II. Indications

  1. Cardiomyopathy
  2. Refractory Heart Failure (NYHA Class III to IV)
  3. Refractory Angina or Arrhythmias (uncommon)
  4. Hemodynamic instability
  5. Peak VO2 <14 ml/kg/min

III. Contraindications: Relative

  1. Age over 65 to 70 years
  2. Limited survival due to systemic illness
  3. Fixed Pulmonary Hypertension (PVR >5 Woods units)
  4. Malignancy
  5. HIV Infection
  6. Hepatitis B infection
  7. Hepatitis C infection
  8. Malignancy within the last 5 years

IV. Protocol

  1. Virtual cross-matching (prescreen via computer known HLA mismatches)
  2. Transplant at a large volume center if match found
    1. All Heart Transplant centers perform at least 10 transplants per year
    2. Large volume centers perform upwards of 30 transplants per year

V. Physiology: Nerve Disruption

  1. Unlike vascular supply, nerves are not reconnected during transplant
  2. Efferent parasympathetic vagal nerve disruption
    1. Resting Heart Rate is increased to 80 to 110, due to lack of vagal tone
    2. Cardiac tissue is more responsive to Adenosine (use 25% of typical SVT dose)
    3. Vagal Maneuvers have no effect
    4. Atropine has no effect
  3. Efferent sympathetic vagal nerve disruption
    1. Tachycardia response to stressful stimuli is blunted
  4. Afferent nerve disruption
    1. Typical Anginal symptoms (e.g. Chest Pain) are initially absent
    2. A small subset (20%) will partially reinnervate within 2 years
    3. Post-transplant Myocardial Ischemia may present with Fatigue, Shortness of Breath, especially with exertion

VI. Findings: Post-Transplant EKG

  1. Always compare to prior EKGs
    1. Even subtle changes may suggest coronary vasculopathy or Transplant Rejection
  2. Sinus Tachycardia at rest (80 to 110 bpm) in most cases
    1. New Atrial Fibrillation or Bradycardia may indicate Transplant Rejection
  3. Premature Ventricular Contractions (PVCs) are common and benign
  4. Right Bundle Branch Block is common
  5. EKG Axis varies based on transplant orientation
  6. EKG in Acute MI follows same patterns as for non-transplanted hearts

VII. Complications

  1. Diarrhea (may require change in anti-rejection medications)
  2. Infection (e.g. Fever or Leukocytosis)
    1. Many transplant patients will initially be covered with prophylactic antibiotics
    2. Consider Sepsis, Urinary Tract Infection or Pneumonia
    3. Consider opportunistic infection (e.g. Pneumocystis jiroveci Pneumonia, Cytomegalovirus or fungal infection)
      1. Most transplant patients are on CMV prophylaxis to prevent CMV infection
      2. Cytomegalovirus (CMV) is the most common opportunistic infection in transplant patients
      3. CMV may be acquired or reactivated after transplant
      4. Presents with pneumonitis, enteritis with Diarrhea or generalized infection
    4. Infections follow a pattern based on time from transplant
      1. Month 1: Nosocomial infection (e.g. CAUTI, VAP, SSI)
      2. Month 1-6: Opportunistic infection (CMV, EBV, fungal and Parasitic Infections, Tuberculosis)
      3. Month 6+: Community acquired infection (e.g. Pneumonia) and opportunistic infections
  3. Rejection
    1. Typically occurs within first year of transplant (much lower risk later)
    2. Absolute compliance with anti-rejection drugs is critical
      1. Cardiac Transplant patients are not HLA matched
      2. Even missing 1-2 doses risks Transplant Rejection
        1. Consider short course of high dose Corticosteroids for missed doses (consult transplant team)
    3. Findings
      1. EKG changes (compare to old ekgs; even subtle changes may indicate rejection or coronary vasculopathy)
      2. New signs of Heart Failure or Left Ventricular Dysfunction
      3. New Arrhythmias (esp. Bradycardia, Atrial Fibrillation)
      4. New exertional symptoms
      5. Peripheral Edema
      6. Hemodynamic instability
    4. Management
      1. Consult transplant team
      2. Consider high dose Methylprednisolone 30 mg/kg up to 1 gram
      3. Obtain Echocardiogram as soon as possible
      4. Manage Hypotension
        1. Small fluid boluses (e.g. 10 ml/kg in children or 500 ml in adults)
        2. Consider Vasopressors (Epinephrine is preferred over Norepinephrine)
        3. In RSI and sedation avoid agents with myocardial depression (e.g. Propofol) which will be worse in transplant
      5. Manage Arrhythmias
        1. Decrease Adenosine dose to 25% of typical Supraventricular Tachycardia dose
        2. Atropine will be ineffective in Bradycardia
  4. Top causes of death
    1. Malignancy
    2. Graft failure
    3. Cardiac Allograft vasculopathy
      1. Patient monitored lifelong for this after transplant
      2. Treated with Cardiac Risk reduction, Statins, revascularization, CMV prevention

VIII. Management: Anti-Rejection Protocol

  1. Precautions
    1. Even missing 1-2 doses can significantly increase risk of rejection
    2. Consider short-course of high dose Corticosteroids when anti-rejection medication doses have been missed
      1. Consult with patient's Cardiac Transplant team
  2. Immunosuppression Induction (50% of cases)
    1. Initial intense multi-drug Immunosuppression following transplant
  3. Maintenance: Three drug protocol for first year (then Corticosteroids tapered off and 2 drugs continued)
    1. Calcineurin Inhibitor (Tacrolimus or Cyclosporine)
      1. Nephrotoxic Drugs (avoid all NSAIDs and other Nephrotoxins)
      2. Risk of Hypertensive Emergency including PRES
    2. Mycophenolate mofetil (Cellcept) or other antimetabolite (e.g. Azathioprine)
      1. Gastrointestinal side effects and cytopenias are common
    3. Corticosteroids tapered over 6-12 months and discontinued by 12 months

IX. Management: Routine care following Transplantation

  1. Routine management of comorbidity (e.g. Diabetes Mellitus)
  2. Osteoporosis
  3. Annual complete physical
  4. Malignancy screening
  5. Keep Vaccinations up-to-date (Avoid Live Vaccines)
    1. Pneumovax every 2-5 years
    2. Influenza annually
    3. HPV Vaccine for younger women

X. Prognosis

  1. HLA mismatch decreases survival and in proportion to the number of HLA mismatches
  2. Survival Half-Life following Cardiac Transplantation
    1. Overall survival: 10 year Half-Life
    2. Survival beyond 1 year: 13 year Half-Life
  3. University of Minnesota data as of 2009
    1. Survival at 1 year: 87%
    2. Survival at 3 years: 79%
    3. Survival at 5 years: 72%

XI. References

  1. Gatz and Swaminathan in Swadron (2022) EM:Rap 22(11): 10-2
  2. Claudius, Ruttan and DeFabio in Swadron (2022) EM:Rap 22(11): 13

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Related Studies

Ontology: Heart Transplantation (C0018823)

Definition (MEDLINEPLUS)

A heart transplant removes a damaged or diseased heart and replaces it with a healthy one. The healthy heart comes from a donor who has died. It is the last resort for people with heart failure when all other treatments have failed. The heart failure might have been caused by coronary heart disease, damaged heart valves or heart muscles, congenital heart defects, or viral infections of the heart.

Although heart transplant surgery is a life-saving measure, it has many risks. Careful monitoring, treatment, and regular medical care can prevent or help manage some of these risks.

After the surgery, most heart transplant patients can return to their normal levels of activity. However, fewer than 30 percent return to work for many different reasons.

NIH: National Heart, Lung, and Blood Institute

Definition (NCI) A surgical procedure in which a damaged heart is removed and replaced by another heart from a suitable donor.
Definition (NCI_CDISC) A surgical procedure in which a damaged heart is removed and replaced by another heart from a suitable donor.
Definition (MSH) The transference of a heart from one human or animal to another.
Definition (CSP) transference of a heart or heart tissue between individuals of the same species or between individuals of different species.
Concepts Therapeutic or Preventive Procedure (T061)
MSH D016027
ICD9 37.51
ICD10 90205-00
SnomedCT 149204008, 32413006
CPT 33945
English Cardiac Transplantation, Cardiac Transplantations, Grafting, Heart, Graftings, Heart, Heart Graftings, Heart Transplantation, Heart Transplantations, Transplantation, Cardiac, Transplantation, Heart, Transplantations, Cardiac, Transplantations, Heart, heart transplantation, TRANSPL CARDIAC, CARDIAC TRANSPL, TRANSPL HEART, HEART TRANSPL, transplantation of heart, transplantation of heart (treatment), Cardiac transplant, Heart Grafting, Transplant;cardiac, cardiac transplants, heart transplant, heart graft, heart transplantations, cardiac transplantation, heart transplants, Heart transplant (procedure), Heart--Transplantation, CARDIAC TRANSPLANT, Heart Transplant, Heart transplantation, CTx - Cardiac transplant, HTx - Heart transplant, Heart transplant, Transplantation of heart, HtTx - Heart transplant, Transplantation of heart (procedure), Transplantation of heart, NOS, Heart Transplants, cardiac transplant
Spanish Trasplante cardiaco, trasplante cardíaco, trasplante de corazón (procedimiento), trasplante de corazón, Trasplante de corazón, Injerto de Corazon, Trasplantación Cardíaca, Trasplantación de Corazon, Trasplante Cardíaco, Trasplante de Corazón
Swedish Hjärttransplantation
Japanese シンゾウイショク, 心臓移植, 移植-心臓, 心移植, 心臓移植術
Finnish Sydämensiirto
French Greffe du coeur, Transplantation du coeur, Greffe cardiaque (procédure), Greffe de coeur (procédure), Greffe cardiaque, Transplantation cardiaque
Russian PERESADKA SERDTSA, SERDTSA TRANSPLANTATSIIA, TRANSPLANTATSIIA SERDTSA, KARDIOTRANSPLANTATSIIA, КАРДИОТРАНСПЛАНТАЦИЯ, ПЕРЕСАДКА СЕРДЦА, СЕРДЦА ТРАНСПЛАНТАЦИЯ, ТРАНСПЛАНТАЦИЯ СЕРДЦА
Czech Transplantace srdce, srdce - transplantace, transplantace srdce, srdeční štěp, srdeční transplantace
Croatian TRANSPLANTACIJA SRCA
Polish Przeszczepianie serca, Przeszczep serca, Transplantacja serca
Hungarian Szív transzplantáció, Szívtranszplantáció
Norwegian Hjertetransplantasjon
Italian Trapianto di cuore, Trapianto cardiaco
Portuguese Enxerto de Coração, Transplante cardíaco, Enxerto Cardíaco, Transplante Cardíaco, Transplante de Coração, Transplantação Cardíaco, Transplantação de Coração
Dutch harttransplantaat, Harttransplantatie, Transplantatie, hart-
German Herztransplantation, Kardiotransplantation, Transplantation, Herz-, Transplantation, kardiale, Verpflanzung, Herz-