Critical Care of Heart Transplantation 1232020 l yekehfallahphd

Critical Care of Heart Transplantation 12/3/2020 l. yekehfallah-phd student of nursing education 1

Heart Transplant �� 1960 s: �� First heart transplants performed �� 1980 s: �� Anti-rejection meds became available (Cyclosporine) �� Today: �� About 80% of heart transplants are alive two years after the operation �� 50% percent survive 5 years 12/3/2020 l. yekehfallah-phd student of nursing education 2

Patients with these noted cardiac conditions that have not responded to maximal medical management should be evaluated for heart transplantation. 12/3/2020 l. yekehfallah-phd student of nursing education 3

Clinical Indications for Heart Transplant l I) Ischemic heart disease with intractable angina l l Not amenable to CABG or PTCA Maximal tolerated medical therapy not effective Rejected for direct myocardial revascularization or transmyocardial revascularization or the procedure was attempted and unsuccessful Intractable arrhytmias l 12/3/2020 Uncontrolled with pacing cardioverter defibrillator l. yekehfallah-phd student of nursing education 4

Clinical Indications for Heart Transplant �� Ischemic cardiomyopathy �� Idiopathic cardiomyopathy �� Viral cardiomyopathy �� Congenital heart disease �� Valvular heart disease 12/3/2020 l. yekehfallah-phd student of nursing education 5

Heart Transplant Contraindications l I. III. IV. V. VI. Absolute Contraindications A. Systemic illness that will limit survival despite heart translplant. Neoplasm. HIV/AIDS CDC definition of CD 4 count of < 200 cells/mm 3. SLE or Sarcoid that has multisystem involvement and is still active. Any systemic illness with a high probability of recurrence in the transplanted heart B. Fixed pulmonary hypertension. 12/3/2020 l. yekehfallah-phd student of nursing education 6

Heart Transplant Contraindications l Relative Contraindications l Age over 65 Peripheral vascular disease. Asymptomatic carotid stenosis > 75% or symptomatic carotid stenosis of less severity l l l Uncorrected abdominal aortic aneurysm > 4 – 6 cm Systemic infection making immune suppression risky HIV, HBV, CMV (positive donor to negative recipient) Severe pulmonary disease 12/3/2020 l. yekehfallah-phd student of nursing education 7

Heart Transplant Contraindications l Relative Contraindications Diabetes Mellitus with end organ damage a) Neuropathy b) Nephropathy c) Retinopathy Psychosocial impairment that jeopardizes the transplanted heart a) antisocial personality disorder b) drug or alcohol addiction c) cigarette smoking 12/3/2020 l. yekehfallah-phd student of nursing education 8

Heart Transplant Contraindications �� Severe osteoporosis �� Severe obesity �� Severe cachexia �� Psychosocial instability �� Non-compliance Active infection �� Recent malignancy (<5 years ) �� Active substance abuse �� HIV Other irreversible major organ failure that would shorten life �� Renal �� Hepatic �� Other indications that increase morbidity, need to carefully evaluate: �� Active peptic ulcer disease �� Diabetes: screen for nephropathy, neuropathy and retinopathy Cardiovascular �� Significant peripheral vascular disease �� Cerebrovascular disease �� Myocardial infiltrative or inflammatory disease �� Active myocarditis �� Pulmonary �� Irreversible, fixed, pulmonary hypertension �� Significant primary lung disease �� Recent pulmonary embolus 6 week interval between onset and possible transplant) 9

Transplant Evaluation �� Left and/or Right Heart Catherization �� Echocardiogram �� EKG �� 24 hour Holter Monitor �� Carotid and peripheral doppler flow studies �� Cardiopulmonary Stress Test �� Metabolic exercise test that determines the maximal oxygen consumption 12/3/2020 l. yekehfallah-phd student of nursing education 10

Transplant Evaluation �� Pulmonary �� Chest radiograph �� CT Chest �� PFT’s – baseline screening, spirometry 12/3/2020 l. yekehfallah-phd student of nursing education 11

Transplant Evaluation �� Renal �� Urinalysis �� 24 hour urine for creatinine clearance �� Renal ultrasound �� Gastrointestinal �� Stool guiac �� Abdominal ultrasound �� CT abdominal and pelvis �� Colonoscopy 12/3/2020 l. yekehfallah-phd student of nursing education 12

Transplant Evaluation �� Antibody screen �� HLA typing �� Infectious disease serologies �� General laboratory studies �� Bone density scan �� Cancer screens – gender specific tests 12/3/2020 l. yekehfallah-phd student of nursing education 13

Social Services, Psychiatry, Neuropsychiatry Consults and Evaluation �� Compliance �� Support �� Depression �� Anxiety �� Substance abuse �� Finances �� Knowledge deficits 12/3/2020 l. yekehfallah-phd student of nursing education 14

Consults �� Infectious disease �� Dermatology �� Dietary �� Endocrinologist �� Ophthalmologist �� Financial �� Transplant Coordinator for education 12/3/2020 l. yekehfallah-phd student of nursing education 15

Dental Clearance l l Dental Panorex Soft tissue exam 12/3/2020 l. yekehfallah-phd student of nursing education 16

Waiting Period Status 1 A �� Patient is admitted to transplant center and has at least one of the following devices or therapies in place. �� Mechanical ventilator �� Mechanical circulatory support • Ventricular assist device for 30 days once they are clinically stable. • Total artificial heart. • Intra-aortic balloon pump. • Mechanical circulatory support with significant device related complications. �� Must re-certify every 14 days 12/3/2020 l. yekehfallah-phd student of nursing education 17

Status 1 A �� Continuous infusion of IV inotropes: �� High dose of a single agent inotrope (i. e. dobutamine >7. 5 mcg/kg/min, or milrinone >/=. 50 mcg/kg/min �� Or multiple agents �� AND continuous hemodynamic monitoring of �� Must re-certify every 7 days 12/3/2020 18

Status 1 B �� Patient must have at least one of the following devices or therapies: �� Left and/or right ventricular assist device implanted for more than 30 days �� Continuous infusion of intravenous inotropes (whether in hospital or at home) 12/3/2020 l. yekehfallah-phd student of nursing education 19

Medical Management of Patients on Waiting List Comprehensive CHF Management Program 12/3/2020 l. yekehfallah-phd student of nursing education 20

Patient Education �� Disease Process �� Medication Use �� Lifestyle Changes �� Fluid Restriction �� Sodium Restriction �� Pre Transplant Immunizations �� Clinic Follow up 12/3/2020 l. yekehfallah-phd student of nursing education 21

Oral Medications Inotropic infusion continuous �� Diuretics �� Vasodilators �� Beta blockers �� Antiarrhythmics 12/3/2020 �� dobutamine/Dopamine �� Milrinone/Amrinone l. yekehfallah-phd student of nursing education 22

Intra-aortic Balloon Pump �� Temporary 12/3/2020 l. yekehfallah-phd student of nursing education 23

CARDIAC ASSIST DEVICES l ABIOMED 12/3/2020 l. yekehfallah-phd student of nursing education 24

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left ventriclar assist device (LVAD) 12/3/2020 l. yekehfallah-phd student of nursing education 29

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Implantable left ventriclar assist device (LVAD) 12/3/2020 l. yekehfallah-phd student of nursing education 31

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Donor Selection Donor Factors Important for Organ Recovery �� Age < 45 years, younger donors are better �� Hemodynamics - CVP �� CPR history –Any down time secondary to presumed cardiac arrest? �� Echo: LVEF, LV wall thickness, Valves, Anomalies �� EKG – No Q waves �� Effect of high dose vasopressors �� Traumatic injury to the heart 12/3/2020 l. yekehfallah-phd student of nursing education 33

Donor Selection �� Negative serologies �� No active systemic infection �� No extracranial malignancies �� No history IV drug use �� Be careful -Colorful social history, ask for specifics? ? �� Coronary Angiography for donors over 40 yrs of age 12/3/2020 l. yekehfallah-phd student of nursing education 34

RECIPIENT SELECTION l With improved outcomes in both quality of life and percentage of patients surviving, cardiac transplantation has become accepted therapy for many patients with end-stage heart disease. 12/3/2020 l. yekehfallah-phd student of nursing education 35

CARDIAC TRANSPLANT RECIPIENTS -General principles l Objective. The primary initial critical care management objective is to optimize cardiopulmonary function with inotropic support, afterload reduction, and judicious fluid management 12/3/2020 l. yekehfallah-phd student of nursing education 36

Monitoring l l l Arterial and central venous monitoring lines and pulse oximetry. Pulmonary arterial catheters are frequently helpful early postoperatively to aid in maximizing cardiac output with inotropic support, IV fluids, and vasodilators and are essential when the recipient has known pulmonary hypertension, donor right ventricular dysfunction. Foley bladder catheter. 12/3/2020 l. yekehfallah-phd student of nursing education 37

Pathophysiology l l l -Early allograft failure a-Early cardiac allograft dysfunction accounts for up to 25%. The most common etiologies include: pulmonary hypertension, myocardial injury due to prolonged ischemia or inadequate preservation, and acute rejection. b-Initial depletion of myocardial catecholamine stores resulting from donor inotropic support frequently triggers need for early posttransplant inotropic allograft support. 12/3/2020 l. yekehfallah-phd student of nursing education 38

Pathophysiology c-Right ventricular failure. Early right ventricular failure is a leading cause of early mortality and is almost always associated with moderate to severe pulmonary hypertension stemming from chronic left ventricular failure in the recipient. 12/3/2020 l. yekehfallah-phd student of nursing education 39

Pathophysiology -Left ventricular failure. Left ventricular failure is less frequently encountered than right ventricular failure. 12/3/2020 l. yekehfallah-phd student of nursing education 40

Pathophysiology l -Atrial fibrillation. Atrial fibrillation or flutter is treated with digoxin at higher doses. l Such arrhythmias may serve as markers for acute allograft rejection. l 12/3/2020 l. yekehfallah-phd student of nursing education 41

Pathophysiology l -Ventricular arrhythmias. l Ventricular arrhythmias, primarily premature ventricular contractions (PVCs) and nonsustained ventricular tachycardia, have been reported in up to 60% of recipients. In these cases, underlying etiologies should be aggressively discerned. l l Potential causes include: l acute rejection, electrolyte disturbances, and acidosis. 12/3/2020 l. yekehfallah-phd student of nursing education 42

Pathophysiology l --Dysrhythmias -Bradycardia. Sinus or junctional bradycardia in more than 50% of heart recipients. Primary risk factor for sinus node dysfunction: prolonged preservation; mechanical trauma during implantation. Most bradyarrhythmias resolve over 1 to 2 weeks; recovery may be further prolonged in recipients receiving amiodarone preoperatively. (1) Because cardiac output is primarily rate dependent after transplantation, the heart rate should be maintained between 90 and 110 bpm with parenteral inotropic agents or temporary atrial or atrioventricular epicardial pacing for the first several days. (2) Isoproterenol (Isuprel) is an effective chronotrope. (3) Theophylline may help to achieve adequate heart rates during this early transitional period. (4) In rare cases of persistent bradycardia, permanent pacemakers may be employed. 12/3/2020 l. yekehfallah-phd student of nursing education 43

Pathophysiology --Coagulopathy a-Heart recipients are frequently coagulopathic early postoperatively. Predisposing factors include: preoperative warfarin therapy, cardiopulmonary bypass, hepatic failure, and chronic renal insufficiency. b-Immediately postoperatively, check prothrombin time (PT)partial thromboplastin time (PTT), platelet count, and fibrinogen levels. l Therapy as indicated with fresh frozen platelets (FFP), platelets, cryoprecipitate, and/or protamine 12/3/2020 l. yekehfallah-phd student of nursing education 44

Management issues -Inotropic and fluid management --Preload optimization. Intravenous fluids (crystalloids or colloids) should be judiciously administered while continuously monitoring for adequacy of systemic perfusion. l (1) Clinical parameters include: palpable distal pulses, warm extremities, adequate urine output (>0. 5 m. L/kg/h) without diuretics, normal acid—base balance, (2) A central venous pressure (CVP) of 8 to 12 mm Hg and/or pulmonary capillary wedge pressures of 15 to 20 mm Hg. 12/3/2020 45

Management issues -Afterload management. Mean arterial pressures in excess of 80 mm Hg should be treated to avoid excessive ventricular wall stress in the allograft. (1) Early postoperatively, IV sodium nitroprusside or nitroglycerin is administered. l (2) Afterload reduction should be titrated to achieve mean arterial pressures between 65 and 80 mm Hg. (3) If hypertension persists, an oral antihypertensive can be added to permit weaning of parenteral agents. -Blockers are generally avoided in heart recipients early postoperatively. (4) Transient vasodilation with systemic hypotension, frequently seen early after cardiopulmonary bypass in patients previously taking angiotensin-converting enzyme inhibitors, is usually effectively managed with inotropes containing an adrenergic component, such as epinephrine or norepinephrine. 46

Management issues l l --Respiratory management. The respiratory management of the cardiac transplant recipient follows the same principles used following routine cardiac operations. Initial ventilator parameters on arrival in the intensive care unit (ICU): tidal volume of 10 m. L/kg, ventilatory rate of 10 breaths per minute, positive end-expiratory pressure (PEEP) of 5 cm H 2 O, and fraction of inspired oxygen (Fi. O 2) of 1. 0. l Goal is to reduce the Fi. O 2 to 0. 4, maintaining oxygen saturation greater than 90%, with an arterial oxygen tension (pa. O 2) greater than 70 mm Hg. l Ventilatory rate and tidal volume are adjusted to achieve partial arterial pressure (pa. CO 2) between 30 and 40 mm Hg and normal p. H (7. 35 to 7. 45). 47

Management issues l l Electrolyte balance and renal function Management of fluid and electrolytes homeostasis of the cardiac transplant recipient. l Serum electrolytes are checked frequently. l Maintaining normal K+, Mg++, and Ca++ levels is particularly important to reduce the frequency of arrhythmias. 12/3/2020 l. yekehfallah-phd student of nursing education 48

Management issues l Electrolyte balance and renal function l Serum glucose is monitored every 6 hours. l l Hyperglycemia is commonly observed, particularly in the first 24 to 48 hours after surgery due to : physiologic stress, inotropic support, and glucocorticoid administration. l Insulin (subcutaneous or continuous IV infusion) is titrated to maintain serum glucose levels between 100 and 150 mg/d. L. l A daily fluid restriction of 2, 000 m. L is maintained for the first 3 to 4 days, depending on the recipient's preoperative fluid status and postoperative renal function. l On initiation of immunosuppressant therapies, particularly cyclosporine, serum creatinine is followed closely to monitor for early nephrotoxicity. l Diuresis with furosemide is usually initiated 24 to 48 hours postoperatively. 49

l l l --Perioperative infection prophylaxis First-generation cephalosporins are given perioperatively. Routine strict isolation is no longer employed. Hand washing, gloves, and gowns are used to avoid infectious cross-transmission. Nystatin or clotrimazole is usually used as prophylaxis for mucocutaneous candidiasis. Fluconazole is indicated for candidiasis refractory to these topical antifungal agents or involving the esophagus. Routine low-dose acyclovir to reduce frequency and severity of herpes simplex and varicella-zoster infections. Recipients with a positive PPD skin test should be considered for isoniazid (rifampin) prophylaxis. l Cytomegalovirus (CMV) is the most common causative pathogen in cardiac transplant recipients and is thought to play a role in chronic allograft rejection. l Routine prophylaxis with intravenous ganciclovir for 1 to 2 weeks followed by oral maintenance dosing for 3 months is recommended, particularly for a CMV seronegative recipient/seropositive donor 50 combination.

l l l --Immunosuppression The primary objectives of immunosuppressive therapy include: l (1) the selective modulation of the immune response to prevent allograft rejection l (2) maintaining immunocompetence to prevent infection and neoplasia l (3) minimizing during toxicity The choice and combinations of immunosuppressive agents, doses, and schedules vary significantly among transplantation centers. Most centers employ triple immunosuppressive therapy consisting of cyclosporine, corticosteroids, and azathioprine or mycophenolate mofetil. . 12/3/2020 l. yekehfallah-phd student of nursing education 51

Immunosuppressive Regimen for Heart Transplantation at the Johns Hopkins Hospital Preoperative preparation Cyclosporine: 10 mg/kg PO (dosage based on serum creatinine) Intraoperative management Methylprednisolone: 500 mg IV. Immediate postoperative therapy Methylprednisolone: 125 mg/kg IV for 3 doses Prednisone: 1 mg/kg PO Qd tapered to 0. 4 mg/kg by wks Cyclosporine: 0. 5 mg/kg/day IV until taking PO then 10 mg/kg/day PO Postoperative meintenance therapy Prednisone: 0. 2 mg/kg PO Qd Mycophenolate Mofetil: 1 g PO/IV B. I. D. Cyclosporine: 5 mg/kg PO Qd (dose adjusted to maintain serum levels between 200 -350 mg/m. L) 52

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Major Post Transplant Complications l l l Rejection Infection Cardiac allograft vasculopathy (CAV) Hypertension Nephrotoxicity Malignancy 12/3/2020 l. yekehfallah-phd student of nursing education 60

Rejection 12/3/2020 l Invasive surveillance biopsies are the best established method for following patients l Typically 13 -15 biopsies are done in the first year l Each biopsy requires a minimum of 3 samples from 3 different sites to be meaningful l A new biopsy grading has been developed for widespread adoption 61

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International Society For Heart and Lung Transplantation Standardized Grading For Cardiac Biopsies Rejection grade Description 0 No evidence of rejection 1 - Mild A - Focal perivascular and/or interstitial infiltrate without myocyte damage B - Diffuse infiltrate without myocyte damage 2 - Moderate (focal) One focus of infiltrate with myocyte damage 3 - Moderate A - Multifocal infiltrate with myocyte damage Multifocal B - Diffuse 4 - Severe Diffuse infiltrate with myocyte damage Diffuse polymorphous infiltrate with extensive myocyte damage ± edema ± hemorrhage ± vasculitis 64

GRADE 1 A GRADE 1 B GRADE 2

GRADE 3 A GRADE 3 B Threshold Mandatory For Therapy 12/3/2020 GRADE 4 66

Treatment of Rejection l l Rejection without hemodynamic compromise l Oral prednisone (100 mg daily for 3 days) l IV steroids l Decision dependent on grading severity and time post transplantation Steroid resistant rejection with or without hemodynamic compromise Cytolytic antibodies; IVIG; plasmapheresis; photopheresis; anti-B cell antibodies; rapamycin; methotrexate; cyclophosphamide; total lymphoid irradiation 12/3/2020 l. yekehfallah-phd student of nursing education 67 l

Long Term Challenges l l l Renal failure and metabolic adverse effects Cardiac allograft vasculopathy Malignancy 12/3/2020 l. yekehfallah-phd student of nursing education 68

The Problem Of Cardiac Allograft Vasculopathy l Cardiac allograft vasculopathy (CAV) is the leading cause of death in cardiac transplant recipients at 5 years post-transplant, accounting for up to 30% of deaths l CAV is characterized by a proliferation of the allograft vascular intima, resulting in narrowing of the vascular lumen l Due to the lack of premonitory signs, CAV often presents as sudden death, silent myocardial infarction or severe arrhythmia 12/3/2020 69

Immune Factors Cellular Rejection score Antibody –mediated rejection Balance of Immunosuppression SMC PDGF, FGF, IGF TGF-ß, TNF, IL-1 Platelets T-lymphocyte Macrophage EC injury Denuding Nondenuding injury Non. Immune factors Mode of Brain Death Ischemia Reperfusion injury Hyperlipidemia Hypertension CMV infection Donor age INFLAMMATION MHC-II ICAM, VCAM selectins IL-1, IL-2, IL-6, TNF PDGF, FGF, IGF, TGF-ß 70

Common Immunosuppressive Regimen l l Primary: cyclosporine / tacrolimus (utilized in conjuction with therapeutic drug monitoring) Adjunctive: mycophenolate mofetil Supportive: prednisone (only 20 to 30% centers wean prednisone off if possible) Additive: statins (shown to be immunomodulatory and associated with improved long term survival) 12/3/2020 l. yekehfallah-phd student of nursing education 71

Rejection l l Cellular rejection remains an important issue despite the incidence having declined over the past two decades Antibody mediated rejection is now recognized as an important entity but has not been previously standardized therefore not uniformly incorporated in trials of immunosuppressive therapy or investigations pertaining to transplantation 12/3/2020 l. yekehfallah-phd student of nursing education 72

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Heart Preservation Device 1) Thermoelectric cooler 2) Intermittent perfusion 3) Preservation solution 12/3/2020 l. yekehfallah-phd student of nursing education 74

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Transmedics, Inc 12/3/2020 l. yekehfallah-phd student of nursing education 76

Heart Preservation Device: 2 nd Generation Devices 12/3/2020 l. yekehfallah-phd student of nursing education 77

Postoperative Transplant Management 12/3/2020 l. yekehfallah-phd student of nursing education 78

Survival Following Transplant �� Operative mortality rate is between 5 -10% �� Other leading causes of mortality include: �� Infection (15 -20%) �� Acute RV failure �� Rejection 12/3/2020 l. yekehfallah-phd student of nursing education 79

Postoperative Management Complicated by �� Denervation �� Global ischemic injury associated with perfusion injury �� Myocardial dysfunction �� Dysrhythmia �� Hypertension �� Pulmonary Hypertension 12/3/2020 l. yekehfallah-phd student of nursing education 80

Infection Post Transplant: �� Prophylaxis �� Viral - CMV �� Pneumocystis carinii �� Fungal �� Based on recipient and donor serologies • Toxoplasmosis • TB • Cocci 12/3/2020 l. yekehfallah-phd student of nursing education 81

TRANSPLANT REJECTION �� Three types of transplant rejection �� Hyperacute �� Acute �� Chronic 12/3/2020 l. yekehfallah-phd student of nursing education 82

Hyper acute Rejection • Rare. Incidence <0. 4% • Occurs within minutes to few hours • Humeral response mediated by B cells • Mediated by preformed circulating antibodies in the recipient • Rapid tissue necrosis and allograft failure • Prognosis: Poor • Treatment: Immediate re-transplant or device 12/3/2020 l. yekehfallah-phd student of nursing education 83

Acute Rejection • During the first few months after transplant. Can occur anytime. • Common. Seen in 30 -50% of patients • Cellular immunity, the T cell response • Characterized by interstitial and perivascular mononuclear cell infiltrates. • Detectable on biopsy Prognosis: Good if treated early 12/3/2020 l. yekehfallah-phd student of nursing education 84

Chronic Rejection �� Incidence increases with time (about 20 -30% of patients at 5 years post transplant have disease requiring stinting or CABG) �� Can develop as early as 6 months post transplant �� Associated with cell mediated and humeral injury to the endothelium (blood vessel lining) �� Progressive and insidious decline in graft function; affects pericardial and myocardial vessels 12/3/2020 l. yekehfallah-phd student of nursing education 85

Signs of Rejection �� Edema �� Increased fatigue �� Intolerance of exercise �� Onset of low grade fever �� Increase in weight �� Exertional dyspnea �� Enlarged heart silhouette �� Rub (pericardial friction) �� EKG voltage decreased �� Jugular venous distention �� Cardiac dysrhythmias �� New S 3 or S 4 �� Onset of hypotension �� Echocardiogram changes �� Change in Allo. Map Score 12/3/2020 l. yekehfallah-phd student of nursing education 86

Diagnosing Cardiac Rejection �� Echocardiography �� Decreased systolic function, change in LV mass and wall thickness, decrease in LV chamber size, decrease in mitral deceleration time. �� Abnormalities greatly lag behind tissue evidence of rejection. �� Several parameters, but insufficient sensitivity and specificity. 12/3/2020 l. yekehfallah-phd student of nursing education 87

Cardiac Biopsy �� Invasive and very unpleasant for the patient �� May result in significant complications �� Inaccurate and variable �� Incomplete sensitivity for rejection �� Highly variable interpretation �� High false positives lead to significant over immunosuppression �� Detects rejection only after cellular infiltration and damage �� Expensive and time consuming for the physician 12/3/2020 l. yekehfallah-phd student of nursing education 88

Treatment of Rejection �� Variables: �� Grade of rejection �� Length of time since transplant �� Treatment: �� Steroids �� Augmentation of immunosuppresion 12/3/2020 l. yekehfallah-phd student of nursing education 89

Treatment of Rejection Humoral Rejection �� Plasmapharesis for 3 successive days �� Augmentation of immunosuppression to optimize level �� Consider addition of antilymphocytic therapy • Thymoglobulin / ATGAM • OKT 3 • Cytoxan 12/3/2020 l. yekehfallah-phd student of nursing education 90

Treatment of Chronic Rejection �� Adjust and/or change medications �� Control of traditional risk factors �� Angioplasty and Stents �� Re-Transplantation 12/3/2020 l. yekehfallah-phd student of nursing education 91

Immunosuppression Balance 12/3/2020 l. yekehfallah-phd student of nursing education 92

Recovery Phase Hospital Discharge 12/3/2020 l. yekehfallah-phd student of nursing education 93

Home Assessment �� Weight �� Blood pressure �� Heart rate �� Temperature �� Blood sugar monitoring 12/3/2020 l. yekehfallah-phd student of nursing education 94

Routine Testing �� Lab work �� Chest X-ray �� EKG �� Endomyocardial biopsy and or Allo. Map �� Echocardiogram �� Bone Densitometry 12/3/2020 l. yekehfallah-phd student of nursing education 95

Transplant Clinic Visits �� Health Maintenance follow-up �� Continuing education �� Psychosocial issues 12/3/2020 l. yekehfallah-phd student of nursing education 96

Cardiac Rehabilitation �� Heart rate response to exercise is blunted and delayed �� Increase in heart rate is caused by circulating catecholamines �� Maximum heart rate is achieved after exercise is completed �� Deceleration of heart rate is gradual and prolonged. 12/3/2020 l. yekehfallah-phd student of nursing education 97

Long Term Follow Up Management and Complications 12/3/2020 l. yekehfallah-phd student of nursing education 98

Medical Issues �� Immunosuppression �� Infection �� Rejection �� Coronary artery vasculopathy �� Hypertension �� Hyperlipidemia �� Diabetes �� Osteoporosis 12/3/2020 �� Obesity �� Renal insufficiency �� Gastrointestinal disorders �� Reduced exercise tolerance �� Malignancy �� Poor compliance �� Depression l. yekehfallah-phd student of nursing education 99

Quality of Life Issues The functional effect of an illness and its consequent therapy upon a patient, as perceived by the patient • Reproduction and Sexuality • Recurrent Disease • Travel • Adjustment 12/3/2020 l. yekehfallah-phd student of nursing education 100

Mental and Emotional Health �� Quality of Life �� Psychiatric Disorders �� Body Image �� Social Adaptation �� Family Dynamics �� Financial Burdens 12/3/2020 l. yekehfallah-phd student of nursing education 101

Return to Work vs Disability Issues �� Insurance �� Employment �� Vocational Rehab �� Disabilities 12/3/2020 l. yekehfallah-phd student of nursing education 102

Yearly Evaluation �� Cardiac catherization with Intravascular Ultrasound �� Echo �� Dobutamine Stress Echo �� Abdominal Ultrasound �� Chest X-Ray �� Bone Density Scan �� Labs �� 24 -hour urine for creatinine clearance �� Cancer Screens 12/3/2020 l. yekehfallah-phd student of nursing education 103

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