Heart Transplant

1. 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
2. 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
3. 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
4. Precautions: Observe
   1. Diarrhea (may require change in anti-rejection medications)
   2. Signs of infection (e.g. Fever or Leukocytosis)
   3. Signs of rejection
      1. New signs of Heart Failure or Left Ventricular Dysfunction
      2. Arrhythmias
5. Management: Anti-rejection protocol
   1. Trials of newer protocols include Tacrolimus or Sirolimus
   2. Typically 3 drug protocol
      1. Calcineurin Inhibitor
      2. Mycophenolate mofetil (Cellcept)
      3. Corticosteroids for first 6 months
6. 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
7. Adverse effects: Top causes of death
   1. Malignancy
   2. Graft failure
   3. Cardioac allograft vasculopathy
      1. Patient monitored lifelong for this after transplant
      2. Treated with Cardiac Risk reduction, Statins, revascularization, CMV prevention
8. 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%
9. References