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HEART TRANSPLANTATION

HEART TRANSPLANTATION. MARTIN SUSSMAN MILPARK HOSPITAL. ISSUES. Improvements in survival with medical therapy impacted on old indications for HT. Remain survival and QOL benefits for HF pts despite this Exercise testing strongly recommended, not routinely performed in JHB Peak VO2 < 12.

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HEART TRANSPLANTATION

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  1. HEART TRANSPLANTATION MARTIN SUSSMAN MILPARK HOSPITAL

  2. ISSUES • Improvements in survival with medical therapy impacted on old indications for HT. • Remain survival and QOL benefits for HF pts despite this • Exercise testing strongly recommended, not routinely performed in JHB • Peak VO2 <12

  3. INDICATIONS • End stage heart failure of any cause – on maximal medical therapy, no alternative therapy, eg revascularisation, valve repair/replacement • ICD 10 codes I 40, I 41, I 42, and I 43 (acute myocarditis of any cause and associated with any other illness or disease, chronic cardiomyopathy of any cause or associated disease or illness)

  4. INDICATIONS 2 • A definitive list, incorporating every possible condition is complex, of necessity incomplete, and potentially inappropriately limiting. • The 3 important “safety nets” are • All patients are screened by a multidisciplinary team before being listed • Exclusion criteria are more important • Sickest patients get operated first – majority in ADHF, or multiple recent admissions in HF

  5. EXCLUSION CRITERIA • Pulmonary hypertension • Severe co-morbidity not expected to improve with heart transplant –heart/lung, heart kidney/liver? • Malignancy • Malnutrition • Advanced age

  6. EXCLUSIONS 2 • Interplay between donor quality and following relative contra-indications to ensure optimal utilisation of scarce resource • Age, DM, PVD, obesity, cancer, renal function • Negative factors are cumulative, but no weighting for each • Role for alternate listing system

  7. PULMONARY HYPERTENSION • Right heart catheterisation for all HT candidates • Repeat 3-6 monthly while on waiting list • If PAP >50mm Hg, PVR > 3 Wood units, or TPG > 15 mm Hg, trial of vasodilators, inotropes for 24-48 hours, MCS. Irreversible PHT if non responder. • NO ABSOLUTE CUT-OFF, but if PVR remains > 5, TPG > 16, with PAP > 60, mortality is increased • If PVR drops <2.5, but SBP also drops below 85mm Hg, risk is increased

  8. MALIGNANCY • Type, curability, recurrence risk. • Ensure no metastatic disease. • No absolute time line, but 5 years is mentioned as arbitrary cut-off

  9. DIABETES • Duration • No end-organ damage - NOT C/I, but still worse outcome • With end organ damage – relative to absolute C/I • Hypoglycamia unawareness and autonomic dysfunction increase concern

  10. MALNUTRITION • Obesity – BMI > 30 is C/I • Undernutrition – BMI < 21 males, 19 females

  11. RENAL FUNCTION • Must decide role of HF – reversibility • Irreversible, with creat > 300, is a strong C/I

  12. URGENCY • Acute decompensated heart failure – if BP < 115 mm Hg, urea and creatinine elevated, on inotropes

  13. Recommended Schedule for Heart Transplant Evaluation

  14. Evaluation of multi-organ function

  15. Preventive and malignancy

  16. Infectious serology and vaccination

  17. F/U EMB, ANGIOGRAPHY • EMB • ANGIOGRAM + IVUS 1-2 YEARLY Biopsy 1, 2, 3, 4, and 5: Weekly Biopsy 6, 7, and 8: Every 14 days Biopsy 9 and 10: Every 3 weeks Biopsy 11, 12, and 13: Every 4 weeks Subsequent biopsies during the 1st year after HT: Every 5 to 6 weeks

  18. NEW DEVELOPMENTS • Harvesting • Organ transport • MCS • Centres of excellence

  19. FEES • Harvesting heart – 75 units. • Insertion IC drain under local – 86 units. • Tonsillectomy and adenoids – 115 units • Diagnostic coronary angiogram – 140 units

  20. Estimated U.S. Average 2008 First-Year Billed Charges Per Transplant Estimated U.S. Average 2008 First-Year Billed Charges Per Transplant

  21. FEES 2 • Heart transplant – 875 units • Lung transplant – 600 units

  22. Generic Drug Immunosuppression in Thoracic Transplantation:An ISHLT Educational AdvisoryPatricia A. Uber, PharmD,a Heather J. Ross, MD,b Andreas O. Zuckermann, MD,c Stuart C. Sweet, MD,dPaul A. Corris, MD,e Keith McNeil, MD,f and Mandeep R. Mehra, MBBSa 1. Clinicians should educate their patients to inform the coordinating center if a change in either the labeling or appearance of their immunosuppressive medications suggests that a generic drug substitution has occurred. 2. Clinical care coordinating centers must develop structured approaches for the education of all personnel with regard to use of generic immunosuppressants. 3. In unique clinical situations, where critical drug dosing represents a fine balance, caution should be exercised in the use of generic immunosuppression. 4. Heightened vigilance to adverse sequelae and closer therapeutic drug monitoring is indicated until a stable immunosuppression milieu can be established

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