ABCP Clinical Questions for Boards With Correct Answers

Who was granted a federal contract in 1986 to operate the organ procurement and transplantation network? - Answer UNOS (United Network of Organ Sharing) In the 1980" there was an sudden increase in organ transplantation, Why? - Answer wide spread use of anti-rejection medications Why get a "used" heart? - Answer 1) NHLBI- end stage cardiac disease 2) NYHA class III and IV CHF a) refractory to max medical treatment b) continuous mechanical or inotropic support required c) Peak O2 uptake (VO2 max) 14ml/kg/min d) LVEF 20% 3) Refractory angina pectoris- inoperable CAD 4) Refractory ventricular arrhythmias- life threatening 5) Myocardial tumor- w/o metastasis Who gets new hearts? - Answer 1) Status 1A- 1st to get heart: critically ill, in ICU, adv life support 2) Status 1B: 2nd: Require IV inotropes, hospital or home care 3) Status 2: 3rd in line: No IV meds required, usually not hospitalized Who absolutely contraindicated to receive heart transplant? - Answer 1) terminal malignancy 2) severe, irreversible major organ disease- multi-organ failure 3) Active infection 4) HIV 5) current alcohol or IV drug use Who have relative contraindications for heart transplant? - Answer 1) old people 65 2) severe CVD or PVD 3) IDDM- insulin deppendent DM 4) Pulmonary infarction or hypertension 5) morbid obesity 6) major psychiatric disorder- won't be compliant w/ meds Why can't a patient drink alcohol and receive a heart transplant? - Answer because cyclosporin is metabolized in liver Who can donate a heart? - Answer 1) confirmed brain death and organ viability 2) EKG evaluation of heart function 3) coronary angiogram male40 female45: no severe CAD 4) ABO blood group matching 20% reactive antibodies or is plasmapheresed Who absolutely can't donate a heart? - Answer 1) syphilis, HTLV-4, HIV 2) malignancy w/ extracranial metastasis 3) LVEF 40% 4) Significant valvular abnormality 5) significant CAD Who has relative contraindications to heart donation? - Answer 1) Thoracic trauma 2) Sepsis 3) HepB surface antigen -positive 4) repeated CPR 5) high dose inotrpic support 24 hrs What is the heart haversting procedure? - Answer 1) kidneys and liver removed 1st 2) donor heparinized 3) heart excised "en bloc" 4) SVC and IVC ligated 1st: allows for exsanguination 5) Aorta X-clamped: is cross-clamp time 6) Cold CPG administered 7) Aorta and PA transected: left as long as possible 8) Pulmonary Veins individually divided 9) Pericardium preserved What are 4 types of heart transplants? - Answer 1) Orthotopic :98%: replace w/ new donor heart 2) Heterotopic: 2%: 2 hearts in parallel circulation 3) Live donor: donor hrt and lung goes in and reciepient hrt to someone else 4) deceased donor What is the cannulation for orthotopic heart transplant? - Answer 1) redo's: femoral 2) Aortic 3) bicaval venous In the original bi-atrial surgery, how is the recipient heart surgery performed? Why was this a problem? - Answer 1) native RA and LA preserved to preserveSA node and native rate 2) created a clot haven and has 2nd P-wave In Bicaval cannulation heart surgery, how is the recipient heart surgery performed? - Answer 1) LA cuff w/ PV's: make an island 2) SVC and IVC cuffs: make an island What are the benefits of bicaval "island" cuffs in heart transplantation? - Answer 1) decrease the distortion of tricuspid valve 2) improve right heart function 3) decrease risk of thrombolic emboli 4) lower right sided pressures 5) won't need pacemaker as often 6) decreases regurgitance 7) no 2nd P-wave What is the sequence of events in orthotopic donor implantation? - Answer 1) LA: island 2) RA cuff or IVC then SVC 3) Aorta 4) PA Where is the donor heart placed in Heterotopic heart transplant? - Answer 1) in right anterior thorax: in parallel circulation 2) Aortas anastamosed: donor LV provides most output 3) Conduit joins PAs" Native RV provides most output 4) LA of donor and recipient are mearged together 5) donor SVC= recipent RA 6) Donor IVC is closed up What are advantages to heteroropic heart transplant? - Answer 1) recipients w/ severe pulm HTN 2) small donor to recipient size ratio: crossmatch except for size What are disadvantages for heterotopic heart transplants? - Answer 1) high mortality rate 2) continued medical treatment for failing native heart 3) native heart: Clot haven (sludgy heart) 4) compromised pulmonary function: donor heart placement Why is there a lot of volume in CHF patients? - Answer brain thinks there is not enough flow so triggers epo to make more cells and gut to absorb more fluids What are the post-op considerations in heart transplant? - Answer 1) Native heart remains innervated 2) donor heart is denervated a) loss of efferent & afferent sympath, parasymp innervation b) 1st degree AV block is common c) Vagus nerve -SA and AV node 3) Rapid resting heart rate 4) No angina 5) loss of some medicinal effects 6) prolonged P-R interval .2 sec 7) slower A-V conduction 8) can't respond to acute HTN or hypovolemia 9) only starling effects effect: CO, preload ,afterload 10) Preload dependent What are post-operative complications to heart transplant? - Answer 1) enlarged pericardial space - can get cardiac tampenade 2) dysrhythmias alter Renin-angiotensin-Aldosterone regulation 3) PHTN 4) cardiac edema 5) Acute rejection 6) Decreased SVR: made worse by long term use of amioderone & catecholamine 7) prevents treatment of RV failure: CAN'T USE NITRATES, PROSTAGLANDINS, PROSTACYCLINES 8) diurinal blood pressure: circadian rythmm is absent txp What is the highest incidence complication in the 1st month post transplant - Answer 1) rejection a) cellular: most common: infiltrated T-cells b) Vascular/Humoral: Ab mediated c) Hyperacute rejection: w/in a few hours : recipient AB to donor 2) infection is the lead cause od rejection 3) 1st month is greatest time of rejection what are the 1 yr, 3yr and 5 yr survival rates for men and women heart transplant patients? - Answer 1) Men: 87.5%, 78.8%, 72.3% 2) Women: 85.5%, 76%, 67.4% What is the most common reason for liver transplant? - Answer Irreversible Cirrhosis What are indications for liver transplant? - Answer 1) ESLD- end stage liver disease 2) Irreversible cirrhosis 3) Chronic Hepatitis 4) Cholestatic disease: interruption in bile production 5) Acute hepatic necrosis: viral, drug toxicity 6) Primary Hepatic tumors 7) Metabolic Disease a) Wilson's, Hemochroatosis 8) Serum albumin 3.5 g/dl 9) Bilirubin 2 mg/dl