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Pre Transplant Evaluation

Who needs Heart transplant ?
A heart transplant is a strict and complicated procedure, which is performed only when all other options of cure have been exhausted. There aren’t enough donor hearts for every person who needs a heart transplant. Hence, a very careful screening process is followed to evaluate who requires the heart urgently and to ensure that the hearts are distributed evenly. Some major conditions that are considered to determine eligibility of a patient for heart transplant are: -

  • Failure of the heart to pump blood well enough so that it can supply the blood with oxygen and nutrients for the various organs of the body.
  • Some patients are in need of a new heart due to the complete failure of cardiac function leading to sudden cardiac death.
  • When the life expectancy without a transplant is less than 1 year and no other alternate treatment is feasible.
  • The life quality of the patient has deteriorated so much that they are not able to perform basic functions.
  • Patient Suffering from End Stage Congenital Heart Failure.

 

Pre-Transplant Evaluation
The heart transplant candidate is put through laboratory tests, imaging studies and other necessary tests as required. The patient is closely monitored during his waiting period for a suitable donor organ for any signs of clinical deterioration in which case, the patient might be deemed necessary to be admitted so that he can be evaluated for the implantation of an artificial cardiac assist device or upgraded on the waiting list or both. In some cases, the condition may deteriorate to a point where heart transplantation does not remain an option anymore.

  • Psychological and social evaluation
    Psychological evaluation helps in identifying factors that may cause difficulty during the patient’s waiting period, postoperative period and recovery period.
    Any active or past abuser of alcohol or drugs is not a suitable candidate for the transplantation. Potential heart transplant candidates have to quit smoking.
    Social issues include financial matters and support from family members who have a significant effect on how the patient fares after the transplant.
     
  • Laboratory Studies
    Blood tests are essential to match a suitable donor and help in improving the chances of the donor's heart not getting rejected by the recipient body. HIV tests are also to be conducted to dismiss the presence of AIDS.
    Since a patient who is either carrier of the disease or has the active disease is not eligible for heart transplantation, a hepatitis panel is done to determine if he is fit for the transplantation.
    Testing of various viruses such as Epstein-Barr virus, cytomegalovirus, and herpes simplex virus. Past exposure to these viruses indicates a risk of. If active, then it has to be treated before the transplantation process is done.
    Fungal serological testing and tuberculosis skin testing are performed for past exposure and to predict reactivation. Those with active disease are first treated before they are placed on the list for transplantation.
    Prostate-specific antigen (PSA) and Papanicolaou test results should be negative. Appropriate referral for evaluation is initiated if the results are positive before the patient is recommended for transplantation.
    *Results for complete blood count (CBC) with differential, platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT) and complete chemistry profile should all be normal before the evaluation.
     
  • Diagnostic Tests / Imaging Studies
    The patient has to undergo diagnostic tests to assess the lungs and overall health. The diagnostic tests include X-rays, ultrasound, CT scan, pulmonary function test (PFT) and dental examination. Women may have to get a PAP smear, a mammogram, and gynecological evaluation done.

     
  • EKG and Chest X-ray 
    An Electrocardiogram or EKG is performed to record the electrical activity of the candidate’s heart and determine the effect that it has on the functioning and efficiency of the heart. The relative size and position of the heart and the lungs are determined with chest X-rays
    .
  • Cardiopulmonary Stress Test 
    The cardiopulmonary stress test involves walking on a treadmill with a target heart rate fixed or until the damaged heart forces the patient to stop. This test helps to assess the extent of heart damage and find out its functional capacity.

     
  • Echocardiogram
    Echocardiography is done for determination of the cardiac ejection fraction and also for cardiac function monitoring of the patient. For ejection fractions which are 25% or lesser, the chances of long-term survival rate are poor.  
         
  • Coronary arteriography
    In cases of cardiomyopathy, is performed to determine if the cause of the dysfunction is amenable to conventional therapies like coronary artery bypass grafting (CABG), valvular repair or coronary artery angioplasty.

     
  • MUGA Scan
    It is done to determine the functioning of the heart during exercise or at rest. A tracing radioisotope is added to the bloodstream, and its flow is scanned with the help of a gamma camera. An EKG which is done simultaneously contributes to check the size of the chambers of the heart and measure how efficiently the heart muscles contract.

     
  • Carotid Doppler Studies 
    This is an ultrasound procedure which helps to determine any arterial blockage by evaluating blood flow to the brain.

     
  • Non-Invasive Flow Study
    Blood pressure cuffs are applied to each calf of the patient, and the pressure of the blood flowing through the lower extremities is determined.

     
  • Abdominal Ultrasound
    An abdominal ultrasound is performed to examine the liver, kidneys, gallbladder and the abdomen.

Cardiac and Pulmonary Evaluation

  • Pulmonary Function Testing - Overall pulmonary functions are assessed with pulmonary function tests. The PFT determines whether the patient has any breathing problems which are not connected to the heart disease
  • Cardiac Evaluation- Overall cardiac function is assessed with maximal venous oxygen consumption (MVO2). This predicts the severity of the congestive heart failure and also the survival rate. An MVO2 prognostic value which is less than 15 ml/dl/min indicates poor chances of a 1-year survival for the patient.
  • Biopsy- Endomyocardial biopsy is carried out only if a systemic process involving the heart is considered to be the cause of cardiomyopathy.

Other Preparations
The patient is administered several vaccines to minimize the risks of developing infections after the surgery. These tests together, help in understanding the extent of the heart disease and also any other complications that may be present in the body. They contribute to discovering any condition such as high lung pressure, a systemic infection or a condition which will make it impossible for the patient to take immunosuppressant or anti-rejection medicines later.

 

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