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C38 Cardiology and Cardiac Surgery
Effects of Donor Pre-Treatment with Dopamine on Survival After Heart Transplantation: A Cohort Study of Heart Transplant Recipients Nested in a Randomized Controlled Multicentre Trial
J Am Coll Cardiol 2010;58:1768-1777
Treatment of brain-dead donors with dopamine of
4 μg/kg/min will not harm cardiac allografts but appears to improve the clinical course of the heart allograft recipient.
Cardiac Transplantation Toronto Notes 2019 Cardiac Transplantation
• treatmentforend-stageheartdisease;duetoischemicornon-ischemiccardiomyopathy
• worldwide1yrsurvivalis85-90%,5yrsurvivalabout60%,annualmortalityrateof4%
• matchingisaccordingtobloodtype,bodysizeandweight(shouldbewithin25%),andHLAtissue
matching (if time allows)
Indications for Surgery
• severecardiacdisabilitydespitemaximalmedicaltherapy(e.g.recurrenthospitalizationsforCHF, NYHA III or IV, peak metabolic oxygen consumption <14 mL/kg/min in absence of β-blocker)
• symptomaticcardiacischemiarefractorytoconventionaltreatment(e.g.unstableanginanotamenable to CABG or PCI with LVEF <30%; recurrent, symptomatic ventricular arrhythmias)
• exclusionofallsurgicalalternativestocardiactransplantation
Relative Contraindications
• incurablemalignancy
• majorsystemicillness
• irreversiblemajororgandisease
• activesystemicinfection
• obesity
• irreversiblepulmonaryHTN(pulmonaryvascularresistance[PVR]>6Woodunits) • severeCOPD(FEV1<1L)
• activedrugaddictionoralcoholism
Prerequisites
• psychosocialstability
• medicallycompliantandmotivated
Complications
• rejection
■ common, <5% have serious hemodynamic compromise
■ gold standard to detect rejection: endomyocardial biopsy
■ risk of acute rejection is greatest during the first 3 mo after transplant
• infection
■ leading cause of morbidity and mortality after cardiac transplantation
■ risk peaks early during the first few months after transplantation and then declines to a low
persistent rate • allograftCAD
■ approximately 50% develop graft CAD within 5 yr of transplantation
■ most common cause of late death following transplantation • malignancy
■ develops in 15% of cardiac transplant recipients due to immunosuppressive medication
■ second most common cause of late death following transplantation
■ cutaneous neoplasms most common, followed by non-Hodgkin’s lymphoma and lung cancer
• immunosuppressivemedicationsideeffects(prednisone,cyclosporine,tacrolimus,sirolimus)
Ventricular Assist Devices
• work to unload the ventricle while maintaining output; also results in decreased myocardial oxygen consumption permitting recovery of the myocardium that is not irreversibly injured
• cansupporttheleft(LVAD),right(RVAD),orbothventricles(BiVAD) • indications:
■ bridge to transplantation, bridge to decision (for transplant), or long term permanent therapy (“destination therapy”)
■ post-operative mechanical support when unable to separate from cardiopulmonary bypass despite inotropic and intra-aortic balloon pump (IABP) support
◆ IABP is a catheter based device inserted into the femoral artery and advanced to the descending aorta that decreases myocardial O2 demand and increases blood flow to coronary arteries
◆ inflation of the balloon occurs during diastole to increase ascending aorta and coronary artery perfusion pressure; deflation occurs at systole to reduce intra-aortic pressure thus reducing afterload
• post-operativecardiogenicshock
REMATCH Trial
NEJM 2001;345:1435-1443
Increased survival of 23% vs. 8% with LVAD vs. medical management of heart failure after 2 yr. Heartmate VAD has a biologic surface, therefore, does not require long-term anticoagulation but higher risk of infection
Canadian Cardiovascular Society Focused Position Statement Update on Assessment
of the Cardiac Patient for Fitness to Drive: Fitness following Left Ventricular Assist Device Implantation
Can J Cardiol 2012;28:137-140
Patients with a continuous flow, NYHA class I-III, LVAD that are stable 2 mo post LVAD implantation qualify for private driving only and are disqualified from commercial driving.