SOLID ORGAN TRANSPLANTATION

VI.  Thoracic Transplantation (heart, lung, heart/lung)

Introduction
Absolute Contraindications to Thoracic Transplantation
Relative Contraindications to Thoracic Transplantation
Temporary Contraindications to Thoracic Transplantation
Evaluation
Care During Waiting Time
Complications
Future of Thoracic Transplantation


Introduction

Michael Petty MS, RN, CCNS, CNS; Cardiothoracic Clinical Nurse Specialist at Fairview-University Medial Center, Minneapolis, Minnesota presented the following information at United Resource Network’s, A Course In Transplantation For Case Managers, Newport, RI, October 2003.

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Absolute Contraindications to Thoracic Transplantation

  • Positive prospective crossmatch with donor.
  • Bone marrow failure.
  • Malignancy precluding long-term survival.
  • Etiology likely to recur in transplanted organ(s).
  • Irreversible renal and/or hepatic dysfunction.
  • Diabetes with end organ damage.
  • Morbid obesity and sever cachexia.
  • Current cigarette/alcohol/drug use.
  • Fixed pulmonary hypertension in adult heart candidates.
  • History of noncompliance with medical regimens.
  • Inability to fully understand the procedure and its follow-up care (Petty, M., MS, RN 2003).

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Relative Contraindications to Thoracic Transplantation

  • Physiologic age

            Heart - </= 65 years of age.
            Single lung transplant  </= 65 years of age.
            Bilateral lung transplant </= 55 years of age.
            Heart-lung transplant </= 50 years of age.

  • Weight outside acceptable range.
  • Prednisone dose > 20 mg per day or 40 mg per day for lung recipients.
  • Tobacco use within 6 months.
  • Mechanical ventilation in lung transplant candidates.
  • Intrinsic renal disease (Petty, M., MS, RN 2003).

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Temporary Contraindications to Thoracic Transplantation

  • Inadequate insurance coverage – related to costs of the surgery, related to costs of immunosuppressive mediations, related to costs of follow-up visits (Petty, M., MS, RN 2003).

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Evaluation of Heart Candidates

  • Laboratory panels including immunology evaluation.
  • Viral antibody status (CMV, HSV, HIV, HBV, HCV).
  • Cardiopulmonary exercise testing.
  • Right and left heart catheterization with coronary angiogram if none recently.
  • Echocardiogram.
  • Cardiac biopsy.
  • Neurohormone levels.
  • DEXA scan.
  • Up-to-date primary care evaluation.
  • Neuropsychological evaluation (Petty, M., MS, RN 2003).

Evaluation Heart-Lung Candidates

  • Laboratory panels including immunology evaluation.
  • Viral antibody status (CMV, HSV, HIV, HBV, HCV).
  • Right and left heart catheterization with coronary angiogram if none recently.
  • Pulmonary function tests.
  • X-ray, CAT scan.
  • V/Q scan.
  • DEXA scan.
  • Up-to-date primary care evaluation.
  • Neuropsychological evaluation as needed (Petty, M., MS, RN 2003).

Evaluation Single or Bilateral Lung Candidates

  • Laboratory panels including immunology evaluation.
  • Viral antibody status (CMV, HSV, HIV, HBV, HCV).
  • Coronary angiogram.
  • Pulmonary function tests.
  • X-ray, CAT scan.
  • V/Q scan.
  • DEXA scan.
  • Up-to-date primary care evaluation.
  • Neuropsychological evaluation as needed (Petty, M., MS, RN 2003).

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Care During Waiting Period

  • Flolan (Epoprostenol) for Pulmonary Hypertension administered as a continuous infusion.

Needs dedicated intravenous line.
Cannot be stopped for more than 3-5 minutes.
Prolonged cessation can lead to rebound pulmonary hypertension and death (Petty, M., MS, RN 2003).

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Pulmonary Problems following Lung transplantation

  • Acute lung injury.
  • Pneumothorax, hemothorax.
  • Bacterial pneumonia.
  • Acute rejection.
  • Anastomatic problems.
  • CMV Pneumonia.
  • Non-CMV Viral Pneumonia.
  • Obliterative bronchiolitis.
  • Infection due to immunocompromised state.

Evaluation – Chest x-ray, bronchoscopy, brochoalvelar lavage, culture (blood, urine, sputum).
Treatment – Antibiotics, reduction in immunosuppression.

  • Decreased gas exchange due to airway narrowing.

Evaluation – Chest x-ray, bronchoscopy, spiral chest CT scan.
Treatment – Balloon dilation, stenting, laser therapy (Petty, M., MS, RN 2003).

Long Term Complications

  • Transplant Vasculopathy (Chronic Rejection).

Evaluation – endomyocardial biopsy, cardiac catheterization, echocardiogram, EKG.

  • Obliterative Bronchiolitis, Chronic Rejection, Bronchiolitis Obliterans Syndrome.

Evaluation – Chest x-ray, transbronchial biopsy, open lung biopsy (Petty, M., MS, RN 2003).

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Thoracic Transplantation in the future – Xenotransplantation, Artificial lung (Petty, M., MS, RN 2003).

Future state of the Art Cardiac Assist Programs

  • Abiomed BVS 5000 Left/Right/Bi-Ventricular Assist device.
  • Thoratec Left/Right/Bi-Ventricular Assist System.
  • HeartMate XVE Vented Electric Left Ventricular Assist System.  (Petty, M., MS, RN 2003).

Immunosuppression remains vital for patient/graft survival in thoracic transplants, as with all other transplants.  OPTN/SRTR 2005 noted some changes in immunosuppression after heart transplant.  One year after transplantation based on 2003 data, the use of tacrolimus-based regimens increased to 50% while that of cyclosporine-based regimens decreased to 43%.  Of these tacrolimus-based regimens, tacrolimus-mycophenolate mofetil remained the most commonly prescribed.  Two years following transplantation the most common maintenance regimens are mycophenolate mofetil combined with cyclosporine or tacrolimus (36% and 31%, respectively).  (2005 OPTN/SRTR Annual Report)

Post lung transplant, OPTN/SRTR (2005) data noted that for persons who received transplants in 2003 the use of tacrolimus-based regimens increased to 71% at one year post-transplant, while use of cyclosporine-based regimens decreased to 21%.  Of these tacrolimus-based regimens, tacrolimus-mycophenolate mofetil remained the most commonly employed (35%), followed by tacrolimus-azathioprine (23%).  Sirolimus was used as part of a regimen for only 5% of patients at one year following transplantation.  The data was further defined to note that at two years following transplantation done in 2002, the most common maintenance regimens are tacrolimus combined with mycophenolate mofetil (33%) or azathioprine (22%).  Cyclosporine is only administered in 21% of the regimens.  (2005 OPTN/SRTR Annual Report).

Based on the 2005 OPTN/SRTR Annual Report, the data for heart-lung transplants performed in 2003 indicated that the most prominent immunosuppressant regimen consisted of the use of tacrolimus-based medications.  The use of tacrolimus-based medications increased to 77%, while cyclosporine-based regimens decreased to 23%.  Tacrolimus-mycophenolate mofetil remained the most commonly used (36%), followed by tacrolimus-azathioprine (23%).  (2005 OPTN/SRTR Annual Report).

The Milliman Research Report 2005 outlined the following waiting times for Thoracic transplants.  In 2002 a patient had a 50% chance of receiving a heart transplant in 141 days on the waiting list.  The waiting lists for lung transplants estimated a 50% chance of receiving a single or double lung transplant in 694 days in 2001 and a 25% chance of receiving a transplant in in 215 days in 2002.  Heart-lung potential recipients had a 25 % chance of receiving transplant in 211 days in 2002.  (Milliman 2005)

The Milliman Research Report 2005 outlines the cost of thoracic transplants through the first year of follow-up as follows: 
Heart:  Evaluation - $20,100; Procurement - $74,400; Hospital - $240,500; Physician - $34,900; Follow-up - $81,600; Immunosuppressants - $27,400.
Lung (single):  Evaluation - $17,200; Procurement - $41,700; Hospital - $128,600; Physician - $28,200; Follow-Up - $56,500; Immunosuppressants - $27,700.
Lung (double):  Evaluation - $27,300; Procurement - $83,400; Hospital - $236,700; Physician - $44,700; Follow-Up - $89,700; Immunosuppressants - $26,400.

Heart-Lung:  Evaluation - $21,900; Procurement - $134,400; Hospital - $323,000; Physician - $46,500; Follow-up - $87,200; Immunosuppressants - $27,800.

 

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