Cardiac Transplant Evaluation (Case 53)

Chapter 72 Cardiac Transplant Evaluation (Case 53)

Jaromir Kohout, MD, Louis Samuels, MD

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.

Speaking Intelligently

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.

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.
• Identify the most important contraindications for heart transplantation, such as fixed pulmonary hypertension, neoplasm, HIV, or the noncompliant or psychosocially unsuitable candidate.

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.
• Stage D patients suffer from end-stage CHF, requiring frequent hospitalizations or special treatments such as a left ventricular assist device, artificial heart, inotropic infusions, heart transplantation, or hospice care.

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.
• In most patients, one often finds a combination of signs and symptoms due to right- and left-sided dysfunction.

Tests for Consideration

1. Compatibility testing
  
• Blood type, antibody screen, CBC, CMP Panel-reactive antibody HLA typing and crossmatch (completed when donor identified). $240
2. Optimizing current physiology
  
• 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
3. Testing immune status and testing for occult infection
  
• 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
4. Screening for underlying malignancy
  
• 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

Interpretation of Laboratory Tests

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.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Cardiac Transplant Evaluation (Case 53)

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