Page 631 - Cardiac Nursing

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LWBK340-c25_ pp595-622.qxd 06/30/2009 17:45 Page 607 Aptara
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C HAPTER 2 5 / Cardiac Surgery 607
after heart transplantation is 87%, the 5-year survival rate is 71%, donation. The success of heart transplantation has created an ever-
50
and the 10-year survival rate is 52%. These figures represent pa- increasing gap between the number of transplantation candidates
tients who underwent transplantation from 1987 to 2006. This and usable heart donors. In March 2008, there were 2,656
section outlines expectations, therapeutic treatment regimes, and patients waiting for a heart donor and 2,210 transplantations in
a plan of nursing care. the United States from January 1, 2007 to January 1, 2008. 55
Transplant centers and organ procurement organizations work to-
Progress in Cardiac Transplantation gether to promote organ donation by providing public and health
care professional education. 56
One-year survival rates after cardiac transplantation have im- With a greater number of centers involved in transplantation
50
proved from 22% in 1968 to more than 87% in 2006. In 1974, and listing potential recipients in organ registries, the average wait
major changes in survival were attributed to the introduction of for a donor heart has increased dramatically. As a result, the pa-
the endomyocardial biopsy technique for monitoring rejection, to tients often become sicker while waiting. Because of the increas-
the treatment of rejection, and to the introduction of polyclonal ingly sophisticated management of the patient with heart failure,
antibodies. Survival results took another upward leap after the in- the use of -blockers to produce hemodynamic and symptomatic
troduction of cyclosporine therapy in 1980. We are now benefit- improvement, and the pressure for transplant physicians to man-
ing from better prevention, diagnosis, and management of rejec- age patients on an outpatient basis, patients are put on an acuity
tion and the complications of immunosuppressive therapy. scale (status) of need that includes strict definitions of illness.
The calcinurin inhibitors, cyclosporine and tacrolimus, are the Medical review boards are used to monitor transplant centers list-
most effective immunosuppressant drugs available and are capable ing criteria.
of specific immunosuppressant activity to control rejection with-
out totally suppressing the body’s ability to fight infection. 51,52 Evaluation of Recipients
Cyclosporine contributed to an approximate 20% increase in 1-
year patient survival in the early 1980s. This increase is caused in Candidates for cardiac transplantation should have severe func-
large part by cyclosporine’s superior ability selectively to inhibit tional limitation and poor life expectancy from their heart disease.
T-cell proliferation and reduce the incidence of rejection. The candidates should be without the established contraindica-
Improved survival has led to alterations in patient selection cri- tions or usual exclusions. The most frequent medical diagnoses of
teria with respect to age. Other selection criteria have changed lit- these patients are cardiomyopathy of various origins (idiopathic,
tle since the earlier years of cardiac transplantation. Before the in- viral, or valvular) and ischemic heart disease. 57 Candidate criteria
troduction of cyclosporine therapy, an upper age limit of 50 years have been established for use in the evaluation process to identify
and a lower age limit of adult-sized adolescence were followed. patients most likely to benefit from the operation. Table 25-2 out-
Earlier data indicated that patients older than age 50 years did not lines contraindications to cardiac transplantation.
tolerate immunosuppression and had poorer survival. 53 Because Pediatric patients who may benefit from cardiac transplanta-
calcinurin inhibitors do not totally suppress the entire immune tion include those with cardiomyopathy and those with structural
58
system, older patients are considered for transplantation. The gen- heart disease without severe pulmonary vascular disease. These
eral trend is to define the upper age limit as 60 to 65 years. The patients might have been treated surgically initially, but progres-
current age range is from newborn to 75.3 years, with a mean age sive, severe ventricular dysfunction or progressive pulmonary vas-
of 45 years. 50 Before 1980, children younger than 10 years of age cular disease limits further therapeutic options. A child with se-
were not considered to be transplantation candidates. This crite- vere pulmonary vascular disease is not a cardiac transplant
rion was reevaluated. Before 1980, each year, fewer than five chil- candidate because of the likelihood of irreversible right ventricu-
dren (18 years of age or younger) underwent heart transplanta- lar failure after transplantation. Pediatric transplantation has been
tion. In 2006 to 2007, 102 transplantations were performed in at a plateau since the early nineties. Neonatal transplantation is
children from newborn to 1 year of age, and 242 transplantations performed on a smaller scale. In 2007, 102 children younger than
were performed in children between 1 and 18 years of age. 54 Ac- age 1 year underwent transplantation; less than 1% of this donor
tuarial 1-year survival for pediatric patients less than 1 year is 80% population cause of death was from sudden infant death syn-
and around 90% for children 1 to 17 years. The primary causes of drome. 55 Once a child reaches late adolescence, it becomes feasi-
death for patients surviving greater than 1 year are coronary vas- ble to use adult donor hearts, and organ procurement is no more
culopathy, acute rejection, and malignancy (including lym- difficult than it is with adults. However, there has been a trend
phoma). 54 over the past 10 years to transplant pediatric donor hearts into
Distant organ procurement enables transplantation centers to children because the allocation policy gives preference for the
increase the number of transplantations performed. A surgical pediatric recipient to receive the pediatric donor organ. 59
team can be dispatched from the transplantation center and can As previously indicated, the potential transplant recipient must
travel up to 500 miles to retrieve the needed heart. An ischemic not have fixed irreversible pulmonary hypertension, which is de-
time of up to 4 hours is considered acceptable. This allowable is- fined as a pulmonary vascular resistance greater than 6 to 8 Wood
chemic time permits an approximate travel time of 2.5 hours, units. The presence of severe pulmonary hypertension would
with the remaining time required to implant the heart into the pa- result in certain right ventricular failure in a newly transplanted
tient. Greater public awareness and media attention focused on heart. The transplanted heart is developed normally and not ac-
the need for donors have also contributed to an increase in the customed to pumping against such elevated pressures. Irreversible
available donor pool and transplantation activity. Legislation in hepatic and renal failure also may preclude transplantation. Some
some states requires that a family of a potentially eligible donor be dysfunction may exist, but this should be because of the patient’s
asked if that person wished organ donation. However, the limit- low cardiac output and is expected to reverse with replacement with
ing factor in solid organ transplantation continues to be organ a healthy heart. Cyclosporine, tacrolimus, and mycophenolate