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Center for Congenital Heart Disease/Pediatric Cardiology Heart- and Diabetescenter NRW, University Clinic of Ruhr-University Bochum. Bad Oeynhausen, Germany
Department of Pharmacy, NewYork-Presbyterian Hospital Columbia University Irving Medical Center, Department of Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy, Long Island University. New York, NY
David Baran, Tiffany Buda, Adam Cochrane, Maria Crespo Leiro, Anne Dipchand, Brian Feingold, Kathleen Grady, Edward Horn, Maryl Johnson, Donna Mancini, Sean Pinney, Heather Ross, Kari Wujcik, Andreas Zuckermann
The International Society for Heart and Lung Transplantion (ISHLT) Guidelines for the Care of Heart Transplant Recipients were originally published in 2010. These guidelines provided the first comprehensive guideline for the care of Heart Transplant patients. A great deal has changed in the years after this initial unprecedented document. The ISHLT has made the commitment to convene experts in all areas of heart transplantation to develop a focused update to the original practice guidelines. Writers and Chairs were charged with reviewing the existing guidelines and where signifigant new literature exists, updating those original recommendations. Additionally, they were charged to add specific new areas of focus that were undeveloped, undiscovered, or unsupported at the time of the original publication. After a vast effort involving 39 writers from 11 countries worldwide, the “ISHLT Guidelines for the Care of Heart Transplant Recipients” has now been completed and the Executive Summary of these guidelines is the subject of this article.
The document results from the work of 4 Task Force groups each co-chaired by a pediatric heart transplant clincian who had the specific mandate to highlight issues unique to the pediatric heart transplant population and to ensure their adequate representation.
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Task Force 1 addresses the peri-operative care of heart transplant recipients, including:
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Pre-Transplant Optimization
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Surgical Issues Impacting Care in the Immediate Post-operative Period
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Considerations in Patients Bridged with Mechanical Circulatory Support
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Early Post-Operative Care of the Heart Transplant Recipient
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Evaluation of Allosensitization, Approaches to Sensitized Heart Transplant Recipients, and Hyperacute and Delayed Antibody-Mediated Rejection
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Management of ABO “Incompatible” Heart Transplant Recipients
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Coagulopathies in Heart Transplant Surgery
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Documentation and Communication with the Multidisciplinary Team
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Use of Extracorporeal Membrane Oxygenation for the Management of Primary Graft
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Task Force 2 discusses the Immunosuppression and Rejection including:
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Rejection Surveillance
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Monitoring of Immunosuppressive Drug Levels
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Principles of Immunosuppression and Recommended Regimens
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Treatment of Acute Cellular Rejection
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Treatment of Hyperacute and Antibody-Mediated Rejection
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Management of Late Acute Rejection
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Task Force 3 addresses the Long-term Care of Heart Transplant Recipients; Management of Complications including:
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Minimization of Immunosuppression
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Management of Neurologic Complications After Heart Transplantation
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Cardiac Allograft Vasculopathy
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Malignancy After Heart Transplantation
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Chronic Kidney Disease After Heart Transplantation
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Management of Cardiovascular Risk After Heart Transplantation
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Other Complications of Chronic Immunosuppression
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Arrhythmias
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Anticoagulation after Heart Transplant
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Monitoring Recipients of Organs from Donors at Higher Risk of Infectious Diseases
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Graft Failure & Considerations for Cardiac Retransplantation
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Taskforce 4 covers the Long-term Care of Heart Transplant Recipients: Prevention and Prophylaxis including:
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Frequency of Routine Tests and Clinic Visits in Heart Transplant Recipients
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Prophylaxis for Corticosteroid-Induced Bone Disease
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Exercise, Nutrition and Physical Rehabilitation After Heart Transplantation
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Management of Intercurrent Surgery in Heart Transplant Recipients
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Reproductive Health After Heart Transplantation
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Psychosocial and Psychologic Issues Particularly Related to Adherence to Medical Therapy in Heart Transplant Recipients
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Substance Use & Abuse
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Endocarditis Prophylaxis After Heart Transplantation
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Return to Work or School and Occupational Restrictions After Heart Transplantation
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Return to Operating a Vehicle After Heart Transplantation
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Family Screening
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Management of the Transition from Pediatric to Adult Care After Heart Transplantation
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Principles of Shared Care After Heart Transplantation
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Travelling After Heart Transplant
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Emerging Pathogens, Epidemics and Pandemic Considerations for Heart Transplant Recipients
International Society for Heart and Lung Transplantation Standards and Guidelines Committee Grading Criteria
Tabled
1
Class I
Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, and effective
Class II
Conflicting evidence and/or divergence of opinion about the usefulness/efficacy of the treatment or procedure
Class IIa
Weight of evidence/opinion is in favor of usefulness/efficacy
Class IIb
Usefulness/efficacy is less well established by evidence/opinion
Class III
Evidence or general agreement that the treatment or procedure is not useful or effective and in some cases may be harmful
Level of evidence A
Data derived from multiple randomized clinical trials or meta-analyses
Level of evidence B
Data derived from a single randomized clinical trial or large non-randomized studies
Level of evidence C
Consensus of opinion of the experts and/or small studies, retrospective studies, registries
However, frailty is also associated with increased mortality and morbidity in the elderly and general HF population. The prevalence of frailty is high in advanced HF patients, accounting for over 30% amongst those referred for advanced HF therapies, including heart transplantation (HT). It is an independent prognostic factor for morbidity and mortality, especially in patients with lower peak oxygen consumption (VO2).
A variety of methods have been utilized to assess frailty in HF with increasing support for its value in assessing HT patients. Currently, the modified Fried frailty criteria with five physical domains (fatigue, hand grip strength, gait speed, unintended weight loss and physical activity) and additional cognitive assessment (Montreal Cognitive Assessment [MoCA] tool) appears to be a reasonable resource for HT candidates.
While frailty is associated with increased morbidity and mortality in patients undergoing ventricular assist device (VAD) implantation and HT, it is also largely reversible following these procedures.
Reduced Handgrip Strength as a Marker of Frailty Predicts Clinical Outcomes in Patients With Heart Failure Undergoing Ventricular Assist Device Placement.
Pre transplant body mass index (BMI) is a factor that has been shown to correlate with survival post heart transplant. A United Network for Organ Sharing (UNOS) registry study showed the relationship between BMI and post-transplant survival to be U-shaped, with transplant candidates who were underweight (BMI <18.5 kg/m2) and candidates who were obese (BMI > 35 kg/m2) having significantly decreased survival from year 1 to 5.
It is important to note, however, that in regards to nutritional screening and assessment of patients with heart failure, the accuracy of any single nutritional indicator may be compromised by many confounding factors, especially be edema. Edema is caused by fluid retention in addition to inflammatory responses, induced by cytoprotective responses to cellular damage caused by under perfusion of peripheral tissues. Both fluid retention and the inflammatory response affect anthropometric measures such as BMI, triceps skinfold measurement and mid-arm circumference, as well as serum markers, such as albumin and prealbumin. Given secondary confounding factors, multidimensional tools should be used to assess nutrition status.
Based on a systematic review of literature, the most commonly used tools that provide scores that were independent prognostic factors for mortality risk in heart failure patients, were the Mini Nutrinritional Assessment, MNA-short form, Nutritional Risk Index, and Geriatric Nutritional Risk Index.
Preliminary studies regarding prehabilitation, exercise, and nutrition interventions prior to surgery have shown promising results with improved outcomes post-surgery.
Interventions may include strategies to: 1) improve appetite, such as appetite stimulating agents, including megestrol acetate and anabolic steroids; 2) augment caloric intake, including oral food supplements, or with enteral feedings via nasogastric feeding tube, or percutaneous endoscopic gastrostomy; and 3) directly provide micronutrients, carbohydrates and proteins, such as total parental nutrition.
Lastly, post-transplant patients are at high risk for osteopenia and osteoporosis, largely due to use of glucocorticoids and calcineurin inhibitors. Transplant candidates should therefore be evaluated for bone disease by bone marrow density (BMD) and parameters of bone and mineral metabolism, so that appropriate therapies, such as vitamin D supplementation and bisphosphonates, can be initiated to minimize patient's risk for osteopenia following transplant.
Cardiac rehabilitation has been shown to improve functional capacity and decrease hospital readmissions in HF patients, and is currently recommended by guidelines.
Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation.
2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.
and better functional capacity and health-related quality of life in heart failure, heart transplant or left ventricular assist device (LVAD) patients.
Efficacy of the cardiac rehabilitation program in patients with end-stage heart failure, heart transplant patients, and left ventricular assist device recipients.
Pre-transplant psychosocial factors, including patients’ history of medical adherence, mental health, substance use, and social support, can predict outcomes following heart transplantation. Certain factors, such as noncompliance to medical regimen, smoking and alcohol abuse, psychiatric conditions such as depression, and minimal or no social support, have been shown to lead to behaviors of continued or relapse of nonadherence to medical regimen, relapse of substance use, poor self-care, and poor coping. These behaviors lead to poor health-related quality of life with increased morbidity and mortality post-transplant. To maximize outcomes, efforts should be made, prior to transplant, to optimize factors that are modifiable, based on pre-transplant psychosocial evaluation. Interventions may include support groups for substance use, ongoing counseling or therapy, optimization of medical therapy for psychiatric illnesses, and utilization of community resources.
The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support.
The Journal of Heart and Lung Transplantation.2018; 37: 803-823
The presence of pre-transplant pulmonary hypertension (PH) in heart organ recipients increases the risk of post-transplant PH and deterioration in right ventricular function in the donor heart. Large registry studies show pre-transplant PH is associated with significantly worse short-term survival post HT compared to patients without pre-transplant PH.
However, assessment of isolated pulmonary hypertension, related to left ventricular failure and reversibility following transplant, remains challenging. In 2018, the 6th World Health Symposium on Pulmonary Hypertension developed two main changes in the definition and classification of PH.
Prognostic value of the pre-transplant diastolic pulmonary artery pressure–to–pulmonary capillary wedge pressure gradient in cardiac transplant recipients with pulmonary hypertension.
The Journal of Heart and Lung Transplantation.2014; 33: 289-297
First, PH is defined by a mean PAP (mPAP) greater than 20mmHg (previously greater than 25mmHg). The lower parameter reflects recent studies suggesting that individuals with mPAP 21-24mmHg are at increased risk of poor outcomes and tend to progress to “overt PH” (mPAP 25 or greater) more often than patients with lower mPAP(20mmHg or less).
In addition, PH was further subclassified by pulmonary vascular resistance (PVR) to help stratify pre-capillary PH (as seen in PAH), and isolated post-capillary PH (IpcPH, related to left ventricle (LV) dysfunction, as well as combined pre- and post- capillary PH (CpcPH) (Table 1). While subcategorization and method of detecting CpcPH remains controversial, current evidence suggests that CpcPH is a distinct entity from PAH or IpcPH and carries a different prognosis both before and after HT.
Prognostic value of the pre-transplant diastolic pulmonary artery pressure–to–pulmonary capillary wedge pressure gradient in cardiac transplant recipients with pulmonary hypertension.
The Journal of Heart and Lung Transplantation.2014; 33: 289-297
Strategies to assess and optimize elevated pulmonary artery (PA) pressures should be utilized to determine reversibility in order to prevent right ventricular failure post-transplant (Figure 1). Medical therapies include diuretics, inotropes, and vasoactive agents, both inhaled (i.e., nitric oxide and prostacyclins), and intravenous (i.e., nitroglycerin and nitroprusside). Phosphodiesterase-3 (PDE-3) inhibitors (i.e., milrinone) have shown immediate hemodynamic effects, however, with no long-term effects on clinical outcomes in PH due to LV failure. Other therapies typically used for WHO Group 1 PH (pulmonary arterial hypertension) have been utilized for WHO group 2 PH (due to LV failure) with varying results. PDE-5 inhibitors (i.e., sildenafil) has demonstrated some beneficial effects. Additionally, endothelin receptor antagonists (ERAs) such as bosentan and tezosentan have shown some improvement in hemodynamics in pre-clinical and small studies albeit with adverse effects, including hepatic dysfunction. Newer ERAs, such as macetentan, without adverse effects on hepatic function are currently being studied. Finally, PH refractory to medical therapy has been effectively treated with mechanical circulatory support, such as LVADs, with improvement in PH and successful bridging to transplant.
Figure 1Established effects of some targeted interventions. Blue bars symbolize depleting or reducing effect. Anti-CD20 antibodies show strong effect on naïve, effector, and memory B cells but no effect on plasma cells, which are not expressing CD20. Proteasome inhibitors show strong effect on PC and moderate effect on memory B cells. Anti-CD19 cells target PC but are currently not available as an effective clinical therapeutic for transplant. Effect of all of these therapies on LLPC is unclear but appears to be limited. (IL: interleukin, LLPC: long lives plasma cell, PC: plasma cell)
Consideration of mechanical circulatory support (MCS) for Bridging to Transplant
Patients with HF refractory to optimal medical therapy, with hemodynamic instability and/or progressive end organ dysfunction, should be considered for short-term and/or long-term MCS. MCS therapy should be directed by the trajectory of HF progression and clinical status.
Short-term mechanical circulatory support as a bridge to durable left ventricular assist device implantation in refractory cardiogenic shock: a systematic review and meta-analysis.
European Journal of Cardio-Thoracic Surgery.2017; 52: 14-25
International Society for H and Lung T. The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary.
Recommendations for the Use of Mechanical Circulatory Support: Device Strategies and Patient Selection: A Scientific Statement From the American Heart Association.
Society for Cardiovascular A, Interventions, Heart Failure Society of A, Society of Thoracic S, American Heart A and American College of C. 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care: Endorsed by the American Heart Assocation, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention.
Impact of Pediatric Risk Models on Wait-list Management
Selection of pediatric recipients is a multifactorial process including specific considerations of factors that will directly impact posttransplant outcome. Furthermore, the spectrum of advanced therapies as well as donor polices, public initiatives and published studies have significantly changed approaches in the management and care of this special population. Candidate selection and waitlist removal are a multidisciplinary process that balances the risks and benefits for the transplant procedure.
Risk factors for early mortality include: recipient variables such as diagnosis, age, gender, sensitization, pulmonary vascular resistance, non-cardiac end organ status, mechanical ventilation, extracorporeal membrane oxygenation, VADs; donor-related factors including ischemic time, donor graft function, cause of death. Small center volume has been described as a potential variable for increased post-transplant mortality. A model for in-hospital mortality after pediatric transplantation has been studied using variables available in Organ Procurement Transplantation Network (OPTN) which includes hemodynamic support; Extracorporeal Membrane Oxygenation (ECMO), VAD, ventilator and medical therapy, cardiac diagnosis, renal dysfunction, and serum total bilirubin. This model has C-statistics of 0.75 and 0.81.
including ischemic time, stroke as the cause of death, donor-to recipient height ratio, donor left ventricular ejection fraction, and donor glomerular filtration rate. This model can be useful when assessing acceptability of a prospective organ in a recipient. Therefore, risk factors models can provide an impact on wait list management after acknowledgement of unmeasured and confounding factors.
Nutritional Assessment, Nutritional Rehabilitation and Nutritional Interventions in the Pediatric Population
Nutritional status in most pediatric chronic conditions is a major determinant of childhood well-being. Chronic HF in children is a major cause of malnutrition.
Malnutrition is an imbalance of nutrients between intake and nutritional requirements. The body is unable to meet metabolic demands in the setting of cardiac dysfunction. The pathophysiology of heart failure involves activation of compensatory pathways, pro-inflammatory cytokines, neurohormonal abnormalities, increased metabolic demands, reduced intake, and malabsorption.
These mechanisms lead to starvation, malabsorption nutritional loss and hypermetabolism which result in malnutrition and suboptimal growth. Therefore, it is recommended that nutritional status should be addressed by history, and nutritional and physical assessment. The basic tools for initial evaluation include a history of energy, protein and fluid intake, weight, length, head circumference measurements on sex- and age- specific growth curves
(weight for age, length for age, body mass index) on which individual patient's values can be plotted and detection of growth velocity deviation. Nutritional support includes hypercaloric feeds, oral supplements, and enteral and parenteral nutrition. Enteral nutrition is required when oral intake is insufficient. Conditions such as severe cord dysfunction, dysphagia, or oral aversion can interfere with adequate oral intake. Nasojejunal tube feeds may be used when nasogastric tube feeds are not tolerated. Nutritional support via gastrostomy can be effective at reversing malnutrition, in maintaining nutritional status, and may be indicated in children requiring prolonged enteral tube feeding. Multidisciplinary discussions surrounding the risk of surgical intervention and anesthesia are required in these cases.
Consideration of Bridge to Transplant with MCS in Pediatric Recipients
The use of VADs in pediatric patients for the treatment of advanced HF has increased significantly in the past decade and has supplanted ECMO as the most common form of MCS as a bridge to HT. The percentage of children with MCS as a bridge to transplantation has increased from 25% in 2010 to 36% in 2019. The majority of MCS implants in the pediatric population are INTERMACS profiles 1 or 2 with significantly decreased waitlist mortality. However, the ISHLT registry data demonstrates no survival difference between children with or without VAD support, except for worse outcomes in those bridged with ECMO.
The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: Twenty-second pediatric heart transplantation report –2019; Focus theme: Donor and recipient size match.
The Journal of Heart and Lung Transplantation.2019; 38: 1028-1041
Vaccination of solid organ transplant candidates and recipients: Guidelines from the American society of transplantation infectious diseases community of practice.
Assessment of frailty using the modified Fried's criteria (3 of 5 possible symptoms, including unintentional weight loss of >10 pounds within the past year, muscle loss, fatigue, slow walking speed, and low levels of physical activity) should be considered when assessing candidacy. Class I, Level of Evidence C
New Recommendation
Multidimensional nutritional assessment tools should be used to evaluate heart transplant candidates for malnutrition or for being at risk for malnutrition. Class I, Level of Evidence C
New Recommendation
Cardiac rehabilitation is reasonable in patients awaiting heart transplantation in order to decrease readmissions, wait list mortality and improve post-transplant outcomes. Class IIa, Level of Evidence C
New Recommendation
Various interventions, such as oral/enteral supplementation, appetite stimulants, micronutrient replacement, and anabolic steroids may be beneficial in optimizing nutritional status prior to transplant to help decrease adverse outcomes including mortality post transplant. Class IIa, Level of Evidence C
New Recommendation
Based on psychosocial and behavioral evaluation at time of heart transplant evaluation, interventions and therapies should be initiated to address psychosocial and behavioral risk factors that may contribute to poor outcomes post-transplant. Class I Level of Evidence C.
New Recommendation
A vasodilator challenge should be administered when the pulmonary artery systolic pressure is >= 50 mm Hg and either the transpulmonary gradient is >= 15 or the pulmonary vascular resistance (PVR) is > 3Wood units while maintaining a systolic arterial blood pressure > 85 mm Hg. Class I, Level of Evidence C
New Recommendation
When an acute vasodilator challenge is unsuccessful, hospitalization with continuous hemodynamic monitoring should be performed, as often the PVR will decline after 24 to 48 hours of treatment consisting of diuretics, inotropes, and vasoactive agents, including inhaled nitric oxide. Class I, Level of Evidence C
New Recommendation
Following bridging left ventricular assist device (LVAD) implantation, re-evaluation of hemodynamics, particularly in respect of the Trans-Pulmonary Gradient (TPG) and PVR is reasonable to be done after 3 months and at regular intervals thereafter to ascertain reversibility of pulmonary hypertension. Class IIa, Level of Evidence C
New Recommendation
If medical therapy fails to achieve acceptable hemodynamics, and if the left ventricle cannot be effectively unloaded with mechanical adjuncts, including an intra-aortic balloon pump (IABP) and/or mechanical circulatory support (MCS), it may be reasonable to conclude that the pulmonary hypertension is irreversible. Class IIb, Level of Evidence C
New Recommendation
IABP and short-term MCS should be considered in patients in cardiogenic shock refractory to medical therapy until hemodynamic parameters and end organ function are stabilized, followed by further consideration of urgent HT or continued +/- upgrade to longer-term MCS as deemed appropriate. Class I, Level of Evidence C
New Recommendation
Long-term MCS should be considered in patients: (a) When ventricular function is unlikely to recover soon or has been deemed unrecoverable. (b) Who are inotrope dependent and therefore at high risk for death with ongoing medical management. (c) Who are potential HT candidates, with elevated pulmonary vascular resistance that is considered reversible with left ventricular (LV) decompression. (d) Who are potential HT candidates, with contraindications requiring substantial time to reverse, i.e., cancer, obesity, drug and/or alcohol dependence. (e) With a reversible cardiac disease process that requires substantial time for ventricular recovery. (f) Who are ineligible for HT and where long-term MCS is an option. Class I, Level of Evidence C
New Recommendation
Pediatric risk models may be reasonable to assist with pediatric wait-list management including the removal of patients who are too sick to undergo and benefit from HT. Class IIb, Level of Evidence B
New Recommendation
Pediatric transplant recipients plotting below the third percentile (–2 standard deviation) can benefit from further assessment, referral, or intervention for nutrition support. Class IIa, Level of Evidence C
New Recommendation
Consideration should be given to address moderate or severe wasting and an elevated weight/height as these findings are independent risk factors for waitlist mortality in young patients aged 0-2 years despite the fact there is no apparent effect of these conditions on post-HT mortality. Class IIa, Level of Evidence C
New Recommendation
Energy and nutrient intake and barriers to intake are reasonable to assess at regular intervals. Class IIa, Level of Evidence C
New Recommendation
The decision to insert a gastrostomy tube is reasonable to be determined by a multidisciplinary team through a holistic consideration of medical, ethical, psychological, and quality-of-life issues. Class IIa, Level of Evidence C
New Recommendation
Temporary MCS should be considered for potential or actual transplant candidates at high risk of mortality with medical management alone Class I, Level of Evidence C
New Recommendation
Temporary MCS devices permit a longer duration of hemodynamic assistance with superior patient survival when compared to conventional Extracorporeal Membrane Oxygenation (ECMO) therapy. Therefore, MCS should be considered as bridging therapy to pediatric HT in the case of refractory heart failure Class I, Level of Evidence A
New Recommendation
Bridging ventricular assist device (VAD) rather than ECMO support should be considered in children for better survival to HT. Class I, Level of Evidence C
New Recommendation
Based on current technology and availability, paracorporeal devices are recommended for children smaller than 20-25 kg. Class I, Level of Evidence C
New Recommendation
ECMO support may be used as a bridge to decision-making, as a bridge to VAD therapy, or as a bridge to transplantation in critical situations. Class IIa, Level of Evidence C
New Recommendation
Pediatric heart failure patients ≤24 months of age and who meet criteria for respiratory syncytial virus prophylaxis should receive palivizumab in accordance with established guidelines. Class I, Level of Evidence A
New Recommendation
Vaccine history and assessment of seroprotection (as appropriate) should be reviewed prior to listing for heart transplantation. Transplant candidates who are unvaccinated or incompletely vaccinated should receive recommended vaccinations as early as possible, as end-organ failure and iatrogenic immunosuppression may diminish vaccine responses. Class I, Level of Evidence C
New Recommendation
In most situations, live virus vaccines are contraindicated following transplantation. Every attempt should be made to complete live virus vaccines, including MMR, varicella, live attenuated zoster, and rotavirus, prior to transplantation in non-immune patients according to established guidelines. Live virus vaccination should ideally be completed four weeks prior to transplantation. Class I, Level of Evidence C
New Recommendation
Prior to transplantation, candidates should receive inactivated vaccines, including but not limited to influenza, pneumococcal, tetanus, pertussis, hepatitis A and B, and human papillomavirus vaccines, in accordance with established guidelines. Inactivated vaccines should ideally be completed two weeks prior to transplantation. Class I, Level of Evidence C
New Recommendation
The recombinant subunit zoster vaccine is preferred over the live-attenuated vaccine for transplant candidates and should be given in accordance with local vaccination guidelines. Class IIa, Level of Evidence C
Topic 2: Surgical Issues Impacting Care in the Immediate Post-Operative Period
Transplantation of Hearts from Donors with Infection
Donor-derived disease transmissions are uncommon. However, the decision to utilize organs from donors with documented infection should be made with involvement of the transplant infectious diseases team. The use of organs from hepatitis C viremic donors has been associated with excellent short-term outcomes in HT recipients.
Transmissions of leukemia, lymphoma, rabies, and other central nervous system infections have been reported from donors with encephalitis of unknown etiology, and such donors should be avoided.
Transplantation of Hearts from Donors with Potential Drug Toxicities
While small single center studies have shown conflicting results with donor use with various drug toxicities in heart transplantation, large retrospective registry studies have demonstrated that use of donors with history of alcohol abuse, cocaine use (active or past), or drug overdose does not have deleterious effects on short- and long-term survival post HT.
Several case studies show successful transplantation with donors who suffered carbon monoxide poisoning. While safety is not completely established, the use of hearts in these donors can reasonably be considered in the setting of clinical and objective evidence of satisfactory cardiac function.
Use of Donors with Pre-existing Cardiac Abnormalities
There is data limited to small studies and case reports regarding the use of donors with coronary artery disease (CAD) that demonstrate varying results and effects of donor CAD on post-transplant vasculopathy and overall outcomes.
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