Heart Transplant

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Introduction

Cardiac transplantation, also called heart transplantation, has evolved into the treatment of choice for many people with severe heart failure (HF) who have severe symptoms despite maximum medical therapy. Survival among cardiac transplant recipients has improved as a result of improvements in treatments that suppress the immune system and prevent infection.

Definition

A heart transplant, or a cardiac transplantation, is a surgical transplant procedure performed on patients with end-stage heart failure or severe coronary artery disease

Indications

The general indications for cardiac transplantation include deteriorating cardiac function and a prognosis of less than 1 year to live. Specific indications include the following:

Dilated cardiomyopathy

Ischemic cardiomyopathy

Congenital heart disease for which no conventional therapy exists or for which conventional therapy has failed

Ejection fraction less than 20%

Intractable angina or malignant cardiac arrhythmias for which conventional therapy has been exhausted

Pulmonary vascular resistance of less than 2 Wood units

Age younger than 65 years

Ability to comply with medical follow-up care

Contraindications

Some patients are less suitable for a heart transplant, especially if they suffer from other circulatory conditions related to the heart. The following conditions in a patient increase the chances of complications:

Kidney, lung, or liver disease

Insulin-dependent diabetes with other organ dysfunction

Life-threatening diseases unrelated to heart failure

Vascular disease of the neck and leg arteries.

High pulmonary vascular resistance

Recent thromboembolism

Age over 65 years (some variation between centers)

Active systemic infection

Active systemic disease such as collagen-vascular disease or sickle cell disease

Active malignancy - Patients with malignancies who have demonstrated a 3- to 5-year disease-free interval may be considered, depending on the tumor type and the evaluating program

An ongoing history of substance abuse (eg, alcohol, drugs, or tobacco)

Psychosocial instability

Inability to comply with medical follow-up care.

Procedures

Pre-operative

A typical heart transplantation begins when a suitable donor heart is identified. The heart comes from a recently deceased or brain dead donor, also called a beating heart cadaver. The patient is contacted by a nurse coordinator and instructed to come to the hospital for evaluation and 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 suitable condition.

Preprocedural Evaluation

Evaluation of the heart transplant candidate includes laboratory tests, imaging studies, and other tests as appropriate.

Closely monitor the heart transplant candidate for signs of clinical deterioration during the waiting period for a suitable donor organ. Administer standard therapy for congestive heart failure (CHF), Maintain close contact with the transplant center, keeping the consultants informed of ongoing medical and social issues pertaining to the candidate.

In the event of clinical deterioration, the transplant center may deem it appropriate to admit the patient so that he or she can be evaluated for implantation of an artificial cardiac assist device, an upgrade on the waiting list, or both. At times, the candidate may deteriorate to the point where transplantation is no longer an option. Carefully discuss these issues with the treating physicians, the patient, and the family.

Laboratory Studies

A hepatitis panel can serve as a screen, provided that no active antigenicity exists. Patients who are carriers of the disease or who have active disease are not considered candidates for heart transplantation. Hepatitis C positivity remains controversial with...
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