2/20/2015. Cardiac Evaluation of Potential Solid Organ Transplant Recipients. Issues Specific to Transplantation. Kidney Transplantation.

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1 DISCLOSURES I have no relevant financial relationships to disclose. Cardiac Evaluation of Potential Solid Organ Transplant Recipients Michele Hamilton, MD Director, Heart Failure Program Cedars Sinai Heart Institute 2 Issues Specific to Transplantation Kidney Transplantation Operative risk Liver>Lung>Kidney Cardiac risk factors common in these patients Special Considerations for Transplantation Donated organ is a scarce resource Possible changes in risk while waiting Cardiac risks over the years post Medium Risk Surgery both a vascular and abdominal surgery Long waiting time Most potential candidates have multiple risk factors for CAD/stroke HTN, DM, etc.. Primary causes of post tx mortality are cardiovascular 3 4 Kidney Transplant Case Question 1 55 M with DM type 1 since childhood and longstanding HTN. He has CKD stage 4 due to DM, but is not yet on hemodialysis. He exercises daily with brisk walking. He denies CP, SOB, orthopnea, PND, or edema. He denies syncope, presyncope or palpitations. He is disabled from his job as a salesman due to his decreased vision. What evaluation does this patient need? A. EKG only B. Stress test. C. Coronary angiography regardless of stress test results. D. He is not a candidate for kidney due to cardiac risk factors. 1

2 ACC/AHA guidelines ACC/AHA guidelines discourage pre op screening of asymptomatic patients Testing doesn t improve operative outcomes 770 patients with 1-2 cardiac risk factors undergoing intermediate risk surgery were randomized to stress testing or no testing No difference in death or MI at 30 days or beyond Testing delayed surgery by 3 weeks Fleisher L A et al. Circulation 2007;116: Poldermans D et al. JACC 2006; 48: Renal candidates are treated differently Pre Kidney Transplant Case 55 M with DM type 1 since childhood and longstanding HTN. He has CKD stage 4 due to DM and is not yet on hemodialysis He exercises daily with brisk walking. He denies CP, SOB, orthopnea, PND, or edema. He denies syncope, presyncope or palpitations. He is disabled from his job as a salesman due to his decreased vision. Friedman S E et al. CJASN 2011;6: Question 1 Question 2 What evaluation does this patient need? A. EKG only B. Stress test. C. Coronary angiography regardless of stress test results. D. He is not a candidate for kidney due to prior CAD. Nuclear adenosine stress test shows a large reversible defect in the anterior wall consistent with a proximal LAD lesion. Based on the abnormal stress test, you decide: A. Medical management. B. Coronary angiogram. C. Repeat stress testing in 1 year. D. He is no longer a kidney candidate due to an abnormal stress test. 2

3 Kidney Transplant Coronary Artery Evaluation Question 2 No symptoms Low risk finding Abnormal stress test Anginal symptoms High risk finding Nuclear adenosine stress test shows a large reversible defect in the anteroseptum and anterolateral wall consistent with a proximal LAD lesion. Based on the abnormal stress test, you decide: Medical management Stents List for Angiogram CABG No targets Not a candidate for A. Medical management. B. Coronary angiogram. C. Repeat stress testing in 1 year. D. He is no longer a kidney candidate due to an abnormal stress test. Question 3 Preoperative cardiovascular risk assessment Coronary angiogram shows a 90% proximal LAD lesion with no other disease. What should the cardiologist do? A. Continue medical management and list the patient for kidney. B. Perform FFR of the LAD lesion. C. Stent the LAD lesion. D. Decline the patient for kidney ation due to the severe LAD stenosis. Revascularization doesn t improve outcomes 510 patients scheduled for vascular surgery with significant CAD and stable symptoms were randomized to revascularization or no revascularization No difference in death or MI at 30 days or beyond McFalls E et al. NEJM 2004; 351: For Kidney Tx Candidates, is revascularization better? Kidney Transplant Coronary Artery Evaluation Observational study of 1460 patients referred for kidney evaluation Low risk finding Abnormal stress test Medically managed CAD is a risk factor for poor outcomes No symptoms Anginal symptoms High risk finding But... does revascularization really help? Revascularized patients were more likely to receive aspirin, beta blocker, and statin therapy Angiogram Bottom line: Revascularization should be considered... but so should optimal medical management Medical management Stents List for CABG No targets Not a candidate for Kahn M et al. Am J Transplant 2011; 11: Kittleson MM et al. Am J Transplant 2011; 11:

4 Question 3 Question 4 Coronary angiogram shows a 90% proximal LAD lesion with no other disease. What should the cardiologist do? A. Continue medical management and list the patient for kidney. B. Perform FFR of the LAD lesion. C. Stent the LAD lesion. D. Decline the patient for kidney ation due to the severe LAD stenosis. The patient has stent of LAD lesion and is listed for a deceased donor kidney. Given the long projected wait time, the patient is listed one week after stent placement while on aspirin and clopidogrel. What surveillance is needed? A. Annual nuclear adenosine stress tests. B. Annual coronary angiograms. C. Annual cardiology consultations. Question 4 The patient is listed for a deceased donor kidney. Given the long projected wait time, the patient is listed one week after stent placement while on aspirin and clopidogrel. What surveillance is needed? A. Annual nuclear adenosine stress tests. B. Annual coronary angiograms. C. Annual cardiology consultations.* *He should have regular follow-up appointments with his cardiologist Low EF Assess for reversible causes: stress test/angio Initiate evidence based therapy with ACEI and BB Optimize fluid balance and BP NYHA I II List for kidney Impaired Ventricular Function NYHA III IV Consider heart kidney if eligible Severe AS HF symptoms Low EF Dilated ventricle Valve surgery Severe AR/MR Valvular Heart Disease No HF Normal EF Normal LV size Moderate AS/AR/MR Pre op Cardiac Liver Transplant Evaluation High operative hemodynamic stress: hypotension acidosis aorta cross clamping afterload transient high preload electrolyte and calcium imbalances List for Annual echocardiograms for all patients while on waiting list Bonow RO et al. Circulation 2008; 118: e523-e

5 Liver Transplant Evaluation Potential co existing cardiovascular problems: CAD (25%) infiltrative cardiomyopathies (amyloid, hemochromatosis, sarcoid) Alcoholic cardiomyopathy Cirrhotic Cardiomyopathy long QT interval pulmonary hypertension Liver candidate History/physical exam Electrocardiogram Echocardiogram Pre op Cardiac Evaluation for Liver Transplant Normal evaluation Abnormal electrocardiogram Abnormal history/physical Abnormal echocardiogram Age > 40 Risk factors for CAD No No further testing Yes Q waves, ST-T changes, LVH, BBB Normal Stress test Age > 60y Diabetes > 5 y Symptoms of ischemia History of CAD Abnormal Coronary angiogram EF < 40% Wall motion abnormalities RVSP > 40 mm Hg Right heart catheterization 26 Cardiovascular Contraindications to Liver Transplant Coronary Artery Disease: not amenable to revascularization excessive bleeding risk for PCI/surgery (Childs Class B,C) LVEF less than 40% Severe valvular disease not a candidate for repair/replacement Severe, irreversible pulm HTN Preoperative Cardiac Evaluation for Lung Transplant High incidence of CAD in patients with COPD also increased risk in pulmonary fibrosis Pulmonary HTN can cause RV failure, tricuspid regurgitation both reversible if not severe, longstanding Preoperative Cardiac Evaluation for Lung Transplant Cardiac Evaluation: ecg, echo stress testing if any risk factors for CAD consider coronary angio, RHC for age over 50 or multiple risk factors Possible concurrent surgeries: CABG Valve repairs Heart lung Summary We must consider: both the immediate operative risk and long term cardiac risks The scarce resource of a donor organ risk factors, not just symptoms to determine testing Contraindications: CAD, valvular disease not amenable to treatment Persistent symptoms of CHF?low LVEF Cardiology Consultation and follow up: for abnormal stress tests and high risk patients cardiologist on the team 30 5

6 Pre-Kidney Transplant Cardiac Evaluation All patients: History, Physical, EKG Thank you! Symptoms Abnormal EKG Risk Factors Nuclear adenosine stress test Symptoms Murmur Echocardiogram CAD Heart Failure Valvular disease Arrhythmias High risk ischemia/infarction EF < 45% Mod sev valvular disease Mod sev pulmonary htn Cardiology Consultation 6