Chapter 72 Cardiac Transplant Evaluation (Case 53)
Case: A 55-year-old man with severe coronary artery disease and hx of heavy smoking presented with an acute myocardial infarction not amenable to percutaneous revascularization. After being taken to the operating room for surgical revascularization, he developed profound cardiogenic shock unresponsive to medical therapy. A ventricular assist device (VAD) was placed. He remained in the ICU, awaiting heart transplantation.
When asked to evaluate a patient for heart transplantation, I examine the underlying reasons for the patient’s heart failure, his age, comorbidities, and risk factors. I review the patient’s echocardiogram, coronary angiogram, as well as all of his current vasoactive medication and type of mechanical circulatory support. I consider the possible options of advanced medical, interventional, or nontransplant surgical therapies.
|• Blood type, antibody screen, CBC, CMP Panel-reactive antibody HLA typing and crossmatch (completed when donor identified).||$240|
|• CBC to look for anemia, thrombocytopenia||$21|
|• Comprehensive metabolic panel||$30|
|• CXR and pulmonary function tests||$190|
|• EKG to look for cardiac disease; echocardiography, right and left heart catheterization, coronary angiography||$2,500|
|• B-natriuretic peptide (BNP)||$50|
|• U/A and creatinine clearance||$85|
|• Anergy panel, PPD, HIV test||$115|
|• Culture urine/sputum/blood to r/o infection||$45|
|• Hepatitis panel (hepatitis B/C)||$65|
|• HBsAg, HBsAb, HBcAb; hepatitis C antibody; and RNA assay by PCR||$65|
|• Cytomegalovirus (IgG, IgM titer)||$45|
|• Prostate-specific antigen (men > 50 years) to r/o prostate cancer||$65|
|• PAP smear/mammography (women > 40 years) to r/o malignancy||$125|
|• Colonoscopy (men/women > 50 years)||$625|
B-natriuretic peptide (BNP) assays are key in evaluating heart failure patients. BNP levels greater than 100 pg/mL identify patients with heart failure with over 95% specificity and over 98% sensitivity.
Peak ventilatory oxygen uptake (Peak VO2): This parameter provides the most objective assessment of functional capacity in patients with heart failure and is an important predictor of when to perform cardiac transplantation. It is measured during exercise with rapidly responding gas analyzers that are capable of breath-by-breath determination of O2 and CO2 concentrations. Patients with peak VO2 14 mL/kg per minute are likely to experience the most pronounced improvement in survival with transplantation.