Cardiac Transplantation: A Manual for Health Care Professionals PDF
Preview Cardiac Transplantation: A Manual for Health Care Professionals
Cardiac Transplantation Jeffrey D. Hosenpud Adnan Cobanoglu Douglas J. Norman Albert Starr Editors Cardiac Transplantation A Manual for Health Care Professionals • Springer-Verlag New York Berlin Heidelberg London Paris Tokyo Hong Kong Barcelona JEFFREY D. HOSENPUD, M. D., Associate Professor of Medicine/Cardiology, Head, Cardiac Transplant Medicine, Oregon Health Sciences University, Portland, Oregon 97201, USA ADNAN COBANOGLU, M.D., Professor of Surgery and Chief, Cardiopulmonary Surgery, Director, Heart Transplantation Program, Oregon Health Sciences University, Portland, Oregon 97201, USA DOUGLAS J. NORMAN, M.D., Professor of Medicine, Director, Transplantation and Immunogenetics Laboratory, Director, Medical Transplantation Program, Oregon Health Sciences University, Portland, Oregon 97201, USA ALBERT STARR, M.D., Professor of Surgery, Oregon Health Sciences University, Portland, Oregon 97201, USA With 65 illustrations in 72 parts Library of Congress Cataloging-in-Publication Data Cardiac transplantation : a manual for health care professionals 1 J.D. Hosenpud ... let al.l, editors, p. cm. Includes bibliographical references. Includes index. ISBN-l3: 978-1-4612-7757-6 e-ISBN-13: 978-1-4612-3008-3 DOl: 10.1007/978-1-4612-3008-3 I. Heart-Transplantation-Handbooks, manuals, etc. I. Hosenpud, J. D. (Jeffrey D.) [DNLM: I. Heart Transplantation. WG 169 C2673] RD598.35.T7C35 1990 617.4' 120592-dc20 DNLM/DLC for Library of Congress 90-9750 Printed on acid-free paper © 1991 Springer-Verlag New York, Inc. Softcover reprint of the hardcover 1st edition 1991 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Verlag New York, Inc., 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or schol arly analysis. Use in connection with any form of information storage and retrieval, elec tronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use of general descriptive names, trade names, trademarks, etc., in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Typeset by David E. Seham Associates, Inc., Metuchen, NJ. 987654321 Preface Over the past ten years, cardiac transplantation has evolved from an exper imental procedure performed in a handful of university centers to a viable therapeutic modality now performed in more than 150 centers worldwide. The complexity of the procedure, the changing immunosuppressive re gimes, and the follow-up care have necessitated a multidisciplinary ap proach involving a variety of medical, nursing, and social sciences special ties and subspecialties. In addition, health care trainees and referring physicians are increasingly becoming involved in the care of the cardiac transplant recipient. This book does not attempt to be a comprehensive treatise on cardiac transplantation; rather, we hope that it will serve as a manual and guideline for all health professionals involved in cardiac trans plantation. JEFFREY D. HOSENPUD, M.D. Contents Preface v Contributors IX 1. Cardiac Transplantation: An Overview JEFFREY D. HOSENPUD AND ALBERT STARR 2. Immunogenetics and Immunologic Mechanisms of Rejection 15 DOUGLAS J. NORMAN 3. Medical Therapy Tailored for Advanced Heart Failure 33 LYNNE WARNER STEVENSON 4. Ventricular Assistance as a Bridge to Cardiac Transplantation 53 D. GLENN PENNINGTON AND MARC T. SWARTZ 5. Recipient Selection for Cardiac Transplantation 71 GEORGE A. PANTELY 6. Donor Selection and Management for Cardiac Transplantation 85 JEFFREY SWANSON AND ADNAN COBANOGLU 7. Operative Techniques and Early Postoperative Care in Cardiac Transplantation 95 ADNAN COBANOGLU 8. Endomyocardial Biopsy: Techniques and Interpretation of Rejection 115 JUDITH RAY AND JEFFREY D. HOSENPUD 9. Chronic Immunosuppression and the Treatment of Acute Rejection 139 DANIEL R. SALOMON AND MARIAN C. LIMACHER viii Contents 10. Physiology and Hemodynamic Assessment of the Transplanted Heart 169 JEFFREY D. HOSENPUD AND MARK J. MORTON 11. Medical Complications in Patients after Cardiac Transplantation 191 JOHN B. O'CONNELL 12. Psychiatric Considerations in the Cardiac Transplant Recipient 213 ROBERT A. MARICLE Appendices l. Pre- and Postoperative Transplant Orders 235 II. Pharmacologic Therapy Pre- and Postcardiac Transplantation 251 Index 257 Contributors ADNAN COBANOGLU, M.D. Professor of Surgery and Chief, Cardiopul monary Surgery, Director, Heart Transplantation Program, Oregon Health Sciences University, Portland, Oregon 97201, USA JEFFREY D. HOSENPUD, M.D. Associate Professor of Medicine/Cardi ology, Head, Cardiac Transplant Medicine, Oregon Health Sciences U ni versity, Portland, Oregon 97201, USA MARIAN C. LIMACHER, M.D. Assistant Professor of Medicine, Transplant Cardiologist, University of Florida Medical Center, Gainesville, Florida 32610, USA ROBERT A. MARICLE, M.D. Associate Professor of Psychiatry, Direc tor, Psychiatric Consultation and Liaison Service, Oregon Health Sci ences University, Portland, Oregon 97201, USA MARK J. MORTON, M.D. Associate Professor of Medicine/Cardiology, Director, Catheterization Laboratory, Oregon Health Sciences Univer sity, Portland, Oregon 97201, USA DOUGLAS J. NORMAN, M.D. Professor of Medicine, Director, Trans plantation and Immunogenetics Laboratory, Director, Medical Trans plantation Program, Oregon Health Sciences University, Portland, Ore gon97201, USA JOHN B. O'CONNELL, M.D. Associate Professor of Medicine, Medical Director, UTAH Cardiac Transplant Program, University of Utah Medi cal Center, Salt Lake City, Utah 84132, USA GEORGE A. PANTELY, M.D. Associate Professor of Medicine, Oregon Health Sciences University, Portland, Oregon 97201, USA D. GLENN PENNINGTON, M.D. Professor of Surgery, St. Louis U niver sity Medical Center, Director, Heart Replacement Services, St. Louis, Missouri 63110, USA x Contributors JUDITH RAY, M.D. Assistant Professor of Pathology, Oregon Health Sciences University, Portland, Oregon 97201, USA DANIEL R. SALOMON, M.D. Associate Professor of Medicine, Medical Director, Kidney and Heart Transplant Programs, University of Florida Medical Center, Gainesville, Florida 32610, USA ALBERT STARR, M.D. Professor of Surgery, Oregon Health Sciences University, Portland, Oregon 97201, USA LYNNE WARNER STEVENSON, M.D. Assistant Professor of Cardiology, UCLA School of Medicine, Director, Cardiomyopathy Center and Trans plant Clinic, UCLA Center for the Health Sciences, Los Angeles, Califor nia 90024, USA JEFFREY SWANSON, M.D. Assistant Professor of Surgery, Oregon Health Sciences University, Portland, Oregon 97201, USA MARC T. SWARTZ, B.A. Director, Circulatory Support, Saint Louis University Medical Center, Saint Louis, Missouri 63110, USA 1 Cardiac Transplantation: An Overview JEFFREY D. HOSENPUD AND ALBERT STARR Cardiac transplantation has evolved from a highly experimental proce dure to an accepted modality for the treatment of end-stage cardiac dis ease in slightly more than 20 years. In just the past 8 years the number of hospitals performing cardiac transplantation has increased from 14 to 173 centers worldwide (Fig. 1.1), with the number of operations increas ing from 92 to approximately 2500 in 1988 (Fig. 1.2). The obvious success of cardiac transplantation can be attributed to substantial improvements in a variety of areas, including preoperative management of congestive heart failure, surgical techniques, donor management and organ preserva tion, prevention and treatment of rejection, and early and aggressive man agement of medical complications after transplantation. One-year sur vival has increased from around 70% to more than 85% in just the past 5 years, and long-term survival is now a realizable goal. This chapter will 1 review the history of cardiac transplantation, its current successes and limitations, and the evolution of the multidisciplinary approach to cardiac transplantation. Historical Perspective Carrell and Guthrie2 reported the first experience of transplanting the heart in 1905. The operation consisted of anastomosing the great vessels, cavae, and pulmonary vein of a smaller dog heart on to the carotid artery and jugular vein of a larger dog. The circulation was subsequently main tained for approximately 90 min. Mann and colleagues3 maintained allo graft function for several days by using systemic anticoagulation and pro viding oxygenated blood to the donor coronary tree. Because of this prolonged survival (8 days in the longest experiment), this group first rec ognized cardiac allograft rejection manifest clinically by ventricular fibril lation and pathologically by myocardial edema, necrosis, and an exten sive myocardial mixed cellular infiltrate. Sinitsyn in 1948 first described a working heterotopic cardiac transplant model,4,5 and Demikhov, working 2 Jeffrey D. Hosenpud and Albert Starr 200 180 160 ..(c../...r\.. ,.0 .z.. .. 120 u ..... 0 100 .c...r. <:::D;; 80 => Z 60 40 20 0 1979 1980 1981 U82 1983 l'De. ... 11iJI6::l1 Ig06 nJ8;7 I.ea YEARS FIGURE 1.1. The number of centers performing cardiac transplantation has in creased from 17 in 1980 to 173 in 1989. Reproduced from Heck et al. (1989),' with permission. extensively through the 1940s, developed several methods, including an intrathoracic method for heterotopic cardiac transplantation.4.s Demik hov's longest surviving animal lasted 32 days, a feat even more remark able considering the absence of myocardial preservation techniques and cardiopulmonary bypass. With the advent of cardiopulmonary bypass, the stage was set for at tempts to place the transplanted heart in the normal anatomic position. 3000 2500 V> .~.... 2000 ~ 0.. ~ 1500 .c..r.. In ~ 1000 Z ~oo YEARS FIGURE 1.2. The number of cardiac transplant operations has increased almost exponentially in the 1980s, but the rate of increase has lessened over the past 2 years, and may be reaching a plateau. Reproduced from Heck et al. (1989),' with permission.
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