II. Indications
- Cardiomyopathy
- Refractory Heart Failure (NYHA Class III to IV)
- Refractory Angina or Arrhythmias (uncommon)
- Hemodynamic instability
- Peak VO2 <14 ml/kg/min
III. Contraindications: Relative
- Age over 65 to 70 years
- Limited survival due to systemic illness
- Fixed Pulmonary Hypertension (PVR >5 Woods units)
- Malignancy
- HIV Infection
- Hepatitis B infection
- Hepatitis C infection
- Malignancy within the last 5 years
IV. Protocol
- Virtual cross-matching (prescreen via computer known HLA mismatches)
- Transplant at a large volume center if match found
- All Heart Transplant centers perform at least 10 transplants per year
- Large volume centers perform upwards of 30 transplants per year
V. Physiology: Nerve Disruption
- Unlike vascular supply, nerves are not reconnected during transplant
- Efferent parasympathetic vagal nerve disruption
- Resting Heart Rate is increased to 80 to 110, due to lack of vagal tone
- Cardiac tissue is more responsive to Adenosine (use 25% of typical SVT dose)
- Vagal Maneuvers have no effect
- Atropine has no effect
- Efferent sympathetic vagal nerve disruption
- Tachycardia response to stressful stimuli is blunted
- Afferent nerve disruption
- Typical Anginal symptoms (e.g. Chest Pain) are initially absent
- A small subset (20%) will partially reinnervate within 2 years
- Post-transplant Myocardial Ischemia may present with Fatigue, Shortness of Breath, especially with exertion
VI. Findings: Post-Transplant EKG
- Always compare to prior EKGs
- Even subtle changes may suggest coronary vasculopathy or Transplant Rejection
-
Sinus Tachycardia at rest (80 to 110 bpm) in most cases
- New Atrial Fibrillation or Bradycardia may indicate Transplant Rejection
- Premature Ventricular Contractions (PVCs) are common and benign
- Right Bundle Branch Block is common
- EKG Axis varies based on transplant orientation
- EKG in Acute MI follows same patterns as for non-transplanted hearts
VII. Complications
- Diarrhea (may require change in anti-rejection medications)
- Infection (e.g. Fever or Leukocytosis)
- Many transplant patients will initially be covered with prophylactic Antibiotics
- Consider Sepsis, Urinary Tract Infection or Pneumonia
- Consider opportunistic infection (e.g. Pneumocystis jiroveci Pneumonia, Cytomegalovirus or fungal infection)
- Most transplant patients are on CMV prophylaxis to prevent CMV infection
- Cytomegalovirus (CMV) is the most common opportunistic infection in transplant patients
- CMV may be acquired or reactivated after transplant
- Presents with pneumonitis, enteritis with Diarrhea or generalized infection
- Infections follow a pattern based on time from transplant
- Month 1: Nosocomial infection (e.g. CAUTI, VAP, SSI)
- Month 1-6: Opportunistic infection (CMV, EBV, fungal and Parasitic Infections, Tuberculosis)
- Month 6+: Community acquired infection (e.g. Pneumonia) and opportunistic infections
- Rejection
- Typically occurs within first year of transplant (much lower risk later)
- Absolute compliance with anti-rejection drugs is critical
- Cardiac Transplant patients are not HLA matched
- Even missing 1-2 doses risks Transplant Rejection
- Consider short course of high dose Corticosteroids for missed doses (consult transplant team)
- Findings
- EKG changes (compare to old ekgs; even subtle changes may indicate rejection or coronary vasculopathy)
- New signs of Heart Failure or Left Ventricular Dysfunction
- New Arrhythmias (esp. Bradycardia, Atrial Fibrillation)
- New exertional symptoms
- Peripheral Edema
- Hemodynamic instability
- Management
- Consult transplant team
- Consider high dose Methylprednisolone 30 mg/kg up to 1 gram
- Obtain Echocardiogram as soon as possible
- Manage Hypotension
- Small fluid boluses (e.g. 10 ml/kg in children or 500 ml in adults)
- Consider Vasopressors (Epinephrine is preferred over Norepinephrine)
- In RSI and sedation avoid agents with myocardial depression (e.g. Propofol) which will be worse in transplant
- Manage Arrhythmias
- Decrease Adenosine dose to 25% of typical Supraventricular Tachycardia dose
- Atropine will be ineffective in Bradycardia
- Top causes of death
- Malignancy
- Graft failure
- Cardiac Allograft vasculopathy
- Patient monitored lifelong for this after transplant
- Treated with Cardiac Risk Reduction, Statins, revascularization, CMV prevention
VIII. Management: Anti-Rejection Protocol
- Precautions
- Even missing 1-2 doses can significantly increase risk of rejection
- Consider short-course of high dose Corticosteroids when anti-rejection medication doses have been missed
- Consult with patient's Cardiac Transplant team
-
Immunosuppression Induction (50% of cases)
- Initial intense multi-drug Immunosuppression following transplant
- Maintenance: Three drug protocol for first year (then Corticosteroids tapered off and 2 drugs continued)
- Calcineurin Inhibitor (Tacrolimus or Cyclosporine)
- Nephrotoxic Drugs (avoid all NSAIDs and other Nephrotoxins)
- Risk of Hypertensive Emergency including PRES
- Mycophenolate Mofetil (Cellcept) or other antimetabolite (e.g. Azathioprine)
- Gastrointestinal side effects and cytopenias are common
- Corticosteroids tapered over 6-12 months and discontinued by 12 months
- Calcineurin Inhibitor (Tacrolimus or Cyclosporine)
IX. Management: Routine care following Transplantation
- Routine management of comorbidity (e.g. Diabetes Mellitus)
- Osteoporosis
- Annual complete physical
- Malignancy screening
- Keep Vaccinations up-to-date (Avoid Live Vaccines)
- Pneumovax every 2-5 years
- Influenza annually
- HPV Vaccine for younger women
X. Prognosis
- HLA mismatch decreases survival and in proportion to the number of HLA mismatches
- Survival Half-Life following Cardiac Transplantation
- University of Minnesota data as of 2009
- Survival at 1 year: 87%
- Survival at 3 years: 79%
- Survival at 5 years: 72%
XI. References
- Gatz and Swaminathan in Swadron (2022) EM:Rap 22(11): 10-2
- Claudius, Ruttan and DeFabio in Swadron (2022) EM:Rap 22(11): 13