heart_transplant_workup_for_conference.pptx

Heart transplant

1. Pre‑transplant Workup (Practical, Guideline‑anchored, Conference Version) For cardiologists, transplant physicians, and surgeons Presenter: Dr. [Your Name] Date: [Conference Date] Institution: [Your Institution] Key guideline anchors: ISHLT 2024; AHA/ACC/HFSA 2022; ESC 2021; ISHLT MCS 2023.

2. Objectives Give a succinct, clinically practical pre‑transplant evaluation pathway grounded in latest guidelines. Highlight key tests, thresholds, interpretation pitfalls and management decisions (RHC, PVR, CPET, immunology). Offer checklists, algorithms, and real case application for conference discussion.

3. Primary Guideline Anchors (selected) ISHLT 2024 — Evaluation & Care of Cardiac Transplant Candidates (comprehensive). citeturn0search0 AHA/ACC/HFSA 2022 — Heart Failure Guideline (referral, timing, GDMT). citeturn0search1 ESC 2021 — Acute & Chronic Heart Failure (referral and HF algorithms). citeturn0search7 ISHLT 2023 — Mechanical Circulatory Support guidelines (LVAD/MCS interplay). citeturn0search18 ISHLT/JHLT consensus on antibodies & sensitization — informs cPRA/DSA strategy. citeturn1search2turn0search4

4. Workup Domains (Practical Roadmap) 1) Hemodynamic & cardiac (RHC, CPET, imaging, coronary angiography) 2) Pulmonary (PFTs, ABG, CT, integrate PVR) 3) Renal & hepatic assessment (eGFR, LFTs, elastography/biopsy if needed) 4) Infectious screening & vaccinations 5) Immunology (HLA, cPRA, DSA, crossmatch & desensitization) 6) Malignancy screening, metabolic, psychosocial, frailty & nutrition 7) Multidisciplinary committee review and listing decision

5. Practical Pre‑transplant Algorithm (stepwise) 1. Confirm advanced HF despite optimized GDMT (AHA/ACC 2022). citeturn0search1 2. Initiate simultaneous workup streams (cardiac hemodynamics, imaging, infection, immunology). 3. Obtain RHC + vasoreactivity; assess PVR and reversibility (decides candidacy vs LVAD). citeturn0search0 4. Assess end‑organs (renal, hepatic) and treat reversible dysfunction. 5. Multidisciplinary committee integrates data — plan listing, LVAD bridge, or alternative therapy.

6. Hemodynamics: Right Heart Catheterization — What to measure (and why) Mandatory measurements: RA, RV, PA, PAWP (PCWP), cardiac output/index (Fick or thermodilution). citeturn0search0 Calculate PVR = (mPAP − PCWP) / CO (Wood units). Record mixed venous O2, SvO2, and oxygen saturations for shunt/oxygen extraction evaluation. Perform vasodilator testing if PVR elevated: inhaled NO or IV vasodilators (nitroprusside/milrinone) to test reversibility. citeturn0search0

7. Pulmonary Vascular Resistance: Thresholds & Management PVR > 5 Wood units — associated with high post‑transplant RV failure risk; require careful evaluation. citeturn0search0 If PVR reducible on vasodilator testing → transplant may proceed with caution. If fixed, high PVR → consider LVAD as bridge (after unloading PVR may fall) or combined strategies. citeturn0search18 Document pulmonary vascular reactivity and right ventricular function for perioperative planning.

8. Vasodilator Testing — Practical Protocol (example) Baseline hemodynamics documented first. Inhaled nitric oxide 20–40 ppm for 10–20 mins (rapid effect) or IV nitroprusside titrated to MAP and PCWP response. Monitor PCWP, mPAP, CO; consider repeat CO by Fick if values change. Interpretation: ↓PVR by ≥20% or to <3 Wood units (center-dependent) suggests reversibility.

9. Functional Testing: CPET & 6‑minute Walk Cardiopulmonary exercise testing (CPET): peak VO₂ is objective; peak VO₂ <12 mL/kg/min (or <14 off β‑blocker) supports listing. citeturn0search0turn0search1 VE/VCO₂ slope, anaerobic threshold, and oxygen pulse add prognostic info. 6MWT is practical for serial monitoring; track desaturation, distance trend and symptom response.

10. Echo & Cardiac Imaging: What to look for LV: EF, cavity size, CO estimate, diastolic filling pressures, TR severity. RV assessment: TAPSE, RV fractional area change, S' tissue Doppler, RV longitudinal strain — critical for perioperative risk. Strain imaging and cardiac MRI for fibrosis/infiltrative disease when etiology unclear. Coronary angiography or CTCA to define coronary disease and plan revascularization pre‑transplant. citeturn0search1turn0search7

11. Coronary Disease & Viability: Practical Decisions Significant CAD: assess for revascularization prior to listing or plan perioperative strategy. Viability testing (MRI, PET) helps decide revascularization vs transplant urgency. Older patients with multivessel disease need careful discussion re: coronary allograft vasculopathy risk and long‑term care.

12. Pulmonary Workup — Tests & When to Exclude PFTs (spirometry, DLCO): severe COPD/emphysema may preclude transplant. ABG: persistent hypercapnia or severe hypoxemia should be corrected/assessed. HRCT chest: interstitial lung disease or severe pulmonary fibrosis may contraindicate isolated heart transplant. Integrate with RHC PVR to determine candidacy.

13. Renal & Hepatic Assessment: Practical thresholds Renal: eGFR (CKD‑EPI), 24‑h CrCl; sustained eGFR <30 mL/min/1.73m² raises consideration for heart‑kidney transplant (center dependent). citeturn0search0 Hepatic: LFTs, INR, albumin — assess for congestive hepatopathy; use FibroScan/elastography or biopsy if concern for cirrhosis. Consider combined heart‑liver transplant or optimization strategies when irreversible disease present.

14. Infectious Screening & Vaccination (must‑do list) Viral serologies: HIV, HBsAg/anti‑HBc, HBV DNA, HCV RNA, CMV IgG, EBV IgG. citeturn0search0 TB screening (IGRA/TST), nasal MRSA screen, urine culture, dental clearance (source control). Update vaccines pre‑transplant where possible: influenza, pneumococcal, COVID‑19, varicella if seronegative.

15. Immunology: HLA, cPRA, DSA and Desensitization HLA Class I/II typing, calculate cPRA early — identifies sensitization and waiting time impact. citeturn1search4 ISHLT/consensus suggests cPRA ≥50% often triggers desensitization strategies (center dependent). citeturn1search2 Donor‑specific antibody (DSA) monitoring; virtual crossmatch to avoid incompatible donors. citeturn0search0 Desensitization tools: plasmapheresis/IVIG, rituximab, proteasome inhibitors (bortezomib) in select cases — evidence evolving (specialist center protocols). citeturn1search6turn1search5

16. Malignancy Screening: Practical Checklist Age‑appropriate screening: colonoscopy, mammogram, Pap/HPV, PSA as per local guidelines. citeturn0search0 Low‑dose chest CT for smokers; full‑body skin exam for suspicious lesions. Active malignancy is generally a contraindication until successfully treated and a disease‑free interval achieved (case by case).

17. Psychosocial Assessment & Adherence Formal psychiatric evaluation: screen for active substance abuse, severe mood disorders, cognitive impairment. citeturn0search0 Assess caregiver support, transportation, medication affordability, health literacy. If active issues identified — arrange addiction/psychiatric interventions and re‑evaluate candidacy.

18. Frailty & Nutrition — Modifiable Risk Factors Assess grip strength, gait speed, sarcopenia (CT psoas area if available). Nutrition: correct hypoalbuminemia, optimize protein calorie intake; consider dietitian involvement. Start tailored physiotherapy/prehabilitation while on the waitlist; LVAD patients benefit from supervised exercise programs. citeturn0search18

19. MCS (LVAD) — When and Why (practical points) Indications: cardiogenic shock, refractory HF with end‑organ dysfunction, or as planned bridge to transplant. citeturn0search18 LVAD can reduce PVR and reverse pulmonary vascular remodeling — useful when fixed PVR would preclude listing. Consider impact on sensitization (blood products, device) and infection risk — plan immunology and infection surveillance.

20. Waitlist Management & Ongoing Monitoring Regular re‑assessment schedule: hemodynamics (if indicated), labs, infection surveillance, immunology titers. Manage GDMT, optimize volume status and nutrition while waiting. Consider listing status exceptions or priority for highly sensitized or rapidly deteriorating patients. citeturn0search0

21. Donor Selection & Perioperative Practicalities Donor factors: age, size (BSA/height matching), ischemic time (aim <4 hours), ABO compatibility. Consider CMV/EBV serostatus for prophylaxis planning. High‑risk donors (long ischemia, donation after circulatory death) require center-level acceptance criteria and informed consent.

22. One‑page Clinical Checklist (Quick Reference) Cardiac: Echo, RHC (+vasoreactivity), CPET, coronary angiography Pulmonary: PFTs, ABG, HRCT Renal/Hepatic: eGFR, LFTs, FibroScan/biopsy if indicated Infectious: HIV/HBV/HCV, CMV/EBV, TB (IGRA), dental clearance Immunology: HLA, cPRA, DSA, plan for crossmatch Psychosocial: Addiction screen, caregiver + finances Nutrition/Frailty: baseline physio, albumin, BMI Committee: document decision & plan (LVAD vs listing)

23. Case Vignette: 58‑yr M, Ischemic CMP, Recurrent CHF Presentation: EF 15%, recurrent admissions, peak VO₂ 10 mL/kg/min, eGFR 40, PVR 4.8 WU (reduced to 2.8 with iNO). Workup decisions: RHC documented reversibility → listed for transplant; HLA cPRA 12% → routine immunology monitoring. If PVR had been fixed >5 WU, plan: LVAD implantation for PVR reversal and reassessment.

24. Troubleshooting & Common Pitfalls Single elevated creatinine measurement — recheck and assess volume status before excluding candidate. Thermodilution CO in severe TR/low flow is unreliable — use Fick if possible. Mistaking isolated pulmonary hypertension for true fixed PVR — always correlate with vasoreactivity. Underestimating psychosocial barriers — address early with SW/psychiatry.

25. Key Takeaways RHC + vasoreactivity, immunology (HLA/cPRA/DSA), and infectious/malignancy screening are non‑negotiable. citeturn0search0turn1search2 Use LVAD strategically to reverse PVR when appropriate (ISHLT MCS guidance). citeturn0search18 Document multidisciplinary committee decisions and maintain active, dynamic re‑evaluation.

26. References & Further Reading Selected references: ISHLT Guidelines 2024 — Evaluation & Care of Cardiac Transplant Candidates. citeturn0search0 Peled et al., JHLT 2024 (ISHLT guideline overview). citeturn0search10 AHA/ACC/HFSA 2022 Guideline for Management of Heart Failure. citeturn0search1 ESC 2021 Guidelines for Acute & Chronic Heart Failure. citeturn0search7 ISHLT 2023 MCS Guidelines (LVAD). citeturn0search18 cPRA / Sensitization summaries and ISHLT consensus. citeturn1search2turn0search4