POM 1 - Exam 4 - Cardiac transplant

Cardiac transplant - Indications

-cardiogenic shock that requires mechanical support

-inotrope dependence

-peak VO2 <12-14 mL or EF <20

-Class III or IV HF despite optimal therapy

-refractory life-threatening arrhythmias
(basically you’ve done all that you could do medication wise and they are down bad, hence the arrhythmias)

Cardiac transplant - Absolute CI

-systemic illness with life expectancy UNDER 2 yr

-recent malignancy/CANCER

-AIDS with opportunistic infections

-SLE (Systemic Lupus Erythematosus), sarcoidosis, amyloidosis

-irreversible renal/hepatic dysfunction

-significant obstructive pulmonary disease

-Fixed pulmonary HTN (not moving)

Cardiac Transplant - Relative CI

-Active tobacco, drug, or ETOH use/abuse

-poorly controlled DM (HbA1C >8%)

-Severe PVD (Peripheral Vascular Disease)

-morbid obesity

-lack of social support

-medical non-compliance
can change/improve

Acute Cellular Rejection

-T cell mediated

-20-40% of pts experience this, usually occurs within first 6 months

-days/weeks, persists, but risk decreases after first 12 months

Acute Rejection S/S

-usually subtle

-generalized malaise

-nausea/vomiting

-arrhythmia (a fib/a flutter)

-heart failure sx

-elevated troponin

-peripheral edema

-flu-like syndrome

Chronic Rejection

-many years post-transplant

-approximately 50% of patients have evidence of CAV (Cardiac Allograft Vasculopathy) at 5 years

Chronic Rejection S/S

-allograft vascular injury (where the transplanted organ's blood vessels are damaged by the recipient's immune system, leading to inflammation, thickening, and potential loss of function)

- diffuse progressive obliteration of epicardial arteries

-intimal thickening and fibrosis, leads to luminal occlusion

Heart Re-innervation

-donor heart is completely denervated (complete loss of the heart's connection to the nervous system) during transplantation

-most Heart Transplant patients have higher resting heart rates and significantly reduced heart rate variability

-over time, re-innervation will occur, but degree is variable between patients

Oral Candidiasis

-common after heart transplant

-prophylaxis is nystatin suspension

Toxoplasmosis and PCP

- post-transplant infection

-prophylaxis: bactrim DS 1 tablet on M/W/F

-alternative: dapsone or Atovaquone

-lifelong

CMV (Cytomegalovirus)

-post-transplant infection

-prophylaxis: valcyte 450 mg-900 mg BID

-recipient (+): prophylaxis 6 months (recipient less prophylaxis time)

-recipient (-)/donor (+): prophylaxis 12 months

Early Post-OP Complications

-vasodilatory shock/hypotension

-bleeding

-sinus node dysfunction

-early graft dysfunction

-RV failure

-acute renal failure
* acute kidney failure, heart failure, sinus node weird, early graft weird, bleeding, vasodilatory shock, hypotension

Transplant - Dietary Considerations

-wash all fresh food thoroughly

-fully cook all meat, fish, and poultry

-avoid re-heated foods/buffets

Transplant - Exercise

-30-45 min of CV exercise daily

-no heavy lifting until 8 weeks after surgery (2 months)

Life-style mods

-avoid people with s/s of infection

-mask during flu and covid season

-wash hands frequently

-mask while cutting grass/doing yardwork/gardening

Diabetes - Post-transplant

-primarily oral therapies, insulin if needed

-often insulin during first 4-6 months while on high dose steroids

Dyslipidemia - Post-transplant

patient should be placed on statins

Gout - post-transplant

-steroids

-allopurinol (xanthine oxidase inhibitors, antigout medication)

-colchicine if renal function stable

HTN - Post-transplant

-early post-op: diuretics, vasodilators, CCB

-6-8 weeks post op: ACEI/ARB esp if DM, CCB, thiazides, alpha-blockers

Immunosuppression - Triple Cocktail

-Calcineurin inhibitor (cyclosporine, Tacrolimus)

-Anti-proliferative agent (azathioprine, mycophenolate mofetil)

-Steroids (prednisone)
-MC combo: tacrolimus, mycophenolate mofetil (MMF), and prednisone

Corticosteroids

-immunosuppressive and anti-inflammatory

-bind to intra-cellular glucocorticoid receptors

-bind to DNA and alter transcriptional regulations

-alter expression of genes involved in stimulation and function of all leukocytes

first 3 months

when are you most worried about a bacterial infection (mostly staph and gram (-) bacillus) post-transplant?

duration of transplant

when are you most worried about viral infections post-transplant?

first 30 days

when are you most worried about fungal infections post-transplant?

first 6 months

when are you worried about acute rejection post-transplant?

6 months onward

when are you worried about chronic rejection post-transplant?