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INTRODUCTION

St Paul’s Hospital Heart Transplant Program follows the 2001 Canadian Cardiovascular Society Consensus Conference on Cardiac Transplantation [pdf] (hereafter called “CCS Guidelines”) and advisories circulated by the Canadian Cardiac Transplant Group as a basis for it’s protocols pre-and post-heart transplant[1].

The program regularly reviews it’s outcomes by monitoring several Key Indicators [pdf].

INDICATIONS AND ASSESSMENT

FOR HEART TRANSPLANT

  • Refer to CCS Guidelines [pdf]
  • In addition, at St Paul’s Hospital:
  • NT-pro B-Type Natriuretic Peptide (NT-pro BNP):  Evidence is emerging to suggest that measurement of BNP as a prognostic marker may be a powerful tool.  The St Paul’s Hospital Heart Transplant Program uses NT-proBNP (a form of BNP) in conjunction with the measurements outlined in CCS Guidelines to aid in transplant listing or delisting decisions.  Currently, a level of 1,500pg/ml has been identified.  Levels greater than this has been associated with significantly increased mortality in heart failure patients[2-5]

CONTRAINDICATIONS FOR HEART TRANSPLANT

  • The items listed in the CCS Guidelines are RELATIVE contraindications.  In many cases, patients can still be assessed for heart transplant, however each item listed is considered carefully on an individual basis by the multidisciplinary transplant team before the patient is accepted or declined.
  • Discuss any queries with the Clinical Coordinator by phoning 604-806-8887.

REFERRING A PATIENT FOR HEART TRANSPLANT ASSESSMENT

  • Patients should be referred to the Clinical Coordinator at the B.C. Transplant Society Pre Transplant Clinic.
  • Business Hours:  604-806-8887

                                     604-806-8602

  • After Hours:          604-877-2240
  • Toll Free:                1-800-663-6189
  • Address:                 St.Paul’s Hospital
                                      Heart Centre 5C,
                                      1081 Burrard Street
                                      Vancouver, BC, V6Z 1Y6
  • Patients who are clinically stable are usually assessed for heart transplant as an outpatient through the Pre-Transplant Clinic.  Sometimes admission is required to complete testing, depending on the patient and their condition. The transplant team provides ongoing follow-up.

ASSESSMENT FOR HEART TRANSPLANT SUITABILITY

TRANSPLANT CANDIDACY

  • Transplant candidacy is a decided by the core heart transplant team based on the assessment results.  The decision is made by majority vote at a weekly team meeting, however the transplant surgeon and cardiologist have the final say.  In urgent situations, the Transplant Surgeon, Physician and Clinical Coordinator can decide to list a patient.
  • The core transplant team consists of:
  • Transplant Physicians and Surgeons
  • Nurses working in the transplant program
  • Clinical Coordinator (BCTS)
  • Clinical Nurse Specialist
  • Transplant Clinic Patient Educator
  • Clinical Social Worker
  • Psychologist
  • Physiotherapist
  • Dietician
  • Moral and ethical dilemmas are common.  The team uses as a basis for it’s decision making, a statement of agreed upon values [pdf].  The team also completes a “Heart Transplant Candidate Selection [pdf]” form that aids in the decision-making process.  When deemed necessary, a member of Ethics Services or other teams such as psychiatry or neurology attends the meeting and provides input.
  • During the assessment process the team also determines potential Ventricular Assist Device (VAD) candidacy [pdf] .

ACTIVATION TO THE HEART TRANSPLANT LIST

Once the patient has been accepted for transplant listing, the Clinical Coordinator provides the patient and family with the necessary information including:

  • Pager
  • Contact details
  • Travel
  • Monitoring

LISTING STATUS

In Canada, heart transplant candidates are prioritized according to an organ allocation system [pdf] determined by consensus of heart transplant physicians from all centres.

ORGAN DONATION AND REFERRAL

Organ donation is overseen in the province of BC by the BC Transplant Society (BCTS).  For information about the process please visit the BCTS website at http://www.transplant.bc.ca/odr_criteria_main.htm.

The Transplant

PREOPERATIVE PREPARATION

On 5A, there are pre prepared packages with all specific instructions clearly delineated within them including a nursing checklist [pdf].  There is a preadmission order set [pdf] available.

                         

IMMEDIATE POSTOPERATIVE MANAGEMENT

Immediate post-operative management is best outlined by reviewing the “Post-operative Heart Transplant Orders [pdf]”.

Post operative management is very similar to routine cardiac surgery cases.  The primary difference is tailoring of immunosuppression and overcoming poor initial cardiac function usually manifests as right-sided failure.  It occurs in many cases post-heart transplant[1, 6-8].  The most common causes can be:

  • high pulmonary vascular resistance (PVR) in the recipient either pre or post transplant
  • prolonged ischemic time
  • primary cardiac non-function, cause unknown

TRANSFER TO THE WARD

On average, patients stay in ICU for around 3-6 days.  Once stable, patients are transferred to 5A and transfer orders [pdf] are completed.

The focus, once transferred to the ward is self-management education.  The patient receives detailed training according to a defined clinical practice guideline [pdf].  The patient receives an easy to read version [pdf] of this, so they will know what to expect.

It is recognised that patients often cannot take in large amounts of information when recovering from surgery, so health care providers adhere to a schedule of short competency-based sessions [pdf], spread out over the patient’s stay in hospital.

ISOLATION PRECAUTIONS

Where possible the patient will be nursed in a private room after transplant.  The following guidelines apply to any persons entering the room:

•            Hands must be washed thoroughly.  This is the main control against infection.

•            Any visitor or personnel with a cold, throat infection, or known exposure to viral/bacterial infection should not enter the room.

•            All standard infection control principles apply.

•            Extra precautions will be posted on the patient’s door, depending on individual infection control needs.

 

DISCHARGE

Average length of stay for patients is 10 to 14 days.  Patients are discharged home once deemed stable by the team.  If their place of residence is more than 1 hour from St Paul’s Hospital, alternative accommodation may need to be found.  The Social Worker works with the patient and family during the assessment process to find the most suitable accommodation.

Patients are required to have at least one caregiver with them full-time for the first month at which point it may be assessed by the team on an individual basis.  Normally patients are required to stay near the hospital for at least 3 months, depending on their recovery.

Patients are provided with prescriptions for immunosuppressants [pdf] and other drugs [pdf] prior to their discharge.

IMMUNOSUPPRESSIVE PROTOCOLS

Standard introduction of immunosuppressants can be found in the immediate post-operative order [pdf] set, and in the transfer orders [pdf] .  Cyclosporine or tacrolimus (both calcineurin inhibitors) are usually not started until at least day 3 post-operatively and only in consultation with the transplant team.

Click here for the latest immunosuppressant blood levels [pdf] used in the heart transplant program.  A wallet card size [pdf] is also available.

Immunosuppression

The program uses cyclosporine[pdf] (Neoral®)-based triple therapy.  It is combined with prednisone and mycophenolate mofetil [pdf] (Cellcept®).

Basiliximab [pdf] (Simulect®) induction is used as per the standard protocol

Cyclosporine may be replaced in the following circumstances:

Renal impairment

Continuation with basiliximab titrated to CD25 count.  Once wound healing achieved commencement of sirolimus [pdf] (Rapamune®)

Young adult

Tacrolimus [pdf] (Prograf(®) replaces cyclosporine

Women

Tacrolimus is substituted for cyclosporine

Patients on sirolimus requiring routine surgery

basiliximab protocol [pdf]monitoring of CD25 count

Switching from cyclosporine to sirolimus[pdf] requires a period of careful monitoring.

ACUTE CARDIAC REJECTION

In 2005, the International Society for Heart and Lung Transplantation published an updated paper on revised nomenclature for Acute Cardiac Rejection.  St Paul’s program has adopted this guideline.

Biopsies are performed regularly for the first year post –transplant.  A follow up schedule [pdf] is available and tailored to each individual patient depending on their recovery.  In the inpatient areas the unit coordinator organises the biopsies [pdf] .  In the outpatient area, the transplant clerk organises the biopsies.

Treatment of Rejection:

As much as is possible, patients with cardiac rejection will be treated on an outpatient basis.  The severity of the rejection and accompanying signs and symptoms such as low BP, arrhythmia, fever, decreased exercise capacity may require inpatient treatment.

The program has a standard treatment table [pdf] for medical management of rejection.

CHRONIC REJECTION

Screening for chronic rejection [pdf] or graft atherosclerosis is performed at regular intervals.  The program uses dobutamine stress echocardiography, coronary angiography and intravascular ultrasound to screen for this long-term complication.

INFECTION PROPHYLAXIS

The CCS Guidelines [pdf] outline infection risks and some prophylaxis regimes.  Specifically at St Paul’s Hospital a specific infection prophylaxis protocol [pdf]is in place.  Routine vaccinations [pdf] are also encouraged.  Dental care requires antibiotic prophylaxis [pdf] .

REFERENCES

1.           Ross, H., et al., 2001 Canadian Cardiovascular Society Consensus Conference on cardiac transplantation.[erratum appears in Can J Cardiol. 2003 Jul;19(8):958 Note: Haddad, Henry [corrected to Haddad, Haissam]]. Canadian Journal of Cardiology, 2003. 19(6): p. 620-54.

2.           de Groote, P., et al., B-type natriuretic peptide and peak exercise oxygen consumption provide independent information for risk stratification in patients with stable congestive heart failure.[see comment]. Journal of the American College of Cardiology, 2004. 43(9): p. 1584-9.

3.              Gardner, R.S., et al., N-terminal pro-brain natriuretic peptide. A new gold standard in predicting mortality in patients with advanced heart failure. European Heart Journal, 2003. 24(19): p. 1735-43.

4.           Isnard, R., et al., Combination of B-type natriuretic peptide and peak oxygen consumption improves risk stratification in outpatients with chronic heart failure. American Heart Journal, 2003. 146(4): p. 729-35.

5.              Rothenburger, M., et al., Aminoterminal pro Type B Natriuretic Peptide as a Predictive and Prognostic Marker in Patients With Chronic Heart Failure. Journal of Heart and Lung Transplantation, 2004. 23(10): p. 1189-1197.

6.              Lovoulos, C., et al., Right ventricle-sparing heart transplantation effective against iatrogenic pulmonary hypertension. Journal of Heart & Lung Transplantation, 2004. 23(2): p. 236-41.

7.           Poston, R.S. and B.P. Griffith, Heart transplantation. Journal of Intensive Care Medicine, 2004. 19(1): p. 3-12.

8.              Espinoza, C., et al., Reversibility of pulmonary hypertension in patients evaluated for orthotopic heart transplantation: importance in the postoperative morbidity and mortality. Transplantation Proceedings, 1999. 31(6): p. 2503-4.