With increasing success in heart and heart-lung transplantation, more centers have developed or are contemplating the initiation of a program. Although the introduction of cydosporine has resulted in an increase in survival of the transplant patient, its application alone does not ensure a successful program. Issues and problems necessary for the establishment of a successful program should be addressed and implemented to achieve the survival and quality of life comparable to established centers. This manuscript attempts to define the steps necessary to develop such a program and reports our early experience with heart and heart-lung transplantation.
Materials and Methods
Thorough preparation of all transplant-related disciplines, institutional commitment and a dedicated team are necessary components of a successful program. Guidelines for program development are listed in Table 1.
Development Stages of a Transplant Program Administration Requirements
Strong opinions regarding extra-renal organ transplantation exist in many state health care regulatory commissions. Most states have adopted a certificate-of-need (CON) policy for the establishment of a heart or heart-lung transplantation service. Some states, however, do not require a CON and grant approval as a further extension of the existing cardiac surgery program. Sustain your health conditions with medications of Canadian Health&Care Mall.
These essential administrative prerequisites, as well as ongoing administrative duties, require identification of a specific administrator in the surgical finance office to manage these aspects of the transplant service. Responsibilities of the designated administrator should include organization of the nonclinical departments or divisions rendering care to the transplant recipient; liaison with the state health care commission; and management of all financial aspects of the transplant procedure including recipient and donor procurement costs.
Non-clinical departments or divisions in the hospital, although not involved in the direct care of the transplant recipient, provide essential services in the overall management of the recipient. The Admitting Office should establish protocols to expedite recipient admission as well as donor body transportation to the referring hospital or locale following operation. This latter duty refers specifically to combined heart and lung transplantation carried out together with Canadian Health and Care Mall. Donors for this procedure are transported to the recipient hospital because of inadequate techniques for prolonged lung preservation. Patient billing preoperatively determines the extent of insurance coverage and the likelihood of third party reimbursement. Postoperatively, this department works with insurance companies and state Medicaid departments in securing reimbursement. An efficient and knowledgeable Public Affairs Office should protect the patients rights and physicians privacy while providing the press with accurate and pertinent information.
The Director of the Transplant Service is responsible for organization of the Clinical Departments and the overall operation of the program. Table 2 summarizes the responsibilities of each department.
Most programs maintain a central number to which all calls are directed. Initial screening can be performed at that time and then, if warranted, information packets are sent to the referring physicians. Once this information is returned, a clinic or inpatient visit is arranged. This often consists of right heart catheterization to determine pulmonary vascular resistance, a thorough psychosocial evaluation and an opportunity for all the members of the transplant team to become acquainted with the potential recipient Our present criteria for acceptance into the transplant program include: age <55 yrs; New York Heart Association class 4 symptoms; expected survival less than one year. Patients should be otherwise healthy, compliant, well-motivated and have strong family support. Accepted contraindications include insulin-dependent diabetes; cerebrovascular disease; irreversible liver or kidney disease; pneumonia or a recent pulmonary embolus; history of alcohol, drug abuse, mental illness, cancer; and elevated pulmonary vascular resistance (PVR). If the PVR can be reduced with pharmacologic interventions in the catheterization lab, patients may be accepted at an increased risk. Patients with a fixed resistance (>6 to 8 Wood units), although not appropriate candidates for heart transplantation, may be considered for heart-lung transplantation. These contraindications are considered likely to limit or preclude rehabilitation and result in survival less than currently expected.
Once a potential transplant recipient is accepted, notification is made to the transplant procurement coordinator. This person or group may exist within the institution or as a nonprofit organization dedicated to organ procurement outside the institution. The recipients age, blood type, size, whether a prospective crossmatch is necessary, other special requirements and severity of illness are listed on two computerized systems: United Network for Organ Sharing (UNOS) and North American Transplant Coordinators Organization (NATCO), according to age.
Evaluation of Heart and Heart-lung Donors
The most common neurologic catastrophe resulting in irreversible brain death is blunt head trauma. Age of the donors is an important criterion. Retrospective analysis of donor age in the Stanford series revealed a significant increase in the development of coronary atherosclerosis in the grafted heart from donors over the age of 35 years. Therefore, acceptable donors for heart and heart-lung transplantation are men less than 35 years of age and women less than 40 years of age. Further criteria of acceptability include stable hemodynamics without prolonged cardiac arrest and absence of previous cardiac diseases, thoracic trauma, infection, or malignancy. Hemodynamic stability is often difficult to maintain in a brain-dead patient. Correct management of these patients requires a thorough understanding of the peripheral effects of brain death and the therapeutic interventions employed. Enhance heart condition with remedies of Canadian Health&Care Mall.
As experience with extra-renal organ transplantation increases in the United States, multiple organ procurement will be obligatory to provide the maximal number of donor organs. Since optimal heart preservation has a limit of five hours, expeditious transportation must be arranged between the donor and recipient hospitals since both operations occur nearly simultaneously. With careful coordination, all harvested organs can be transplanted with a minimal amount of ischemic time, resulting in immediate graft function.
Details of the operative technique have been reported previously. The patient is weaned from bypass by isoproterenol infusion. Postoperatively, the patient is placed in reverse isolation in specialized rooms where positive pressure is maintained and the air recirculates frequently. With newer immunosuppressive medications, this stringent isolation procedure may be relaxed. The current immunosuppressive regimen employed at our hospital is illustrated in Table 3. Diagnosis of rejection in a cyclosporine-treated patient is made by endomyocardial biopsy. This technique is done under local anesthesia, usually in the catheterization lab, and can be accomplished in 20 min. Frequency of biopsy sampling decreases as the time from transplantation lengthens. Histopathologic evidence of myocyte necrosis constitutes moderate rejection requiring treatment. Our current treatment regimen is illustrated in Table 4. Methylprednisolone therapy is given (1,000 mg IV bolus) for three days. For rejection episodes occurring one month following transplantation, treatment consists of an oral dose of prednisone (100 mg for three consecutive days) followed by a rapid taper (10 mg/day) returning to maintenance.
Outpatient Surveillance and Follow-up
Average initial hospitalization following transplantation is three to four weeks. When discharge is anticipated, final education on the medications, their desired effect, side effects and dosage is presented to the patient and family. Arrangements are then made for outpatient clinic visits. Each clinic visit usually consists of a physical examination, transvenous endomyocardial biopsy sampling, selected blood tests and chest roentgenographic examination. Monitoring the patient for development of coronary artery disease consists of an annual hospital admission with repeat catheterization, endomyocardial biopsy and coronary angiography studies.
Table 1—Guidelines for Program Development
|Existing renal transplant program|
|24-hour availability of all requisite personnel|
|Operating room personnel|
|Pathologists experienced in rejection diagnosis|
|Infectious disease consultants|
|Donor procurement team|
|Appropriately equipped facilities|
Table 2—Heart Transplantation Responsibilities by Department
|Cardiology||Recipient evaluation; cardiac biopsies; follow-up care|
|Cardiac surgery||Donor and recipient operation; care of hospitalized recipient; assist in evaluation|
|Anesthesia||Specialized protocol for induction|
|Nursing||Preoperative evaluation; donor and recipient operations; immediate and follow-up care|
|Social services||Psychosocial evaluation|
|Microbiology||Protocol for expeditious handling of cultures|
|Infectious diseases||Prompt evaluation|
|Histocompatibility||Recipient evaluation for preformed antibodies|
|Blood bank||Provides CMV (-) blood when necessary|
Table 3—Immunosuppressive Protocol at the Johns Hopkins Hospital
|Immediate post-op||125 q8 hr x3|
|Early maintenance||1 mg/kg||10 mg/kg*|
|2 weeks||0.5 mg/kg|
|4 weeks||0.5 mg/kg|
|12 weeks||0.2 mg/kg|
|Late maintenance||0.2 mg/kg||10 mg/kgt|
Table 4—Treatment of Rejection