Chapter 105

More documents

Recommendations

Info

1782 PART 5 ■ Anesthetic, Surgical, and Interventional Procedures: Considerations TABLE 105-1. Heart Failure Staging in Pediatric Heart Disease Stage Interpretation Clinical Examples A B C D At risk for developing heart failure Abnormal cardiac structure and/or function No symptoms of heart failure Abnormal cardiac structure and/or function Past or present symptoms of heart failure Abnormal cardiac structure and/or function Continuous infusion of intravenous inotropes or prostaglandin E 1 Mechanical ventilatory and/or mechanical circulatory support Congenital heart defects Family history of cardiomyopathy Anthracycline exposure Univentricular hearts Asymptomatic cardiomyopathy Asymptomatic congenital heart disease Repaired or unrepaired congenital heart defects Cardiomyopathies Same as stage C TABLE 105-2. Indications for Pediatric Heart Transplantation (AHA Scientific Statement 2007) Class I Class IIA Class IIB Class III Recommendations Stage D heart failure associated with systemic ventricular dysfunction in cardiomyopathies or congenital heart disease Stage C heart failure with severe exercise and activity limitations (maximal oxygen comsumption 6 Wood unit/m 2 and/or a transpulmonary pressure gradient >15 mmHg if reactive to inotropes or pulmonary vasodilators Stage C heart failure with reactive pulmonary hypertension and a potential risk of developing fixed, irreversible elevation of PVR Certain anatomic and physiologic conditions likely worsen the natural history of functional single ventricle, which can lead to use of heart transplantation as primary therapy: 1) severe stenosis or atresia in proximal coronary arteries 2) moderate to severe stenosis and/or insufficiency of the atrioventricular and/or semilunar valve(s) 3) severe ventricular dysfunction Several anatomic and physiologic conditions likely worsen the natural history of previously repaired or palliated congenital heart disease with stage C heart failure: 1) pulmonary hypertension and a potential risk of developing fixed, irreversible elevation of PVR 2) severe aortic or systemic atrioventricular valve insufficiency not amenable to surgical correction 3) severe arterial oxygen desaturation (cyanosis) not amenable to surgical correction 4) persistent protein-losing enteropathy despite optimal medical-surgical therapy Efficacy of heart transplantation is not established in the following conditions: 1) previous infection with hepatitis B or C or with HIV infection 2) history of recent use of illicit drugs or tobacco or a recent history of alcohol abuse 3) history of psychological, behavioral, or cognitive disorders; poor family support structure; or non - compliance with previous therapies Heart transplantation is not efficacious in the following conditions: 1) Severe irreversible disease in other organ system in a part of a multisystemic disease process. Multiorgan transplantation may be considered 2) Severe irreversible fixed elevation of PVR 3) Presence of severe hypoplasia of the central branch pulmonary arteries and veins 4) Limited supply of pediatric donors, especially infant donors Adopted from Canter et al. Circulation. 2007;115:658–676. 59 Class I, condition for which there is evidence and/or general agreement that heart transplantation is useful and effective; Class II, conflicting evidence or a divergence of opinion about usefulness/efficacy; Class IIA, weight of evidence/opinion is in favor of usefulness/ efficacy; Class IIB, usefulness/efficacy is less well established by evidence/opinion.
CHAPTER 105 ■ Heart and Lung Transplantation: Surgical Considerations 1783 transplantation. 11 This subgroup is frequently associated with secondary PH due to progressive increase in left ventricular enddiastolic pressure, which may complicate transplantation. The freedom from death or transplantation is 39% at 5 years and 20% at 10 years. 12 Less frequently, patients with left ventricular non - compaction or cardiac tumor may be indicated for transplan - tation. Congenital Heart Disease (CHD) Indications of heart transplantation for patients with CHD fall mainly into two categories: (1) heart transplantation as a primary therapy and (2) heart transplantation for previously repaired or palliated complex CHD. Diagnoses in heart transplant recipients older than 6 months of age with previously repaired or palliated CHD are shown in Table 105–3. More than half of the candidates have a functional single ventricle. 13 Primary Heart Transplantation for Unrepaired Complex Congenital Heart Disease Since Loma Linda University pioneered neonatal or infantile heart transplantation for patients with HLHS as a primary surgical therapy, HLHS has been a leading CHD in this category, from the 1980s to the early 1990s. The 5-year survival with neonatal transplantation in patients with HLHS was 84%. 14 This was signi - ficantly superior to the results of staged surgical palliation for this entity, for which the early mortality was as high as 50% at that time. 15 Nonetheless, mortality during waiting for transplantation has also been substantial, as high as 20%. The paradigm has shifted from primary transplantation to staged surgical palliation as a result of significant improvement in management and subsequent survival in patients with HLHS who undergo the Norwood pro - cedure and subsequent Fontan operation. 16 Primary heart trans - plantation for patients with HLHS is currently indicated in most of the centers when patients have severely reduced ventricular function, systemic atrioventricular valve insufficiency, and/or pulmonary valve abnormalities. Other CHDs that can make a patient a candidate for primary heart transplantation include pulmonary atresia with intact ven - tricular septum that has major coronary artery abnormalities, especially if the right ventricle–dependent coronary circulation is TABLE 105-3. Primary Diagnoses of Patients With Congenital Heart Disease Who Required Heart Transplantation Primary Diagnosis Number % Single ventricle not otherwise specified 22 21 Tricuspid atresia 13 12 HLHS/Sshone’s complex 12 11 Double-inlet left ventricle 10 9 D-Transposition of the great arteries 10 9 Tetralogy of Fallot +/– pulmonary atresia 9 8 Pulmonary atresia with intact ventricular 8 7 septum L-Transposition of the great arteries 6 6 Ebstein’s anomaly 3 3 Other 13 12 Adopted from Chen et al. Ann Thorac Surg. 2004;78:1252–1261. 13 present. 17 Patients with heterotaxy syndrome, especially right isomerism, with a functional single ventricle and complex intra - cardiac and systemic and pulmonary venous abnormalities may be candidates for primary heart transplantation, considering that the outcomes of staged single-ventricle palliation have been ex - tremely poor. 18,19 Patients with any type of complex CHD with poor ventricular function and/or severe ventricular hypertrophy can be very high risks for corrective surgery and therefore might be candidates for primary heart transplantation. Heart Transplantation for Previously Repaired or Palliated Complex Congenital Heart Disease Patients who underwent two-ventricle repair for their CHD are less likely to be candidates for heart transplantation in the long term compared with patients who underwent staged singleventricle palliation. Some patients who have the right ventricle in the systemic position, that is, patients with D-transposition of the great arteries who underwent the atrial switch operation (Mustard or Senning procedure), or those with L-transposition of the great arteries who underwent physiologic repair, may have progressive right ventricular dysfunction and/or tricuspid valve regurgitation in the systemic circulation that may require heart transplan - tation. 20,21 Patients who received insufficient myocardial protection at the time of biventricular repair or had significant residual lesions that caused chronic volume and/or pressure overload to the systemic ventricle may be candidates for heart transplantation after two-ventricle repair. The Fontan operation or total cavopulmonary connection is the final physiologic status that patients with a functional single ventricle can possibly have. Major anatomic and physiologic factors that preclude the Fontan completion include poor ventri - cular function, significant systemic atrioventricular valve insuf - ficiency, increased fixed pulmonary vascular resistance (PVR), and unrepairable systemic and/or pulmonary venous abnormali - ties. If patients have such conditions during staged single-ventricle palliation, the Fontan operation is no longer indicated and heart transplantation is considered, although some conditions such as a significant increase in PVR may also preclude heart transplan - tation. Failing or Failed Fontan Physiology Since many patients have survived staged single-ventricle pallia - tion, a population that requires transplantation due to failing or failed Fontan physiology has been growing and has made up the largest single group of patients with CHD requiring heart trans - plantation. Even though patients achieved successful Fontan operations, there are several long-term issues that possibly com - promise Fontan physiology. Major indications for transplantation in this entity include progressive ventricular dysfunction, especially in patients with a right ventricle as a systemic chamber, elevated PVR, thromboembolism in the Fontan circuit, atrial and/or ventricular arrhythmias, protein-losing enteropathy, and persistent pleural effusion. Pretransplantation survival after listing is 78% at 6 months and 74% at 12 months. 22 This patient group may be the highest risk group for transplantation because of poor preoperative condition, potentially elevated PVR, previous multiple open-heart surgeries, and the need for a branch PA and/ or aortic arch reconstruction.
Page 1: Heart and Lung Transplantation: Sur
Page 5 and 6: CHAPTER 105 ■ Heart and Lung Tran

Chapter 105

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?