Thoracic Organ Transplantation

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Thoracic Organ Transplantation

• A. Rüçhan Akar
• Ankara University School of Medicine
• Department of Cardiovascular Surgery
• January-2004
• Contributions to Rakar_at_medicine.ankara.edu.tr

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to donate ones organs after death is an
act of charity that involves no risk at all
yet can provide another human being with
the gift of life
Sir Roy Calne, 1970 A Gift of Life
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Heart Transplantation
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Alexis Carrel Triangulating vessels for an
end-to-end anastomosis 1901 Alexis Carrel and
Charles Guthrie First heterotopic heart
transplantation in dog 1905 Nobel Prize, 1912
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Frank MannMayo Clinic

• Allograft rejection
• biological incompatibility between donor and
  recepient manifested by impressive leukocyte
  infiltration

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Prof. Vladimir P. Demikhov 1946 First
intrathoracic heterotopic heart allograft his
two-headed dog two days after the
operation First heart-lung block
transplantation was not reported in the Western
World until 1962
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John H. Gibbon Father of the cardiopulmonary
bypass pump May-1953
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Tom Starzl, 1963 father of liver
transplantation
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Historical Milestones

• experimental orthotopic cardiac transplantation
• Goldberg et al. (Maryland Un.) 1958
• description of anastomoses of atrial cuffs
• Cass and Brock (Guys Hosp.) 1959
• operative techniques, graft preservation
• Norman Shumway and Richard Lower (Stanford Un.)
  1960

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James HardyUniversity of Mississippi

• 1964- The first human cardiac transplant with
  xenograft (chimpanzee)
• Early mortality (the primate heart was unable to
  maintain the recepients circulatory load

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Barnard, De Bakey, Kantrowitz
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Jesus, its going to work
Christiaan Barnard Groote Schuur Hospital,
South Africa 552 a.m. Sunday 3rd Dec. 1967
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• First Successful Clinical
• Orthotopic Heart Transplantation
• Christiaan Barnard
• Groote Schuur Hospital, South Africa
• 3rd Dec. 1967
• donor 24 year old brain death woman injured by
  a car
• recipient 54 year old male with end-stage IHD
• survival 18 days
• cause of death Pseudomonas aeruginosa pneumonia

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Louis Washkansky on his hospital bed after heart
transplantation
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(No Transcript)
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Norman E Shumway operative techniques, graft
preservation 4th human heart transplantation 6th
Jan 1968
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• 1968
• 102 heart transplantations performed in many
  centers all over the world
• 1970
• poor outcome stopped activities in most centers,
• Stanford team continued efforts to develop
  techniques and treatments

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Tolypocladium inflatum the primitive fungus from
which Cyclosporine is extracted
1980s, (beginning of modern era for
transplantation Cyclosporine A used in clinical
heart transplantation FDA approval-1983
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Adult Heart Transplantation Indications

• Cardiomyopathy 46
• Coronary artery disease 45
• Valvular 3.5
• Congenital 1.8
• Re-transplantation 2
• Misc.. 1.6

15th official report-1998 The registry of the
International Society for Heart and Lung
Transplantation
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Paediatric Heart Transplantation Indications

• Congenital heart disease 46
• Cardiomyopathy 44
• Misc.. 6.4
• Re-transplantation 3.6

15th official report-1998 The registry of the
International Society for Heart and Lung
Transplantation
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Recipient Exclusion Criteria for Cardiac
Transplantation
(I)

• Age gt 70 (controversial)
• Fixed pulmonary hypertension
• PVR gt 6 Wood Units
• Transpulmonary gradient gt 15 mmHg
• coexistent systemic illness with poor prognosis
• coexisting neoplasm other than skin cancer
• HIV/AIDS ( CD4 count lt 200 cells/mm3)
• SLE or sarcoid that has multisystem involvement
• irreversible renal dysfunction
• irreversible hepatic dysfunction

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Recipient Exclusion Criteria for Cardiac
Transplantation
(II)

• irreversible pulmonary parenchymal disease
• Severe PVD or cerebrovascular disease
• peptic ulcer disease
• IDDM with end-organ damage
• past malignancy
• active infection
• acute pulmonary embolism
• current or recent diverticulitis
• myocardial infiltrative disease
• severe obesity, cachexia
• severe osteoporosis
• psychosocial instability or substance abuse
  (alcohol, drug)

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Evaluation of Potential Cardiac Recipient

• Comprehensive history
• Physical examination
• CXR
• 12-lead ECG
• Hematologic and biochemical profile
• Infectious disease serologies
• Exercise test with VO2max
• Right heart catheterization
• Coronary angiography
• Endomyocardial biopsy (for non-ischemic HF)

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Evaluation of Potential Cardiac Recipient

• Thyroid function studies
• Fasting and postprandial blood sugar
• Creatinine clearance
• Lipoprotein electrophoresis
• Viral titers
• Fungal serologies
• Holter monitor
• Echocardiogram
• Pulmonary function tests
• Panel reactive antibody screen
• HLA typing

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Indications for Cardiac Transplantation

• Prognosis for 1-year survival without
  transplantation should be less than 50

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Indications for Cardiac Transplantation

• Low EF lt 20
• Reduced VO2max (lt 10ml/kg/min)
• Reduced serum Na lt 135mEq/dL
• High PCWP gt25 mmHg
• Elevated plasma norepinephrine gt600pg/mL
• Increased cardiothoracic ratio

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Management of Potential Cardiac Recipient

• Pharmalogical
• ACE inhibitors
• beta blockers
• diuretics (especially spironolactone)
• Pharmalogical bridge to TX
• Milrinone
• Dobutamine
• Dopamine

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Management of Potential Cardiac Recipient

• Mechanical bridge to TX
• IABP
• Ventricular assist device (VAD)
• Total artificial heart (TAH)
• AICD (for life threatening ventricular
  arrhythmias)