Post Operative Management in Heart Transplant
Post Operative Management in Heart Transplant
Post Operative Management in Heart Transplant
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Art of Good Cook<strong>in</strong>g• Good Ingredient• Good donor + OK recipient• Good technique• Good team• Good tim<strong>in</strong>g• Good organization• Well practice
<strong>Heart</strong> <strong>Transplant</strong>: Peri-op Issues• Donor• Surgical techniques• Peri operative graft Failure• Imm-suppressive and rejection management• Renal function management
Issues: medium – long term• Renal function management• <strong>Transplant</strong> Allograft Vasculopathy• Malignancy• CMV <strong>in</strong>fection
Donor <strong>Management</strong>• Match<strong>in</strong>g• Donor cardiovascular care• Donor procurement and preservation
Donor Cardiovascular Care• M<strong>in</strong>imize effects of bra<strong>in</strong> dead physiology• DI• Hormone• Vascular tone• Fluid+ Electrolyte deranged• Over Innotropic drug• Low Hct• Low plasma osmolarity
Donor-recipient Match<strong>in</strong>g• Size: Greater than 80% of recipient bodyweight• Blood type: Identical or compatible• HLA-match<strong>in</strong>g: Generally not done• Direct X match only <strong>in</strong> preformedantibody found <strong>in</strong> recipient
Donor Procurement and Preservation• Preservative agent• St Thomas Cardioplegia• Blood Cardioplegia• Celsior• HTK solution Custodiol
Donor Procurement and Preservation• Ischemic Time• Optimum time : less than 4 hours• Acceptable to 6 hours• On arrival blood cardioplegia technique <strong>in</strong> longischemic time case
Surgical Techniques
Surgical Complications• Bleed<strong>in</strong>g• Mal alignment – Flow obstruction• Tricuspid regurgitation
Immediate <strong>Post</strong> Op Complications• Pump<strong>in</strong>g failure• Renal failure• Rejection• Bleed<strong>in</strong>g
Pump<strong>in</strong>g Failure• Graft preservation and Ischemic time• Hyper acute rejection – Acute rejection• Right heart failure• Pulmonary hypertension ?
Right Side <strong>Heart</strong> Failure• Most common cause of death <strong>in</strong> peri operative• Right ventricle is more prone to ischemic <strong>in</strong>jury• Th<strong>in</strong> wall - less reserve muscle contraction• Room temperature exposed
Right <strong>Heart</strong> Failure• High CVP• Distended Rt ventricle• Tricuspid regurgitation• High Pulmonary artery pressure(PAP) +/-• Low PAP but distended RV – very bad sign
Treatments of RV Failure• Decompress right side• Optimal preload volume• Over fill <strong>in</strong>creases Tricuspid regurgitation• Lower Pulmonary vascular resistance• Maximum ventilation support• Drugs : NTG, Isuprel, Primacor, Viagra• Nitric Oxide, Illoprost• Increase RV contraction• Mechanical support :• IABP• Ventricular assist device
Left Side Failure• Mostly from donor heart issues• Donor pre transplant condition• Ischemic time• Myocardium Preservation• Acute rejection is rare• Mostly result of reperfusion <strong>in</strong>jury
Treatments of LV Failure• Rest myocardium : Empty beat<strong>in</strong>g heart• Optimal <strong>in</strong>nothropic drugs• Optimal environment for myocardium recovery• Preload / Afterload• Blood gas, Electrolyte, acid base,calcium etc• Mechanical Support• IABP• VAD
Ventricular Assist Device
Bi Ventricular(a) Cannulation for CentriMagAssistBiVADDeviceTakayama H. et al.; Interact CardioVasc Thorac Surg 2011;12:110-111
Rejection
Immunosuppressive TherapyCNI• Cyclospor<strong>in</strong>e A• FK 506Antimetabolite• Azathiopr<strong>in</strong>e• MycophenolateSteroid• Adrenocortical steroidsLymphocytolytic Therapy• Anti-thymocyte globul<strong>in</strong> (ATG)
Induction TherapyRATG: Reduce• Acute rejection• Periop acute renal failure• Long term rejectionIncrease• Infection
Standard Triple therapy• Preoperative• Azathiopr<strong>in</strong>e: 4 mg/kg IV• Intraoperative• Methylprednisolone: 500 mg• <strong>Post</strong>operative• Cyclospor<strong>in</strong>e: 2-6 mg/kg po bid based on troughlevels and renal function• Azathiopr<strong>in</strong>e: 2 mg/kg/day• Methylprednisolone: 125 mg IV every 8 hours for 3-4 doses, followed by prednisone• Prednisone: (beg<strong>in</strong>n<strong>in</strong>g after Methylprednisolone)1mg/kg/day taper<strong>in</strong>g over 1 week to 0.5 mg/kg/day,
Ma<strong>in</strong>tenance ImmunosuppressionGoal• Lowest overall level of immunosuppression toprevent rejection• Cyclospor<strong>in</strong>e levels• Low therapeutic after 1-2 years• Azathiopr<strong>in</strong>e• 1-2 mg/kg/day after 1-2 years• Prednisone• 0 - 0.1 mg/kg/day after 1 year
Problem with CNI• Renal toxicity esp dur<strong>in</strong>g critical period• Injured and recover<strong>in</strong>g myocardium• Injured renal after CPB• Compromised cardiac output and renal perfusion
CNI free Regimens• m TOR <strong>in</strong>hibitor• Sirolimus (Rapamune)• Everolimus (Certican)• No renal toxicicty• Higher rate of rejection <strong>in</strong> de novo used.
Strategies :Renal ShutdownImmediate <strong>Post</strong> Op• Prolonged Induction• Higher rate of <strong>in</strong>fection• CNI free regimen de novo• Higher rate of rejection• Lower CNI comb<strong>in</strong>ed with mTOR• Forget kidneys and protect heart• Renal transplant after kidney transplant?
Rejection• Endomyocardial biopsy• Acute rejeciton• Hospital• Out-patient
Rejection
Rejection
Rejection
TREATMENT OF REJECTIONGRADEMildModerateModerateSevereNone or oral corticosteroid augmentationOral corticosteroid augmentation or IVcorticosteroidsIV corticosteroids +/- ATG or OKT3
InfectionMost of fatal <strong>in</strong>fection <strong>in</strong> post op heart transplantcame from• Colonized pre transplant (poor conditionrecipient)• Consequences of prolong postop heart failure;prolong <strong>in</strong>tubationCMV is the most common <strong>in</strong>fection problem <strong>in</strong>medium and long term
Infection• Pre transplant prolong <strong>in</strong>tubation is the mostimportant risk factor <strong>in</strong> post transplant <strong>in</strong>fection• Prolong post transplant <strong>in</strong>tubation must beavoid• <strong>Post</strong> op renal failure contribute to fatal <strong>in</strong>fection
Infection• Bacterial - Most Common• Viral• Fungal
Infectious ProphylaxisPathogenicOrganismCytomegalovirusHerpes simplexToxoplasmosisPneumocystisOral candidiasisProphylactic AgentGancyclovir, Acyclovir, IVIgAcyclovirPyrimetham<strong>in</strong>e andLeucovor<strong>in</strong>TMP/SMX, Dapsone,Pentamid<strong>in</strong>eNystat<strong>in</strong>, Mycelex troches
Peri operative Renal Failure• Poor renal perfusion• Poor cardiac function• <strong>Post</strong> cardio pul bypass <strong>in</strong>jury• CNI toxicity <strong>in</strong> not fully recovered renal• Induction Therapy : give renal toxic freew<strong>in</strong>dow period
Renal Failure• Most important side effect of cyclospor<strong>in</strong>—from afferent arteriolar vasoconstriction anddirect tubular cell <strong>in</strong>jury;• Dose related to some extent and will improvewith reduction <strong>in</strong> the Cyclospor<strong>in</strong> dose
Peri operative renal failure• Extended <strong>in</strong>duction technique• Intermittent RATG after complted normal <strong>in</strong>ductionduration• Follow CD 3• CNI free until renal recover• Significantly <strong>in</strong>crease <strong>in</strong>fection
Common Dilemmas• Poor cardiac function• Cannot extubate• Cannot start oral CNI• Prolong use of RATG : over suppress• Infection flare up
Common Dilemmas• Poor cardiac function• Poor ur<strong>in</strong>e flow• Cannot start oral CNI• Higher risk of rejection
Conclusions• Donor recipient condition – Most important• Right side heart failure is the most commoncause of operative dead• Prolong poor cardiac function leaded toprolong <strong>in</strong>tubation and fatal <strong>in</strong>fection• <strong>Post</strong> operative care is the most difficult aspect<strong>in</strong> heart transplant
Thank you