Heart transplantation surgical procedure: Difference between revisions

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(/* Cardiac Transplantation (DO NOT EDIT) {{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.000000000000106...)
 
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'''Editor(s)-in-Chief:''' [[C. Michael  Gibson, M.S., M.D.]]; '''Associate Editor-In-Chief:''' {{CZ}}
__NOTOC__
{{Heart transplantation}}


==Surgical Procedure==
'''Editor(s)-in-Chief:''' [[C. Michael  Gibson, M.S., M.D.]]; '''Associate Editor-In-Chief:''' {{CZ}}{{IF}} {{EdzelCo}}
===Pre-operative===
A typical heart transplantation begins with a suitable donor heart being located from a recently deceased or brain dead donor. The transplant patient is contacted by a [[nurse]] coordinator and instructed to attend the hospital in order to be evaluated for the operation and given pre-surgical medication. At the same time, the heart is removed from the donor and inspected by a team of surgeons to see if it is in a suitable condition to be transplanted. Occasionally it will be deemed unsuitable. This can often be a very distressing experience for an already emotionally unstable patient, and they will usually require emotional support before being sent home.


===Operative===
==Overview==
Once the donor heart has passed its inspection, the patient is taken into the [[operating theatre]] and given a [[general anesthetic]]. Either an '''orthotopic''' or a '''heterotopic''' procedure is followed, depending on the condition of the patient and the donor heart.


====Orthotopic procedure====
Surgery is usually reserved for patients with advanced, irreversible heart failure with a severely limited life expectancy. Surgery is not the first-line treatment option for patients with heart failure. The mainstay of treatment for heart failure is medical/device therapy.
The '''orthotopic procedure''' begins with the surgeons performing a [[median sternotomy]] to expose the [[mediastinum]]. The [[pericardium]] is opened, the [[great vessels]] are dissected and patient is attached to [[cardiopulmonary bypass]]. The failing heart is removed by transecting the great vessels and a portion of the [[left atrium]]. The [[pulmonary vein]]s are not transected; rather a circular portion of the left atrium containing the pulmonary veins is left in place. The donor heart is trimmed to fit onto the patients remaining left atrium and great vessels and [[suture]]d in place. The new heart is restarted, the patient is weaned from cardiopulmonary bypass and the chest cavity is closed.
 
==Indications==
 
*Surgery is the first-line treatment option for patients with either:
===Systolic Heart Failure with a Left Ventricular Ejection Fraction less than 35%===
 
<ref name="pmid26776864">{{cite journal| author=Mehra MR, Canter CE, Hannan MM, Semigran MJ, Uber PA, Baran DA | display-authors=etal| title=The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update. | journal=J Heart Lung Transplant | year= 2016 | volume= 35 | issue= 1 | pages= 1-23 | pmid=26776864 | doi=10.1016/j.healun.2015.10.023 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26776864  }} </ref>
 
*Due to either:
:*Ischemic [[cardiomyopathy]]
:*Dilated [[cardiomyopathy]]
:*[[Valvular heart disease]]
:*[[Hypertensive heart disease]]
:*''Etiologies which are excluded are [[amyloid]], [[HIV]], and cardiac [[sarcoma]]''
 
===Ischemic Coronary Artery Disease with Refractory Angina===
*Ischemia which is not amenable to percutaneous or surgical revascularization ([[coronary artery bypass graft surgery]] CABG) and is refractory to maximally tolerated medical and/or device therapy. <ref name="pmid27772668">{{cite journal| author=Lund LH, Edwards LB, Dipchand AI, Goldfarb S, Kucheryavaya AY, Levvey BJ | display-authors=etal| title=The Registry of the International Society for Heart and Lung Transplantation: Thirty-third Adult Heart Transplantation Report-2016; Focus Theme: Primary Diagnostic Indications for Transplant. | journal=J Heart Lung Transplant | year= 2016 | volume= 35 | issue= 10 | pages= 1158-1169 | pmid=27772668 | doi=10.1016/j.healun.2016.08.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27772668  }} </ref>
 
===Intractable life-threatening Arrhythmias===
*[[Ventricular arrhythmias]] which are not controlled by an [[implantable cardioverter-defibrillator]] and are refractory or not amenable to electrophysiologic guided single or combination medical therapy
* Patients that are not a candidate for catheter ablation therapy. <ref name="pmid25132979">{{cite journal| author=Alraies MC, Eckman P| title=Adult heart transplant: indications and outcomes. | journal=J Thorac Dis | year= 2014 | volume= 6 | issue= 8 | pages= 1120-8 | pmid=25132979 | doi=10.3978/j.issn.2072-1439.2014.06.44 | pmc=4133547 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25132979  }} </ref>
 
===Cardiomyopathies===
*Restrictive and Hypertrophic Cardiomyopathies with [[New York heart association functional classification|NYHA Class IV]] [[heart failure]] symptoms that persist despite maximal medical therapy, [[myomectomy]], [[alcohol septal ablation]], [[mitral valve replacement]]
*Non-dilated cardiomyopathies such as arrhythmogenic right ventricular cardiomyopathy. <ref name="pmid25132979">{{cite journal| author=Alraies MC, Eckman P| title=Adult heart transplant: indications and outcomes. | journal=J Thorac Dis | year= 2014 | volume= 6 | issue= 8 | pages= 1120-8 | pmid=25132979 | doi=10.3978/j.issn.2072-1439.2014.06.44 | pmc=4133547 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25132979  }} </ref>
 
===Congenital Heart Disease===
* CHD resulting in [[New York Heart Association (NYHA) class|New York Heart Association]] functional class IV Heart Failure not amenable to surgery.
* Severe symptomatic [[Congenital heart disease cyanotic|cyanotic congenital heart disease.]]
* Presence of some degree of [[pulmonary hypertension]] with the potential risk of developing fixed and irreversible elevation of [[pulmonary vascular resistance]] (PVR) <ref name="pmid25132975">{{cite journal| author=Thrush PT, Hoffman TM| title=Pediatric heart transplantation-indications and outcomes in the current era. | journal=J Thorac Dis | year= 2014 | volume= 6 | issue= 8 | pages= 1080-96 | pmid=25132975 | doi=10.3978/j.issn.2072-1439.2014.06.16 | pmc=4133537 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25132975  }} </ref>
 
==Surgery==
*The feasibility of [[surgery]] depends on the patient meeting the [[Criterion|criteria]] for a [[Heart transplantation|heart transplant]] and also the [[Risk-benefit analysis|risk-benefit ratio]].
 
===Pre-operative Procedure===
[[Heart transplantation]] needs a [[donor]] heart from a recently deceased or brain dead donor. The transplant patient is then thoroughly evaluated for the [[Surgery|operation]]. The donor heart is also evaluated to check its suitability for transplantation.
 
===Operative Procedure===
Once the donor heart has passed its inspection, the patient is taken into the [[operating theatre]] and given a [[general anesthetic]]. Either an '''orthotopic''' or a '''heterotopic''' procedure is followed, depending on the condition of the [[patient]] and the [[donor]] [[heart]]. <ref name="pmid23487534">{{cite journal| author=Flécher E, Fouquet O, Ruggieri VG, Chabanne C, Lelong B, Leguerrier A| title=Heterotopic heart transplantation: where do we stand? | journal=Eur J Cardiothorac Surg | year= 2013 | volume= 44 | issue= 2 | pages= 201-6 | pmid=23487534 | doi=10.1093/ejcts/ezt136 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23487534  }} </ref>
 
====Orthotopic Procedure====
In the '''orthotopic procedure''' a [[median sternotomy]] is done to expose the [[mediastinum]]. After opening the [[pericardium]], the [[great vessels]] including the superior vena cava, inferior vena cava, pulmonary artery, pulmonary vein and aorta are dissected and [[cardiopulmonary bypass]] is attached. The diseased heart is taken out after transecting the great vessels and a part of the [[left atrium]]. The [[pulmonary vein]]s are not transected; rather a circular portion of the left atrium containing the [[pulmonary]] [[Vein|veins]] is left in place. The donor heart is now fit onto the patient's remaining left atrium and great vessels. The transplanted heart is started after slowly weaning the patient from [[cardiopulmonary bypass]]. The procedure is completed by closing the [[chest]] cavity. <ref name="pmid29492395">{{cite journal| author=Jungschleger JGM, Boldyrev SY, Kaleda VI, Dark JH| title=Standard orthotopic heart transplantation. | journal=Ann Cardiothorac Surg | year= 2018 | volume= 7 | issue= 1 | pages= 169-171 | pmid=29492395 | doi=10.21037/acs.2018.01.18 | pmc=5827120 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29492395  }} </ref> <ref name="pmid387341">{{cite journal| author=Baumgartner WA, Reitz BA, Oyer PE, Stinson EB, Shumway NE| title=Cardiac homotransplantation. | journal=Curr Probl Surg | year= 1979 | volume= 16 | issue= 9 | pages= 1-61 | pmid=387341 | doi=10.1016/s0011-3840(79)80010-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=387341  }} </ref>


====Heterotopic procedure====
====Heterotopic procedure====
In the '''heterotopic procedure''', the patient's own heart is not removed before implanting the donor heart. The new heart is positioned so that the chambers and blood vessels of both hearts can be connected to form what is effectively a 'double heart'. The procedure can give the patients original heart a chance to recover, and if the donor's heart happens to fail (eg. through rejection), it may be removed, allowing the patients original heart to start working again. Heterotopic procedures are only used in cases where the donor heart is not strong enough to function by itself (due to either the patients body being considerably larger than the donor's, the donor having a weak heart, or the patient suffering from [[pulmonary hypertension]]).
In the '''heterotopic procedure''', the diseased heart is left in place and the [[donor]] heart is implanted. The [[donor]] heart is placed in  a way to have the chambers and [[Blood vessel|blood vessels]] of both [[Heart|hearts]] connected. This results in something to the effect of a 'double heart'. In this way, the patient's original heart can be given a chance to recover. Therefore, even if the [[donor]] heart fails, it is removed to allow the patient's original heart to start working again. Heterotopic procedure is advantageous when the [[donor]] heart is not strong enough to function independently. This may be due to various reasons such as disproportionate body size of the patient and donor, the donor heart being weak, or [[pulmonary hypertension]] in the patient.<ref name="pmid15227245">{{cite journal| author=Konertz W, Sheikhzadeh A, Weyand M, Friedl A, Bernhard A| title=Heterotopic heart transplantation: current indications for the procedure, with results in 10 patients. | journal=Tex Heart Inst J | year= 1988 | volume= 15 | issue= 3 | pages= 159-62 | pmid=15227245 | doi= | pmc=324818 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15227245  }} </ref> <ref name="pmid387341">{{cite journal| author=Baumgartner WA, Reitz BA, Oyer PE, Stinson EB, Shumway NE| title=Cardiac homotransplantation. | journal=Curr Probl Surg | year= 1979 | volume= 16 | issue= 9 | pages= 1-61 | pmid=387341 | doi=10.1016/s0011-3840(79)80010-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=387341  }} </ref>
 
===Post-Operative===
Post-operatively the patient requires [[Intensive care unit|ICU]] care. The following are essential in a post-transplant patient:
* Adherence to post-operative immunosuppressive[[Medication| medications]]
* Precautions against infections.
* [[Physical medicine and rehabilitation|Rehabilitation]]
* Emotional support.
Another post-operative change to expect is mild tachycardia of around 100 bpm because the [[vagus nerve]] is severed during transplantation.
 
===Living organ transplant===
 
*In February 2006, at Bad Oeynhausen Clinic for Thorax and Cardiovascular Surgery, Germany, a 'beating heart' was transplanted into a patient.<ref>{{cite news | author= | title=Bad Oeynhausen Clinic for Thorax- and Cardiovascular Surgery Announces First Successful Beating Human Heart Transplant | url=http://www.transmedics.com/wt/page/pr_1140714229 | date=23 February 2006 | publisher=TransMedics | accessdate=2007-05-14}}</ref>
* The donor heart is kept at [[body temperature]] and connected to a [[Organ care system|Organ Care System]]. This machine lets it to continue beating with [[oxygenated blood]] flowing through it. This ensures that the heart remains in a suitable condition for a longer time.
 
==Contraindications==
 
===Absolute Contraindications===
<ref name="ManciniLietz2010">{{cite journal|last1=Mancini|first1=Donna|last2=Lietz|first2=Katherine|title=Selection of Cardiac Transplantation Candidates in 2010|journal=Circulation|volume=122|issue=2|year=2010|pages=173–183|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.109.858076}}</ref>
 
*Patients who have a systemic illness with a [[life expectancy]]  of less than 2 years ''despite'' undergoing a HT, including
**Active or recent solid organ or blood [[malignancy]] in the last 5 years
**[[HIV AIDS|AIDS]] with a history of frequent [[opportunistic infection]]<nowiki/>s
**Active [[Multisystem organ failure|multisystem]] diseases like- [[systemic lupus erythematosus]], [[sarcoidosis]], or [[amyloidosis]]
**End-stage or irreversible [[renal]] or [[Hepatic failure|hepatic dysfunction]]
**Significant [[obstructive pulmonary disease]]
*Fixed or irreversible [[pulmonary hypertension]]
**Pulmonary artery systolic pressure >60 mm Hg
**Mean transpulmonary gradient >15 mm Hg
**[[Pulmonary vascular resistance]] >6 Wood units
 
===Relative Contraindications due to associated [[comorbidities]]===
<ref name="MehraCanter2016">{{cite journal|last1=Mehra|first1=Mandeep R.|last2=Canter|first2=Charles E.|last3=Hannan|first3=Margaret M.|last4=Semigran|first4=Marc J.|last5=Uber|first5=Patricia A.|last6=Baran|first6=David A.|last7=Danziger-Isakov|first7=Lara|last8=Kirklin|first8=James K.|last9=Kirk|first9=Richard|last10=Kushwaha|first10=Sudhir S.|last11=Lund|first11=Lars H.|last12=Potena|first12=Luciano|last13=Ross|first13=Heather J.|last14=Taylor|first14=David O.|last15=Verschuuren|first15=Erik A.M.|last16=Zuckermann|first16=Andreas|title=The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update|journal=The Journal of Heart and Lung Transplantation|volume=35|issue=1|year=2016|pages=1–23|issn=10532498|doi=10.1016/j.healun.2015.10.023}}</ref>
 
*'''Age''' - Patients are considered for cardiac transplant if they are < 70 years of age; or carefully selected patients over age 70.
* '''Obesity'''- [[Body mass index|BMI]] > 35 kg/m 2 is associated with a worse outcome.
* '''Cancer'''- Careful assessment of each [[neoplasm]] with a collaboration with oncology specialists to stratify each patient must be done. <ref name="pmid19195521">{{cite journal| author=Kellerman L, Neugut A, Burke B, Mancini D| title=Comparison of the incidence of de novo solid malignancies after heart transplantation to that in the general population. | journal=Am J Cardiol | year= 2009 | volume= 103 | issue= 4 | pages= 562-6 | pmid=19195521 | doi=10.1016/j.amjcard.2008.10.026 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19195521  }} </ref>
* '''Diabetes'''- End-organ damage and persistent poor [[Glycemic Targets in Diabetes|glycemic]] control ([[glycosylated hemoglobin]] [<nowiki/>[[Glycosylated hemoglobin|HbA 1c]]] > 7.5% or 58 mmol/mol) are relative contraindications
* '''Renal dysfunction'''- Irreversible [[renal dysfunction]] ( [[eGFR]] < 30 ml/min/1.73 m 2) is a relative contraindication
* '''Peripheral vascular disease'''- Clinically severe symptomatic [[cerebrovascular disease]] may be considered a contraindication.
* '''Infections'''- Use of [[Immunosuppressive therapy|immunosuppressive]] therapy post-transplantation may cause a flare up of active [[Infection|infections]].
**[[Human Immunodeficiency Virus (HIV)|Human immunodeficiency viral (HIV) infection]]
**[[Chagas disease]]
**[[Tuberculosis]]
**[[Hepatitis B]] and [[Hepatitis C|C]] viral (HBV and HCV) infections
* '''[[Tobacco Use Disorder|Tobacco]] use'''- Active tobacco smoking is a relative contraindication.
*[[Substance abuse|'''Substance Abuse'''-]] Active substance abusers (including [[Alcohol, Drug Abuse, and Mental Health Services Block Grant|alcohol]]) cannot receive a heart transplant.
* '''[[Psychosocial|Psychosocial evaluation]]'''- Lack of social support of presence of [[Cognitive|cognitive disability]] are relative contraindications.
 
==[[Cardiac Transplantation]] (DO NOT EDIT) <ref name="pmid35363500">{{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.0000000000001062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35363500  }} </ref><ref name="pmid23747642">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Masoudi FA, Butler J, McBride PE et al.| title=2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2013 | volume=  | issue=  | pages=  | pmid=23747642 | doi=10.1016/j.jacc.2013.05.019 |pmc=|url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23747642  }} </ref><ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation.] ''Circulation'' 119 (14):1977-2016.[http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID: [http://pubmed.gov/19324967 19324967]</ref><ref name="pmid16160202">Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al. (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16160202 ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society.] ''Circulation'' 112 (12):e154-235. [http://dx.doi.org/10.1161/CIRCULATIONAHA.105.167586 DOI:10.1161/CIRCULATIONAHA.105.167586] PMID: [http://pubmed.gov/16160202 16160202]</ref>==
 
{|class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
 
|-
|bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For selected [[patients]] with advanced [[HF]] despite GDMT, [[cardiac transplantation]] is indicated to improve [[survival]] and [[QOL]]. <ref name="pmid31548031">{{cite journal| author=Khush KK, Cherikh WS, Chambers DC, Harhay MO, Hayes D, Hsich E | display-authors=etal| title=The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: Thirty-sixth adult heart transplantation report - 2019; focus theme: Donor and recipient size match. | journal=J Heart Lung Transplant | year= 2019 | volume= 38 | issue= 10 | pages= 1056-1066 | pmid=31548031 | doi=10.1016/j.healun.2019.08.004 | pmc=6816343 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31548031  }} </ref><ref name="pmid31898418">{{cite journal| author=Colvin M, Smith JM, Hadley N, Skeans MA, Uccellini K, Goff R | display-authors=etal| title=OPTN/SRTR 2018 Annual Data Report: Heart. | journal=Am J Transplant | year= 2020 | volume= 20 Suppl s1 | issue=  | pages= 340-426 | pmid=31898418 | doi=10.1111/ajt.15676 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31898418  }} </ref><ref name="pmid32115073">{{cite journal| author=Teuteberg JJ, Cleveland JC, Cowger J, Higgins RS, Goldstein DJ, Keebler M | display-authors=etal| title=The Society of Thoracic Surgeons Intermacs 2019 Annual Report: The Changing Landscape of Devices and Indications. | journal=Ann Thorac Surg | year= 2020 | volume= 109 | issue= 3 | pages= 649-660 | pmid=32115073 | doi=10.1016/j.athoracsur.2019.12.005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32115073  }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])'' <nowiki>"</nowiki>
 
|}
 
{|class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:White"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Value Statement: Intermediate Value]]
 
|-
|bgcolor="White"|<nowiki>"</nowiki>'''2.''' In [[patients] with stage D (advanced) [[HF]] despite GDMT, [[cardiac transplantation]] provides intermediate economic value. <ref name="pmid24563450">{{cite journal| author=Long EF, Swain GW, Mangi AA| title=Comparative survival and cost-effectiveness of advanced therapies for end-stage heart failure. | journal=Circ Heart Fail | year= 2014 | volume= 7 | issue= 3 | pages= 470-8 | pmid=24563450 | doi=10.1161/CIRCHEARTFAILURE.113.000807 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24563450  }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])'' <nowiki>"</nowiki>


===Post-operative===
|}
The patient is taken into [[Intensive care unit|ICU]] to recover. When they wake up, they will be transferred to a special recovery unit in order to be [[Physical medicine and rehabilitation|rehabilitated]]. How long they remain in hospital post-transplant depends on the patient's general health, how well the new heart is working, and their ability to look after their new heart. Once the patient is released, they will have to return to the hospital for regular check-ups and rehabilitation sessions. They may also require emotional support. The number of visits to the hospital will decrease over time, as the patient adjusts to their transplant. The patient will have to remain on lifetime [[immunosuppressant]] medication to avoid the possibility of [[transplant rejection|rejection]]. Since the [[vagus nerve]] is severed during the operation, the new heart will beat at around 100 bpm until nerve regrowth occurs.


==References==
==References==
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[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Surgical procedures]]
[[Category:Surgery]]
[[Category:Surgery]]
[[Category:Surgery]]


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Latest revision as of 23:57, 22 June 2022

Heart transplantation Microchapters

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Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D.; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [1]Ifrah Fatima, M.B.B.S[2] Edzel Lorraine Co, DMD, MD[3]

Overview

Surgery is usually reserved for patients with advanced, irreversible heart failure with a severely limited life expectancy. Surgery is not the first-line treatment option for patients with heart failure. The mainstay of treatment for heart failure is medical/device therapy.

Indications

  • Surgery is the first-line treatment option for patients with either:

Systolic Heart Failure with a Left Ventricular Ejection Fraction less than 35%

[1]

  • Due to either:

Ischemic Coronary Artery Disease with Refractory Angina

  • Ischemia which is not amenable to percutaneous or surgical revascularization (coronary artery bypass graft surgery CABG) and is refractory to maximally tolerated medical and/or device therapy. [2]

Intractable life-threatening Arrhythmias

Cardiomyopathies

Congenital Heart Disease

Surgery

Pre-operative Procedure

Heart transplantation needs a donor heart from a recently deceased or brain dead donor. The transplant patient is then thoroughly evaluated for the operation. The donor heart is also evaluated to check its suitability for transplantation.

Operative Procedure

Once the donor heart has passed its inspection, the patient is taken into the operating theatre and given a general anesthetic. Either an orthotopic or a heterotopic procedure is followed, depending on the condition of the patient and the donor heart. [5]

Orthotopic Procedure

In the orthotopic procedure a median sternotomy is done to expose the mediastinum. After opening the pericardium, the great vessels including the superior vena cava, inferior vena cava, pulmonary artery, pulmonary vein and aorta are dissected and cardiopulmonary bypass is attached. The diseased heart is taken out after transecting the great vessels and a part of the left atrium. The pulmonary veins are not transected; rather a circular portion of the left atrium containing the pulmonary veins is left in place. The donor heart is now fit onto the patient's remaining left atrium and great vessels. The transplanted heart is started after slowly weaning the patient from cardiopulmonary bypass. The procedure is completed by closing the chest cavity. [6] [7]

Heterotopic procedure

In the heterotopic procedure, the diseased heart is left in place and the donor heart is implanted. The donor heart is placed in a way to have the chambers and blood vessels of both hearts connected. This results in something to the effect of a 'double heart'. In this way, the patient's original heart can be given a chance to recover. Therefore, even if the donor heart fails, it is removed to allow the patient's original heart to start working again. Heterotopic procedure is advantageous when the donor heart is not strong enough to function independently. This may be due to various reasons such as disproportionate body size of the patient and donor, the donor heart being weak, or pulmonary hypertension in the patient.[8] [7]

Post-Operative

Post-operatively the patient requires ICU care. The following are essential in a post-transplant patient:

Another post-operative change to expect is mild tachycardia of around 100 bpm because the vagus nerve is severed during transplantation.

Living organ transplant

  • In February 2006, at Bad Oeynhausen Clinic for Thorax and Cardiovascular Surgery, Germany, a 'beating heart' was transplanted into a patient.[9]
  • The donor heart is kept at body temperature and connected to a Organ Care System. This machine lets it to continue beating with oxygenated blood flowing through it. This ensures that the heart remains in a suitable condition for a longer time.

Contraindications

Absolute Contraindications

[10]

Relative Contraindications due to associated comorbidities

[11]

Cardiac Transplantation (DO NOT EDIT) [13][14][15][16]

Class I
"1. For selected patients with advanced HF despite GDMT, cardiac transplantation is indicated to improve survival and QOL. [17][18][19] (Level of Evidence: C-LD) "
Value Statement: Intermediate Value
"2. In [[patients] with stage D (advanced) HF despite GDMT, cardiac transplantation provides intermediate economic value. [20] (Level of Evidence: C-LD) "

References

  1. ↑ Mehra MR, Canter CE, Hannan MM, Semigran MJ, Uber PA, Baran DA; et al. (2016). "The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update". J Heart Lung Transplant. 35 (1): 1–23. doi:10.1016/j.healun.2015.10.023. PMID 26776864.
  2. ↑ Lund LH, Edwards LB, Dipchand AI, Goldfarb S, Kucheryavaya AY, Levvey BJ; et al. (2016). "The Registry of the International Society for Heart and Lung Transplantation: Thirty-third Adult Heart Transplantation Report-2016; Focus Theme: Primary Diagnostic Indications for Transplant". J Heart Lung Transplant. 35 (10): 1158–1169. doi:10.1016/j.healun.2016.08.017. PMID 27772668.
  3. ↑ 3.0 3.1 Alraies MC, Eckman P (2014). "Adult heart transplant: indications and outcomes". J Thorac Dis. 6 (8): 1120–8. doi:10.3978/j.issn.2072-1439.2014.06.44. PMC 4133547. PMID 25132979.
  4. ↑ Thrush PT, Hoffman TM (2014). "Pediatric heart transplantation-indications and outcomes in the current era". J Thorac Dis. 6 (8): 1080–96. doi:10.3978/j.issn.2072-1439.2014.06.16. PMC 4133537. PMID 25132975.
  5. ↑ Flécher E, Fouquet O, Ruggieri VG, Chabanne C, Lelong B, Leguerrier A (2013). "Heterotopic heart transplantation: where do we stand?". Eur J Cardiothorac Surg. 44 (2): 201–6. doi:10.1093/ejcts/ezt136. PMID 23487534.
  6. ↑ Jungschleger JGM, Boldyrev SY, Kaleda VI, Dark JH (2018). "Standard orthotopic heart transplantation". Ann Cardiothorac Surg. 7 (1): 169–171. doi:10.21037/acs.2018.01.18. PMC 5827120. PMID 29492395.
  7. ↑ 7.0 7.1 Baumgartner WA, Reitz BA, Oyer PE, Stinson EB, Shumway NE (1979). "Cardiac homotransplantation". Curr Probl Surg. 16 (9): 1–61. doi:10.1016/s0011-3840(79)80010-6. PMID 387341.
  8. ↑ Konertz W, Sheikhzadeh A, Weyand M, Friedl A, Bernhard A (1988). "Heterotopic heart transplantation: current indications for the procedure, with results in 10 patients". Tex Heart Inst J. 15 (3): 159–62. PMC 324818. PMID 15227245.
  9. ↑ "Bad Oeynhausen Clinic for Thorax- and Cardiovascular Surgery Announces First Successful Beating Human Heart Transplant". TransMedics. 23 February 2006. Retrieved 2007-05-14.
  10. ↑ Mancini, Donna; Lietz, Katherine (2010). "Selection of Cardiac Transplantation Candidates in 2010". Circulation. 122 (2): 173–183. doi:10.1161/CIRCULATIONAHA.109.858076. ISSN 0009-7322.
  11. ↑ Mehra, Mandeep R.; Canter, Charles E.; Hannan, Margaret M.; Semigran, Marc J.; Uber, Patricia A.; Baran, David A.; Danziger-Isakov, Lara; Kirklin, James K.; Kirk, Richard; Kushwaha, Sudhir S.; Lund, Lars H.; Potena, Luciano; Ross, Heather J.; Taylor, David O.; Verschuuren, Erik A.M.; Zuckermann, Andreas (2016). "The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update". The Journal of Heart and Lung Transplantation. 35 (1): 1–23. doi:10.1016/j.healun.2015.10.023. ISSN 1053-2498.
  12. ↑ Kellerman L, Neugut A, Burke B, Mancini D (2009). "Comparison of the incidence of de novo solid malignancies after heart transplantation to that in the general population". Am J Cardiol. 103 (4): 562–6. doi:10.1016/j.amjcard.2008.10.026. PMID 19195521.
  13. ↑ Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM; et al. (2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e876–e894. doi:10.1161/CIR.0000000000001062. PMID 35363500 Check |pmid= value (help).
  14. ↑ Yancy CW, Jessup M, Bozkurt B, Masoudi FA, Butler J, McBride PE; et al. (2013). "2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. doi:10.1016/j.jacc.2013.05.019. PMID 23747642.
  15. ↑ Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009)2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016.DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967
  16. ↑ Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al. (2005) ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 112 (12):e154-235. DOI:10.1161/CIRCULATIONAHA.105.167586 PMID: 16160202
  17. ↑ Khush KK, Cherikh WS, Chambers DC, Harhay MO, Hayes D, Hsich E; et al. (2019). "The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: Thirty-sixth adult heart transplantation report - 2019; focus theme: Donor and recipient size match". J Heart Lung Transplant. 38 (10): 1056–1066. doi:10.1016/j.healun.2019.08.004. PMC 6816343 Check |pmc= value (help). PMID 31548031.
  18. ↑ Colvin M, Smith JM, Hadley N, Skeans MA, Uccellini K, Goff R; et al. (2020). "OPTN/SRTR 2018 Annual Data Report: Heart". Am J Transplant. 20 Suppl s1: 340–426. doi:10.1111/ajt.15676. PMID 31898418.
  19. ↑ Teuteberg JJ, Cleveland JC, Cowger J, Higgins RS, Goldstein DJ, Keebler M; et al. (2020). "The Society of Thoracic Surgeons Intermacs 2019 Annual Report: The Changing Landscape of Devices and Indications". Ann Thorac Surg. 109 (3): 649–660. doi:10.1016/j.athoracsur.2019.12.005. PMID 32115073 Check |pmid= value (help).
  20. ↑ Long EF, Swain GW, Mangi AA (2014). "Comparative survival and cost-effectiveness of advanced therapies for end-stage heart failure". Circ Heart Fail. 7 (3): 470–8. doi:10.1161/CIRCHEARTFAILURE.113.000807. PMID 24563450.


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