New heart transplant guidelines address gaps in care

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To make the guidelines for heart transplantation more concrete, the International Society for Heart and Lung Transplantation (ISHLT) have arrived at consensus regarding peri-operative, early post-op and long-term care for heart transplant patients.

ISHLT made the push to develop the practice guidelines, which were published online July 26 in the Journal of Heart and Lung Transplantation, after it became evident that clinician experience surrounding heart transplant varied from center to center. Additionally, the society said that despite the technology and approaches to surgery available, survival for heart transplant patients is low and recipients are subject to adverse effects.

“A concerted effort was also made to highlight the numerous gaps in evidence pertaining to many aspects of the care of heart transplant recipients," the society wrote. "This lack of 'evidence-based' recommendations is mostly due to the limited number of heart transplant recipients worldwide."

The development of the guidelines involved 40 writers from nine countries who were placed on three separate task forces that addressed the peri-operative care surrounding heart transplant patients, the mechanisms, diagnosis and treatment of heart transplant rejection and the clinical issues occurring long-term after heart transplant, such as the adverse effects surrounding immunosuppression and cardiac allograft vasculopathy.

Task force 1: Peri-operative care
While ISHLT said that hearts of donors younger than 45 “will invariably have sufficient reserves to withstand the rigors of heart transplant even in settings of prolonged ischemic time,” those between the ages of 45 and 55 should be used only in situations where ischemic time is four hours or less and when the receiving patient has no comorbidities or surgical issues.

Additionally, the society recommended that “the use of donor hearts greater than 55 years should only be used if the survival benefit of heart transplant for a recipient unequivocally exceeds the decrement in early heart transplant survival due to transplantation of a heart with limited myocardial reserves.”

Additional recommendations stemmed around using the optimal approaches to peri-operatively monitor heart transplant recipients. These "optimal strategies" included continuous ECG monitoring, post-op 12-lead ECG, arterial pressure monitoring, measuring cardiac output and arterial oxygen saturation and continuous assessment of urinary output.

Task force 2: Early post-op care
As for rejection of a heart by a recipient, ISHLT recommended that endomyocardial biopsy be used in recipients thought to have an infiltrative cardiomyopathy or inflammation, such as giant cell myocarditis. Additionally, the society recommended that a biopsy be performed within the first six to 12 months post-transplant to monitor for organ rejection.

For pediatric patients, the society said that clinicians should monitor creatinine kinase levels and administer calcineurin inhibitor maintenance therapy, while adult transplant patients should be administered statins beginning one to two weeks post-transplant.

TASK FORCE 3: Long-term care
The society members recommend that proper management of neurological complications and proper diagnosis for cardiac allograft vasculopathy take place in transplant patients.

To properly manage cardiac allograft vasculopathy in Class I transplant patients, ISHLT recommended:

  • That prevention for cardiac allograft vasculopathy include monitoring of cardiovascular risk factors including hypertension, diabetes, hyperlipidemia, smoking and obesity;
  • Statin therapy for heart recipients after it showed evidence to improve long-term outcomes, regardless of lipid levels;
  • Annual or bi-annual coronary angiography tests to evaluate the development of cardiac allograft vasculopathy; and
  • A six-month coronary CT angiography post-PCI.

The members recommended that cardiac rehabilitation with aerobic exercise be used in transplant patients, along with long-term follow-up at a center in order to prevent rejection and to monitor drug interactions, drug use and comorbidities.

The authors wrote, “Most of the recommendations only achieve a Level of Evidence C, indicating that these recommendations are based on expert consensus and not on randomized controlled clinical trials.

“It is the hope of all contributing writers and reviewers that the increased awareness of the 'gaps in evidence' provided by these guidelines will spur further