Heart_Transplant_Guidelines_Presentation.pptx

Heart transplant

1. Heart Transplant: Contemporary Practice & Guideline Highlights National Cardiology Conference Prepared by: Dr. Sunny Bhasal Date: 05 Oct 2025

2. Outline Epidemiology & Indications Candidate evaluation & listing criteria (ISHLT 2024 highlights) Donor selection & allocation considerations Perioperative & early postoperative care (ISHLT 2023) Mechanical circulatory support (MCS) bridging (ISHLT 2023) Immunosuppression: induction & maintenance Rejection detection: cellular & antibody-mediated rejection (AMR) Antibody management & desensitization (consensus 2025) Long-term complications & outcomes Key takeaways & guideline recommendations References

3. Epidemiology & Indications Global transplant volumes; shifting donor profiles and increased MCS use Common indications: end-stage heart failure refractory to medical therapy, cardiogenic shock despite optimal therapy, select congenital heart disease Relative increase in transplants bridged from durable LVADs

4. Candidate Evaluation & Listing (ISHLT 2024) Comprehensive assessment: functional status, comorbidities, frailty, psychosocial evaluation Cardiac-specific: hemodynamics, pulmonary vascular resistance, RV dysfunction, prior sternotomies Infectious disease, malignancy screening, adherence assessment, substance use evaluation Use risk-stratified pathways; multidisciplinary heart transplant committee decisions

5. Contraindications & High-Risk Features Absolute: active, uncontrolled infection; active malignancy with high recurrence risk Relative: severe irreversible end-organ dysfunction, significant frailty, uncontrolled substance abuse Special considerations: age, comorbid pulmonary hypertension, prior sensitization

6. Donor Selection & Allocation Donor–recipient size and blood type compatibility; HLA considerations in sensitized recipients Evolving donor pool: older donors, donors after circulatory death (DCD) in some centers Allocation systems: prioritize urgency, waitlist mortality, geography (varies by country)

7. Perioperative & Early Postoperative Care (ISHLT 2023) Standard monitoring: continuous ECG, invasive arterial pressure, central venous pressure; early 12‑lead ECG Hemodynamic support: vasopressors/inotropes as indicated; consider MCS if instability persists Glycemic control (target 140–180 mg/dL in ICU), infection prophylaxis, thromboprophylaxis strategies

8. Mechanical Circulatory Support (MCS) Indications for short-term MCS (ECMO, Impella) vs durable LVAD as bridge-to-transplant ISHLT 2023 MCS guidelines: selection, patient optimization, and timing of transplantation Impact on sensitization, infection risk, thrombosis, and post-transplant outcomes

9. Immunosuppression: Induction & Maintenance Induction agents commonly used: anti-thymocyte globulin (ATG), basiliximab (center-dependent) Maintenance: calcineurin inhibitor (tacrolimus preferred), antimetabolite (mycophenolate mofetil), corticosteroids Personalize therapy for infection risk, renal dysfunction; consider CNI-sparing strategies in CKD

10. Rejection Surveillance Endomyocardial biopsy (EMB) remains gold standard for surveillance (schedule varies by center) Noninvasive monitoring: gene-expression profiling, donor-derived cell-free DNA (dd-cfDNA) as adjuncts AMR recognition: clinical, histologic, and immunopathologic criteria; requires high index of suspicion

11. Antibody-Mediated Rejection (AMR) & Desensitization AMR diagnostic framework and grading (ISHLT/consensus statements) Treatment options: plasmapheresis, IVIG, rituximab, bortezomib, complement inhibition (eculizumab in select cases) Pre-transplant desensitization strategies for highly sensitized patients; importance of multidisciplinary planning

12. Infectious Disease Considerations Pre-transplant screening (CMV, EBV, TB, fungal exposures), perioperative prophylaxis Post-transplant: CMV prophylaxis strategies based on serostatus, fungal and PCP prophylaxis recommendations Vaccination guidance: inactivated vaccines pre-transplant when possible; live vaccines contraindicated post-transplant

13. Cardiac Allograft Vasculopathy (CAV) Leading cause of late graft loss; progressive diffuse intimal thickening Surveillance: coronary angiography ± IVUS or CT angiography; noninvasive ischemia testing has limited sensitivity Prevention: risk-factor control, statin therapy early post-transplant, consider mTOR inhibitors in selected patients

14. Long-Term Complications & Outcomes Infections, malignancy (skin cancers, PTLD), renal dysfunction, CAV, metabolic complications (diabetes, dyslipidemia) Survival: improving 1‑year survival but long-term outcomes shaped by CAV and comorbidities Importance of multidisciplinary long-term follow-up and rehabilitation

15. Special Populations Pediatric recipients: size-matching, growth, immunosuppression considerations Elderly recipients: careful frailty and comorbidity assessment Patients with prior sensitization, congenital heart disease, re-transplantation considerations

16. Ethical & Systems Considerations Equitable organ allocation, transparent waitlist practices, and informed consent Resource constraints in some settings—prioritization and program development Importance of transplant registries and quality improvement

17. Key Takeaways for Clinicians Use multidisciplinary, guideline-driven evaluation pathways (ISHLT 2024 candidate guidance) Optimize MCS timing and manage device-related complications (ISHLT MCS 2023) Vigilant rejection surveillance with combination of EMB and noninvasive tools; be proactive about AMR Early statin therapy, infection prophylaxis, and individualized immunosuppression to improve outcomes

18. Selected References & Guidelines ISHLT Guidelines for the care of heart transplant recipients. J Heart Lung Transplant. 2023. (Velleca et al.) ISHLT Guidelines for evaluation and care of cardiac transplant candidates. ISHLT 2024 document. ISHLT Guidelines for Mechanical Circulatory Support. J Heart Lung Transplant. 2023. ISHLT Consensus Summary on Antibodies and AMR (Conference Apr 2023; summary published 2025) ISHLT Registry data and donor selection updates (ISHLT.org)

19. Acknowledgements & Contact Prepared by: Dr. Sunny Bhasal Institution: Apple Saraswati Multi-speciality Hospital, Kolhapur Contact: [email protected] | [phone]