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.
PATIENT CARE
Clinical Thinking
In evaluating a patient for heart transplantation it is important to:
• Assess the severity of heart failure. The prioritization of appropriate recipients for transplantation is based on survival and quality of life expected to be gained.
History
• Candidates for cardiac transplantation generally present with New York Heart Association (NYHA) class III symptoms (patients with marked limitation of activity comfortable only at rest) or class IV symptoms (patients confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest).
• In 2001, a new class system for heart failure patients was released by the American College of Cardiology and American Heart Association. It is meant to be used along with the NYHA functional class system and classifies heart failure in “stages” A through D.
• Stage C patients experience congestive heart failure (CHF) symptoms and have underlying structural heart disease.
Physical Examination
• A detailed physical examination should be performed with emphasis on signs and symptoms of heart failure. Signs of decompensated left heart failure include displaced apical beat (usually to the left due to cardiomegaly), pathologic S3 gallop, S4, and crackles at the lung bases due to pulmonary edema. Increased intensity of the pulmonic component of S2 is also indicative of left heart decompensation. The most common symptom of left heart failure is shortness of breath.
• Signs of right heart failure include peripheral edema, nocturia (due to increased venous return with leg elevation), jugular venous distention, hepatomegaly, hepatojugular reflux, and right ventricular heave. The most common symptoms of right heart failure are bloating and fatigue.
Tests for Consideration
• 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 |