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What are the 3 types of transplants that perfusion is involvedin?

Heart transplants
Lung transplants
Liver transplants


Transplants can be performed individually or in combination often with what organ?



Who described the first heterotropic transplant of a donor heart into the neck of a dog? When?

1905; Carrel and Guthrie


Describe the first heterotropic transplant of a donor heart into the neck of a dog.

Not a functional model, functioned together with the recipients heart; heart was not capable of supporting circulation, lasted 2 hours before the chambers clotted


Who won the Nobel Prize in Medicine and Physiology for work in this area? What year?

Carrell, 1912


What institution did Carrel and Guthrie create innovative surgical technique for vascular anastomoses?

University of Chicago


Describe the "Working Model" of the heterotopic transplant with circulatory unloading of the RV.

1933- Mann, et al. at Mayo Clinic
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


1960- Lower and Shumway

Orthotopic heart transplant in dogs with CPB and topical hypothermia for donor heart preservation; survived 6-21 days; died of rejection


When was Pharmcologic immunosuppression introduced?



What happened not long after pharmacologic immunosuppresion was introduced?

first clinical transplantation occured (kidney)


When was the first human heart transplant? Where?

1967, South Africa; followed shortly by Shumway and colleagues at Stanford in 1968


Many centers initially rushed to perform transplants. How come this didn't continue?

Realized post operative survival was limited
lots of opportunistic infections
graft rejections


When did most center discontinue doing transplants ?

in the 1970's


When did cyclosporine based immunosuppresion get introduced?

1980's; interest in transplantation re-emerged around this time


What patients are selected to get transplants?

Have to be in end stage CHF
Must be able to benefit from a transplant


How to determine end stage CHF?

NYHA function class III or IV
symptomatic refractory to management with medications, electrophysiology devices (pacemakers/AICD) and surgical intervention
LVEF < 35%
Cardiogenic shock (acute MI, acute myocarditis)
ischemic heart disease


Contraindications of transplants?

Advanced age (should be less than 65 y/o)
Irreversible pulmonary hypertension
Active infection and malignancy
Pulmonary fibrosis, emphysema, hepatic and renal dysfunction, cerebral vascular disease, peripheral vascular disease (relative)


Contrainidications of transplants: Age

Should be less than 65 y/o
Can be done in older patients
physiologic age is a better indicator than chronologic age


Contraindications of transplants: Pulmonary HTN

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


Contraindications of transplants: Active Infection and malignancy

infections are exacerbated by immunosuppression required after transplanation
Hepatits B, C, HIV not usually done
Non-melanoma cutaneous cancers, primary cardiac tumors restricted to the heart, low grade prostate cancers


Contraindications: Obesity

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


Contraindication: Diabetes

Relative contraindication
Control of blood sugars on steroids and immunosuppressants
Wound healing


Contraindications: Psychosocial

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


What is done prior to performing a transplant?

Lots of tests/ workups are done prior to transplantation
Must be approved by several committees and departments prior to listing the patient


What is looked at for organ matching?

ABO Blood Compatibility
Overall body size (must be within 20% of body weight)
HLA Cross match
Priority on UNOS Registry
Geographic distance from donor


HLA Cross match

some patients are sensitized to antigen due to pregnancy, prior transplant, or blood transfusion


Waiting List Criteria

Status code and time within the status code
Highest medical urgency and lowest short term survival are assigned higher codes


How Wait List Works?

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.


Going out for Procurement

Donor heart is arrested with 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


What is the ischemic time?

3-4 hours!! can do up for 5-6 hours- not idea


Recipient: 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


Recipient: Bi-atrial tehcnique modified lately

Leave donor atria in tact and make the anastomosis at the SVC and iVV and pulmonary veins (Bicaval techniques)
notice less distortion of the aortic valve
improved atrial and ventricular function
Less AI
less arrhythmias/heart block


Bicaval technique

Leave donor atria in tact and make the anastomosis at the SVC and IVC and pulmonary veins


Post operative course

Same as normal cardiac course:
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"


Physiology of Transplanted Heart

Completely denervated
Faster resting heart rate (95-100 bpm)
intrinsic rate of SA node
no parasympathetic down regulation
slower to increase HR in response to exercise
slower to recover after exercise
no angina with ischemia; will have silent MIs. Will present with CHF, Silent MI, or sudden death
dont respond to drugs that work via the parasympathetic pathway


Perfusion Perspective

Donor heart is located
patient will be in room about the time the harvest team is at the donor site
harvest team will be able to view heart; once they vew a TEE and visualize, they call OR
patient will be induced
harvest team will call saying heart is out
write down donor XC time. This is the start of the ischemic period of the donor organ.
Patient will be draped. If its a redo, incision will be made with the "heart out" call. (median sternotomy; if its a redo you'll go on fem-fem"


What do you do once the heart is in the room?

Go on bypass. Usually drift, or cool to about 32. XC almost immediately


Recipients diseases heart is removed. iS cardioplegia used?

not usually given


What happnes when the sutures are complete?

Some institutions give a "hot shot" type of dose of "cardioplegia." Use glutamate aspartate solution. full of nutrients for that ischemic heart. other places don't.


When was the first beating heart transplant?

May 2007


Being heart transplant maintianed at what temp?

Maintained at normal body temperature and hooked up to the Transmedics ORgan Care system
beats with warm, oxygenated blood inside a sterile box


When was the first human lung transplant done? What was the outcome?

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


What happened with lung transplants in 1986?

Stanford- first heart-lung transplant
Toronto- first single lung transplant


Today, how many lung transports are performed?

More than 1000 lung transplants


What's the wait time for single lung?

24 months


What's the wait time for double lung?

36 months


Indications for a Lung Transplant

Irreversible progressively disabling, end-stage pulmonary disease


What is the life expectancy for those needing lung transplant?

18 months or less
-oxygen dependent
-exercise intolerance
-less than 65 years old
-poor quality of life


Patient is evaluated for lung transplnat in the following areas?

respiratory exam
family hx
psychosocial and cultural hx


Things affecting lung transplant eligibility

Musculoskeletal disease
use of corticosteroids (>20 mg/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.


Types of lung Transplants

Single Lung Transplant (R/L- left side easier)
Double lung transplant (En Bloc; bilateral sequential)
Heart-lung block
Ex-Vivo Lung Transplant


Single Lung Transplant

Idiopathic Interstitial Pulmonary Fibrosis
Eosinophilic Granuloma
Primary Pulmonary HTN
Eisenmengers Syndrome with Cardiac repair


Is CPB necessary with single lung transplants?

Not usually; depends on patient's tolerance to unilateral support during XC


What type of thoracotomy used in single lung transplant?

through bed of excised 5th rib


What is done to the main PA during single lung transplant?

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


Single Lung Transplant: Temp

usually stay warm


Single lung transplant: native lung is....



Single lung transplant: What is clamped



Singel lungs trnasplant: pulmonary veins attached where?

LA Cuff; PA anastomosed. end to end anastomosis of the donor recipient bronchus, atrial clamp then removed


Bilateral Seuqnetial Double Lung

cystic fibrosis
primary pulmonary htn
eisenmenger's syndrome with cardiac repair


Double lung transplant- gives patients better what?

Pulmonary reserve


Double Lung transplant: used to be done .....

En bloc where each lung was implanted seprately through a pleural-pericardial window while on CPB; utilized clamshell incision, big pain from a perfusion standpoint


Now, common to do ________ (2) double lung transplant

bilateral sequential; like 2 single lung transplants, ventilate the native lung while the first goes in. Then ventilate the new lung wile the second goes in


Ex Vivo Lung Perfusion

therapy applied to donor lungs outside the body before transplantation; improves organ quality; expands donor pool


Why does ex vivo lung perfusion improve organ quality?

Allows lungs that were previously unsuitable for transplantation- safe for transplanation


How long is ex vivo lung perfusion procedure?

3-4 hours procedure


How does ex vivo lung perfusion work?

donor lungs placed into plastic dome
attached to ventilator, pump and filters
maintained at normal body temp
treated with a bloodless solution that contains nutrients proteins, oxygen (to reverse lung injury remove excess water)
once suitable- transplanted into waiting patinet


When was the first humna liver transplant done? By Who?

1963, but Thomas Starz in Denver


What happend in 1967?

markes the first time a liver transplant patient lives to 1 year post surgery


Liver Transplants: General Guidelines

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


Liver Transplants: Evaluation of Severity

Recurrent Gi bleeding
Severe fatigue
early stage primary liver tumor


Liver Transplants: Selection Questions?

Do they need the transplants?
can they sustain the operation?
Is there a risk of recurrence?
commitee meeting ot decide eligibility


When does the liver donor organ usually arrive?

Prior to incision; organ is prepped at the back table


How to determine in liver transplant patients if V-V bypass will be done?

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


New Liver is sewn in

suprahepatic IVC
infrahepatic IVC
portal vein
hepatic artery
clamps are removed- bypass is discontinued
bile duct


WHat percent of liver transplants use V-V bypass?

less than 5%


Liver Transplants: what parameters do you monitor?

Core temp
Pulse ox
arterial BP
PA catheter
cardiac output


Liver Transplant- V-V bypass first used by who? When?

Marshall et all 1970; managed a patient with renal cell carcinoma extending into the IVC and RA


1960's liver transplant

realized 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. anticoagulation increased bleeding too much.


When did V-V bypass come into practice with the use of heparin bonded circuits and a centrifugal pump?



Whats the most common flows in liver transplants?

1-2 L most common. No oxygenator, less flows than on CPB


What is cannulated in liver transplants?

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.