Heart transplantation criteria: Difference between revisions

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===Cardiopulmonary stress testing to guide transplant listing===
===Cardiopulmonary stress testing to guide transplant listing===


Exercise capacity as assessed by VO2max is a dynamic objective variable that assesses cardiac reserve and peripheral adaptations to a reduced cardiac output much more accurately than NYHA classification.
Exercise capacity as assessed by VO2max is a dynamic objective variable that assesses cardiac reserve and peripheral adaptations to a reduced cardiac output much more accurately than NYHA classification.  


A maximal cardiopulmonary exercise test is defined as one with a respiratory exchange ratio (RER) > 1.05 and achievement of an anaerobic threshold on optimal pharmacologic therapy.  
* A maximal cardiopulmonary exercise test is defined as one with a respiratory exchange ratio (RER) > 1.05 and achievement of an anaerobic threshold on optimal pharmacologic therapy.
 
The following cutoff values of peak oxygen consumption (VO2) are used to guide listing in various cases-
* Patients intolerant of a β-blocker- Peak Vo 2 of ≤ 14 ml/kg/min
* In the presence of a β-blocker- peak Vo 2 of ≤ 12 ml/kg/min
* Young patients (< 50 years) and women- percent of predicted (≤ 50%) peak Vo 2 and using alternate standards in conjunction it
* Sub-maximal cardiopulmonary exercise test (RER < 1.05)- use of ventilation equivalent of carbon dioxide (Ve/Vco 2) slope of > 35
* Obese (body mass index [BMI] > 30 kg/m 2) patients- adjusting peak Vo 2 to lean body mass may be considered. A lean body mass–adjusted peak Vo 2 of < 19 ml/kg/min is used for listing.


===Use of Heart Failure prognosis scores===
===Use of Heart Failure prognosis scores===

Revision as of 12:21, 7 June 2020

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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]

Criteria for Cardiac Transplantation

While assessment of the indications and contraindications are important first steps in evaluating the appropriateness for cardiac transplantation, the prognosis of a patient with and without transplantation is critical in making the final determination as to whether a patient is suitable for cardiac transplantation. Discussed below are criteria that are used based upon the estimation of the patient's prognosis. The pre-transplantation evaluation includes-

Cardiopulmonary stress testing to guide transplant listing

Exercise capacity as assessed by VO2max is a dynamic objective variable that assesses cardiac reserve and peripheral adaptations to a reduced cardiac output much more accurately than NYHA classification.

  • A maximal cardiopulmonary exercise test is defined as one with a respiratory exchange ratio (RER) > 1.05 and achievement of an anaerobic threshold on optimal pharmacologic therapy.

The following cutoff values of peak oxygen consumption (VO2) are used to guide listing in various cases-

  • Patients intolerant of a β-blocker- Peak Vo 2 of ≤ 14 ml/kg/min
  • In the presence of a β-blocker- peak Vo 2 of ≤ 12 ml/kg/min
  • Young patients (< 50 years) and women- percent of predicted (≤ 50%) peak Vo 2 and using alternate standards in conjunction it
  • Sub-maximal cardiopulmonary exercise test (RER < 1.05)- use of ventilation equivalent of carbon dioxide (Ve/Vco 2) slope of > 35
  • Obese (body mass index [BMI] > 30 kg/m 2) patients- adjusting peak Vo 2 to lean body mass may be considered. A lean body mass–adjusted peak Vo 2 of < 19 ml/kg/min is used for listing.

Use of Heart Failure prognosis scores

1. Seattle Heart Failure Model (SHFM) - An estimated 1-year survival as calculated by the Seattle Heart Failure Model (SHFM) of < 80%

The factors considered in this model are-

  • age
  • sex
  • NYHA class
  • weight
  • ejection fraction
  • blood pressure
  • medications,
  • few laboratory values

SHFM model has also incorporated the impact of newer HF therapies on survival, including ICDs and CRT.

2. Heart Failure Survival Score (HFSS) in the high/medium risk range

The predictors of survival in the HFSS include: [1]

  • Presence or absence of coronary artery disease
  • Resting heart rate
  • Left ventricular ejection fraction
  • Mean arterial blood pressure
  • Presence or absence of an intraventricular conduction delay on ECG
  • Serum sodium
  • VO2max.


3. Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score

Listing patients solely on the criteria of heart failure survival prognostic scores should not be performed. [2]

Role of Diagnostic Right Heart Catheterization

  • Right heart catheterization (RHC) should be performed on all adult candidates in preparation for listing for cardiac transplantation and periodically until transplantation.


Donor Criteria

  1. Brain death declared
  2. Age <45 (special exceptions)
  3. No pre-existent heart disease
  4. Few coronary artery disease risk factors
  5. No untreated acute infections
  6. No systemic malignancy
  7. No cardiac trauma
  8. Normal ECG
  9. Normal echocardiogram
  10. Negative HIV and Hepatitis screen

References

  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.
  2. 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.


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