A heart transplant is an option for patients who have any of these conditions and continue to bear the risk of dying and intolerable symptoms despite optimal medical care and use of medical devices have.
(See also Overview transplant.) A heart transplant is an option for patients who have any of these conditions and continue to bear the risk of dying and have intolerable symptoms despite optimal medical care and use of medical devices. End-stage heart failure Coronary heart disease (CHD) arrhythmias Hypertrophic Cardiomyopathy Congenital Heart Defects A transplant may be indicated in patients who can not be weaned from temporary cardiac assist devices after myocardial infarction or heart surgery without transplantation suffering from cardiac sequelae of lung disease requiring lung transplantation The only absolute contraindication for a heart transplant is pulmonary hypertension, which does not respond to the pre-operative treatments Relative contraindications for transplantation include organ failure (z. B. pulmonary, renal, hepatic), and local or systemic infiltrating disease (z. B. Herzsarkom, amyloidosis). All donor hearts come from brain-dead donors, which must be <60 years old usually had a normal heart and lung function and no coronary heart disease or other heart diseases in history. Donor and recipient must have compatible AB0 types and have a matching heart size. Approximately 25% of suitable for transplant patients die before a donor organ can be provided. Equipment for the support of the left ventricle and artificial heart can temporarily take over hemodynamic function in patients awaiting transplantation. Gedoch these devices pose a high risk for sepsis, further equipment failures, and thromboembolism. Bridging and destination HVADs in recent years have implantable cardiac assist devices greatly improved, and these devices are used to treat some patients who would have previously required a heart transplant, and patients for whom a transplant is contraindicated. These devices are typically used to support the left ventricle as a temporary (bridge-to-transplantation) or long-term (target) treatment. Infections that can be derived from the insertion of the drive trains (drivelines) on the skin that are a problem. However, there are now patients who have survived and where it goes well for some years after these devices were implanted. Procedure The function of the donor heart is obtained by hypothermic storage. You must be transplanted within 4-6 h. The Heart receiver is connected to a bypass pump and his heart away, but get the rear wall of the right atrium in situ. Then, the donor heart is transplanted to orthotopic site (in its normal position) from aortic, pulmonary artery and pulmonary vein anastomoses; a single anastomosis connects the rear wall of the right atrium with the recipient of the donor organ. The use of an in vitro-pump system that modifies the cellular metabolism in the donor organ, and thus prolongs the viability of the transplant> 4-6 h, is currently under investigation. The immunosuppressive regimen may vary, but are similar to kidney or liver transplants (eg monoclonal anti-IL-2 receptor antibody, a calcineurin inhibitor, corticosteroid-see table. Immunosuppressive drugs for the treatment of transplant rejection). Complications rejection in approximately 50-80% of patients will experience at least one rejection crisis (average 2-3); most patients remain asymptomatic, in 5% of cases, however, a left ventricular dysfunction or there is atrial arrhythmia developed. One month after transplantation, the incidence of acute rejection reaches a climax. Over the next 5 months, she decreases and has stabilized a year after the transplant. Risk factors of rejection younger age female recipients are female or black donor HLA mismatching Possible cytomegalovirus (CMV) A graft damage can be catastrophic irreversible and thus for the patient. therefore for observing a biopsy of the myocardium is usually carried out once a year, further degree and distribution of mononuclear cell infiltrates as well as the presence of damaged myocytes are determined in the samples. For the differential diagnosis include perioperative ischemia, CMV infection and idiopathic B cell infiltration (Quilty lesions). Easy rejection (grade 1) with no obvious clinical consequences do not require treatment, while moderate to severe rejection (grade 2-4) or mild reactions with clinical symptoms with corticosteroids (500 mg or 1 g daily for several days), and anti-thymocyte globulin, if necessary be treated (see table: manifestations of heart transplant rejection by category). Manifestations of heart transplant rejection by category rejection manifestations category hyper acute cardiogenic shock accelerated atrial arrhythmia, cardiogenic shock acute therapy, heart failure, atrial arrhythmia chronic shortness of breath on exertion, low stress tolerance * Most patients with heart transplant rejection are asymptomatic. Heart transplant vasculopathy The main complication of heart transplantation is a vasculopathy of heart allograft. It is a form of atherosclerosis, which narrows the vessel lumen diffuse or closes (at 25% of patients). The causes are probably multifactorial. There are correlations with the age of the donor, with cold and perfusionsbedingten ischemia, dyslipidemia, immunosuppressants, chronic rejection and viral infections (adenovirus in children, in adults CMV). To recognize complications in time, at the time of myocardial biopsy also stress tests to monitor or coronary angiographies are often carried out with or without intravascular ultrasound. The treatment consists in an aggressive lowering of lipid levels and the administration of diltiazem. Prognosis The 1-year survival rate after a heart transplant is 85-90%. Accordingly, the annual mortality rate is 4%. Pretransplantationsprädiktoren for 1-year mortality include necessity of preoperative respiratory or left ventricular assist devices cachexia Female Recipient or donor diagnoses other than heart failure or CAD to the predictions after transplantation include Increased CRP (C-reactive protein) and troponin Acute rejection and infection are in after transplantation, the leading causes of death; after 1 year patients die most frequently at a vasculopathy of heart allograft or a lymphoproliferative disease. The functional status in cardiac transplant patients survive one year is excellent; even if the load capacity is still below the normal values, it is initially sufficient for daily activities and may even improve over time as part of the re-innervation with sympathetic nerves. About 95% of these patients reach the NYHA class I (NYHA, New York Heart Association), and> 70% is again fully professional capable.