CardiomyopathyAmpDonor.RecipientSelection History

Hide minor edits - Show changes to output

Changed lines 120-121 from:
|| Pulmonary artery systolic pressure > 70 mmHg despite nitroprusside || X || || 
to:
|| Pulmonary artery systolic pressure > 70 mmHg despite nitroprusside || X || ||
|| Transpulmonary gradient > 15-20 mmHg (mean PAP - PCWP) || || X ||
|| Infection - active, untreated || X || ||
|| Irreversible hepatic disease || X || ||
|| Irreversible renal disease || X || ||
|| Irreversible pulmonary disease || || ||
|| FEV1 < 1 L || X || ||
|| FEV1 < 1.5 L || || X ||
|| Recent pulmonary infarction || || X ||
|| Age > 65 years || X || ||
|| Diabetes mellitus, Type 1, with significant end-organ damage || || X ||
|| Cerebrovascular disease || || ||
|| Symptomatic || X || ||
|| Asymptomatic || || X ||
|| Peripheral vascular disease || || ||
|| Symptomatic || X || ||
|| Peptic ulcer disease || || ||
|| Active bleeding || || X ||
|| Diverticulitis, recent || X || ||
|| Chronic Active Hepatitis || || X ||
|| HIV positive || || X ||
|| Malignancy, recent || X || ||
|| Malignancy, remote || || X ||
|| Psychiatric disease || || ||
|| Acute, unresolved || X || ||
|| Recent, resolved on treatment || || X ||
|| Substance abuse || || ||
|| Active, unresolved || X || ||
|| Recent,resolved || || X ||

Changed line 45 from:
%center%Factor Possibly Predictive Not Predictive
to:
->Factor Possibly Predictive Not Predictive
Changed lines 91-94 from:
||!Hdr ||!Hdr ||!Hdr ||
||     ||    ||     ||
||    ||    ||    ||
to:
|| Improves Survival || Decreases Hospitalization || Decreases Survival ||
|| Enalapril || Digoxin || Dobutamine ||
|| Captropril || Metoprolol || Milrinone ||
|| Isosorbide dinitrate || || Vesnarinone ||
|| Carvedilol || ||
||
Changed lines 116-119 from:
||!Hdr ||!Hdr ||!Hdr ||
||    ||     ||     ||
||     ||     ||    ||
to:
|| Criteria || High Risk || Moderate Risk ||
|| Pulmonary Hypertension || || ||
|| PVR > 8 Wood Units, unresponsive to nitroprusside || X || ||
|| PVR > 8 Wood Units, decreasing in response to nitroprusside, but not below 3 Wood Units || || X ||
|| Pulmonary artery systolic pressure > 70 mmHg despite nitroprusside || X || || 

Added lines 1-156:
%center%%blue%''''+Cardiomyopathy / Cardiac Transplant Donor & Recipient Selection+''''


'''1. Cardiomyopathy definition'''
->'''A.''' Any myocardial disease process that leads to clinically significant myocardial dysfunction

'''2. Cardiomyopathy classification'''
->'''A.''' Dilated cardiomyopathy
->'''B.''' Hypertrophic cardiomyopathy
->'''C.''' Restrictive cardiomyopathy
->'''D.''' Arrhythmogenic right ventricular dysplasia
->'''E.''' Dilated, characterized by dilation and impaired contraction of left or both ventricles
-->1) Idiopathic
-->2) Familial/genetic
-->3) Viral and/or immune
-->4) Alcoholic/toxic
-->5) Presentation with heart failure, often progressive, arrhythmias, thromboembolism, and sudden death
->'''F.''' Hypertrophic, characterized by left and/or right ventricular hypertrophy
-->1) Usually asymmetric with normal or reduced LV volume
-->2) Systolic gradient common
-->3) Familial disease with predominantly autosomal dominant inheritance
-->4) Myocyte hypertrophy and disarray surrounding areas of increased loose connective tissue
-->5) Arrhythmias and premature sudden death are common
->'''G.''' Restrictive, characterized by restrictive filling and reduced diastolic volume of either or both ventricles with normal or near-normal systolic function and wall thickness
-->1) Idiopathic
-->2) Associated with other disease (amyloidosis; endomyocardial disease with or without eosinophilia
->'''H.''' Arrhythmogenic right ventricular dysplasia, characterized by progressive fibrofatty replacement of right ventricular myocardium, initially with typical regional and later global right and some left ventricular involvement with relative sparing of the septum
-->1) Familial disease common, autosomal dominant inheritance and incomplete penetrance
-->2) Presentation with arrhythmias and sudden death is common, particularly in the young

'''3. Specific cardiomyopathies: heart muscle diseases that are associated with specific cardiac or systemic disorders'''
->'''A.''' Ischemic
->'''B.''' Valvular
->'''C.''' Hypertensive
->'''D.''' Inflammatory (e.g., myocarditis, Chagas' disease, HIV, etc.)
->'''E.''' Metabolic (e.g., thyrotoxicosis, hypothyroidism, storage diseases, etc.)
->'''F.''' General system disease (e.g., SLE, sarcoidosis, etc.)
->'''G.''' Muscular dystrophies (e.g., Duchenne, Becker-type, etc.)
->'''H.''' Neuromuscular disorders (e.g., Friedreich's ataxia)
->'''I.''' Sensitivity and toxic reactions (e.g., anthracyclines, irradiation, alcohol)
->'''J.''' Peripartal

'''4. Prognosis'''

%center%Factor Possibly Predictive Not Predictive
||border=1 width=80%
|| Factor || Predictive|| Possibly Predictive || Not Predictive ||
|| Clinical || Symptoms || Acoholism, Peripartum, Family History || Age, Duration, Viral Illness ||
|| Hemodynamic || LVEF, CI || LV size, LAP, RAP || Viral Illness ||
|| Dysrhythmia || IVCD, Complex ectopy || AV block || Simple ectopy ||
|| Histologic || || Myofibril volume || ||
|| Neuroendocrine || PI, NE, ANF, Serum Na || || ||

->[[Cumulative Mortality]]

->[[Probability of Death]]

->[[Probability of Survival]]

'''5. Pharmacological Treatment of Heart Failure'''
->'''A.''' Digoxin*
->'''B.''' Diuretics
->'''C.''' Afterload Reduction
->'''D.''' Isosorbine dinitrate/hydralazine**
->'''E.''' Angiotensin Converting Enzyme Inhibitors
->'''F.''' Enalapril**
->'''G.''' Captoril**
->'''H.''' Lisinopril
->'''I.''' Angiotensin II Receptor Inhibitors
-->1) Losartan
->'''J.''' Calcium Channel Blockers
-->1) Amlodipine

'''6. Beta Blockers'''
->'''A.''' Carvedilol**
->'''B.''' Metoprolol*
->'''C.''' Inotropic Agents
->'''D.''' Beta Agonists
-->1) Dopamine
-->2) Dobutamine
->'''E.''' Phosphodiesterase Inhibitors
-->1) Amrinone
-->2) Milrinone
->'''F.''' Anticoagulation
-->1) *Decreases risk of hospitalization or decompensation
-->2) **Decreases mortality

'''7. Pharmacologic Treatment of Heart Failure'''

||border=1 width=80%
||!Hdr ||!Hdr ||!Hdr ||
||    ||    ||    ||
||    ||    ||    ||

'''8. Recipient Selection Process'''
->'''A.''' Inclusion criteria
->'''B.''' Exclusion criteria
->'''C.''' Ongoing re-evaluation process

'''9. Inclusion Criteria'''
->'''A.''' Absence of reversible or surgically amenable heart disease
->'''B.''' NYHA Class III - IV symptoms despite optimal medical management
->'''C.''' Maximal oxygen consumption < 14 ml/kg/minute
->'''D.''' Estimated 1 year survival without transplant < 50%

'''10. Insufficient Indications for Cardiac Transplantation'''
->'''A.''' Ejection fraction < 20%
->'''B.''' History of NYHA Class III - IV symptoms
->'''C.''' Low maximal oxygen consumption

'''11. Candidate exclusion criteria'''

||border=1 width=80%
||!Hdr ||!Hdr ||!Hdr ||
||    ||    ||    ||
||    ||    ||    ||

'''12. Panel Reactive Antibody (PRA) Screen'''
->'''A.''' AKA: HLA antibody or white blood cell antibody screen
->'''B.''' Technique: Recipient sera placed in 40-60 wells containing lymphocytes with a wide variety of HLA antigens
->'''C.''' Use: Determine presence of preformed antibodies
->'''D.''' If > 10%: Prospective crossmatch

'''13. Management of Transplant Candidate While Waiting'''
->'''A.''' Close follow-up
->'''B.''' Low threshold for hospitalization
-->1) IV diuretics
-->2) Inotropic support
-->3) Mechanical assistance
->'''C.''' Ongoing re-evaluation of candidacy

'''14. Ongoing Re-evaluation for Candidacy'''
->'''A.''' Periodic assessment for degree of illness (VO2, EF, right heart pressures)
->'''B.''' Periodic assessment of acceptability (development of a new or worsening of a pre-existing illness)
->'''C.''' Periodic PRA determinations

'''15. Conditions Which Generally Preclude the Use of a Donor Heart'''
->'''A.''' HIV positivity
->'''B.''' Significant ventricular arrhythmia
->'''C.''' Echocardiographic abnormalities
->'''D.''' Significant global hypokinesis
->'''E.''' Significant valvular abnormality
->'''F.''' Significant coronary disease by arteriography or documented previous myocardial infarct
->'''G.''' Any acute malignancy, except primary brain cancer
->'''H.''' Inadequately treated systemic infection
->'''I.''' HbsAG positive, unless recipient is also positive
->'''J.''' Hepatitis C positivity, unless recipient is also positive
->'''K.''' Death from carbon monoxide poisoning, with carboxyhemoglobin level > 20%
->'''L.''' Significant cardiac contusion
->'''M.''' Severe left ventricular hypertrophy by echo
->'''N.''' History of intravenous drug use

'''16. Donor-recipient Matching'''
->'''A.''' Size: Greater than 80% of recipient body weight
->'''B.''' Blood type: Identical or compatible
->'''C.''' HLA-matching: Generally not done