node  No parasympathetic down regulation  Slower to increase HR in response to exercise  Slower to recover after exercise

Question 29

transplanted heart response to injury

Answer 29

No angina with ischemia  Will have silent MIs. Will present with CHF, Silent MI or Sudden death.  Don’t respond to drugs that work via the parasympathetic pathway.

Question 30

donor heart iscemic time

Answer 30

Write down donor cross clamp time. This is the start of the ischemic period of the donor organ. to cross clamp off after sutures or hot shot

Question 31

type of incision for heart transplant

Answer 31

median sternotomy. if its a redo you will go fem-fem

Question 32

drift or cool to _____ when transplanting

Answer 32

32 C and cross clamp immediately

Question 33

cardioplegia during transplant

Answer 33

not usually given

Question 34

after sutures are complete some institutions will give

Answer 34

“hot shot” type dose of “cardioplegia”. Use Glutamate Aspartate Solution. Full of nutrients for that ischemic heart. Other places don’t.

Question 35

after hot shot is in or suture are done

Answer 35

Cross Clamp off  Pacing wires placed  Fill up heart  Wean from CPB.  Close

Question 36

First beating heart transplant

Answer 36

May 2007

Question 37

system that kept first beating heart alive

Answer 37

Maintained at normal body temperature and hooked up to | the Transmedics Organ Care System.

Question 38

Transmedics Organ Care System advantages

Answer 38

Beats with warm, oxygenated blood inside a sterile box  Can monitor parameters of the heart and blood.  Prolongs time between removal of the heart and transplantation.  Decreases injury while ischemic.  Can allow for the right patient to get the right organ, despite distance.

Question 39

irst human lung transplant

Answer 39

was done over 35 years ago at the University of Mississippi Patient with severe emphysema and carcinoma of L. Bronchus  Died 18 days later of renal failure

Question 40

First heart-lung transplant

Answer 40

1986 Stanford

Question 41

first single lung transplant

Answer 41

1986 toronto

Question 42

amount of lung transplants annually

Answer 42

1000

Question 43

wait time for a single and double lung transplant

Answer 43

24,36

Question 44

Indications for a lung transplant

Answer 44

Irreversible, progressively disabling, end-stage pulmonary disease  Usually life expectancy is less than 18 months  Oxygen dependent  Exercise intolerance  Less than 65 years old  Poor quality of life.

Question 45

lung transplant Patient is evaluated in the following areas:

Answer 45

 History |  Respiratory exam  Past medical history  Family history  Psychosocial and cultural history

Question 46

Things affecting eligibility lung transplant

Answer 46

``` Osteoporosis  Musculoskeletal disease  Use of corticosteroids (>20mg/day)  Malnutrition  130% ideal body weight  Substance abuse/ addiction  Smoking within 4 months of activation on the transplant list  Psychosocial problems – high risk of poor outcome  Mechanical ventilation  Colonization of fungi  Previous thoracotomy, sternotomy, scarring, etc. ```

Question 47

Types of Transplants lung

Answer 47

Single Lung Transplant : Right, Left  Double lung transplant : En Bloc, Bilateral sequential  Heart-lung block  Ex-Vivo Lung Transplant

Question 48

reasons for single lung transplant

Answer 48

 COPD/ Emphysema  Idiopathic Interstitial Pulmonary Fibrosis  Sarcoidosis  Eosinophilic Granuloma  Lymphangiolyomyomatosis  Primary Pulmonary Hypertension  Eisenmengers Syndrome with cardiac repair

Question 49

which side is easier for single lung transplant

Answer 49

Left side is easier

Question 50

is cpb necessary for single lung

Answer 50

No CPB is necessary – usually  Depends on patient’s tolerance to unilateral support during cross clamp.

Question 51

incision type for single lung

Answer 51

Posterolateral thoracotomy through bed of excised 5th rib.

Question 52

how to asses stability of patient for single lung transplant

Answer 52

Main PA is encircled and temporarily clamped  Assess the impact on hemodynamic stability and gas exchange  If not tolerated, femoral cannulation is used, and patient placed on CPB

Question 53

cooling for single lung

Answer 53

stay warm

Question 54

single native lung is excised then ...

Answer 54

Left Atrium is clamped  Pulmonary veins are attached to LA Cuff.  PA is anastomosed  End to end anastomosis of the donor and recipient bronchus  Atrial clamp is remove

Question 55

reasons for Bilateral Sequential Double Lung

Answer 55

 Cystic Fibrosis  Bronchiectasis  Emphysema  Primary Pulmonary Hypertension  Eisenmenger’s Syndrome with cardiac repair

Question 56

Double lung transplant – gives patients

Answer 56

a better pulmonary reserve

Question 57

Double Lung Transplant |  Used to be done

Answer 57

en bloc where each lung was implanted separately through a pleural-pericardial window while on CPB.

Question 58

en bloc utilizes

Answer 58

Clamshell incision  BIG PAIN from a perfusion standpoint!!

Question 59

Now, common to do

Answer 59

bilateral sequential.  Like 2 single lung transplants.  Ventilate the native lung, while the first goes in. Then ventilate the new lung while the second goes in.

Question 60

Ex Vivo Lung Perfusion

Answer 60

Therapy applied to donor lungs outside the body before transplantation  Improves organ quality  Allows lungs that were previously unsuitable for transplantation – safe for transplantation.  Expands donor pool

Question 61

Ex Vivo Lung Perfusion lasts for

Answer 61

3-4 hour

Question 62

ex vivo maintained at

Answer 62

normal body temps.

Question 63

EX VIVO treated with

Answer 63

a bloodless solution that contains nutrients, proteins, oxygen  Reverse lung injury  Remove excess water

Question 64

First human liver transplant was done in

Answer 64

1963 by Thomas Starz in Denver, CO.

Question 65

But 1967, marked

Answer 65

the first time a liver transplant patient lived to 1 year post surgery.

Question 66

Liver Transplants |  General Guidelines

Answer 66

Any patient with a chronic or acute liver disease who is unable to sustain normal quality of life or patients with serious complications related to the underlying liver pathology should be considered.

Question 67

liver transplants evaluation of severity

Answer 67

 Encephalopathy  Ascites  Recurrent GI Bleeding  Severe Fatigue  Early stage primary liver tumor  Others.

Question 68

liver transplant questions before transplant

Answer 68

 Do they need the transplant?  Can they sustain the operation?  Is there a risk of recurrence?

Question 69

test clamp for liver

Answer 69

est Clamp is performed. If patient remains stable – can do it without V-V bypass. If not, V-V bypass is initiated.

Question 70

New Liver is sewn in:

Answer 70

 Suprahepatic IVC  Infrahepatic IVC  Portal Vein |  Hepatic Artery  Clamps are removed – Bypass is discontinued  Bile Duct

Question 71

Less than 5% of liver transplants use

Answer 71

V-V Bypass.

Question 72

liver can use a partial occlusion

Answer 72

clamp on the IVC without cross clamping the entire IVC

Question 73

liver Need to monitor lots of parameters:

Answer 73

 EKG |  HR  Core Temp  Pulse Ox  Arterial BP  PA Catheter  SvO2  Cardiac Output

Question 74

Liver Transplant – V-V bypass |  First used by

Answer 74

Marshall, Et al in 1970.  Managed a patient with renal cell carcinoma extending into the IVC and RA

Question 75

Liver Transplant – V-V bypass 1960s – realized

Answer 75

that they needed a shunt that could train blood from the lower extremities and portal system  First looked at utilizing bypass without a pump  Unsuccessful – circuit clotted, and created embolism  Tried anticoagulation  Increased bleeding too much

Question 76

liver transplant 1980s

Answer 76

V-V Bypass came into practice with the use of heparin bonded circuits and a centrifugal pump.

Question 77

Liver Transplant – V-V Bypass perfusion

Answer 77

No oxygenator  Less flows than on CPB  Flows from 1-2 liters most common  Flow what you can get  Femoral vein is cannulated and advanced to the bifurcation of the IVC  2nd cannula placed in the portal vein to drain the portal system.  Wyed into the venous line.  Centrifugal pump  Return to axillary vein or internal jugular vein.

Question 78

Liver Transplant – V-V Bypass |  No heparin

Answer 78

is used  Flows adequate unless less than 1 liter per minute and cardiac preload is maintained  Need to maintain flow to prevent clot  Preload dependent.  Closed system, so no volume can be added.

Question 79

To avoid pulmonary hypertension give

Answer 79

Inhaled NO