Page 28 - Heart Transplant Protocol

Heart Function Service: Heart Transplant Protocols

motion abnormalities) or evidence of significant restrictive physiology (which is common
but not specific; see text for definitions)

Definitions
a. A “Primary Vessel” denotes the proximal and Middle 33% of the left anterior descending
artery, the left circumflex, the ramus and the dominant or co-dominant right coronary
artery with the posterior descending and posterolateral branches.
b. A “Secondary Branch Vessel” includes the distal 33% of the primary vessels or any
segment within a large septal perforator, diagonals and obtuse marginal branches or
any portion of a non-dominant right coronary artery.
c. Restrictive cardiac allograft physiology is defined as symptomatic heart failure with
echocardiographic E to A velocity ratio >2 (>1.5 in children), shortened isovolumetric
relaxation time (<60 msec), shortened deceleration time (<150 msec), or restrictive
hemodynamic values (Right Atrial Pressure >12mmHg, Pulmonary Capillary Wedge
Pressure >25 mmHg, Cardiac Index <2 l/min/m2)

Management

 Start Sirolimus in place of anti-proliferative agents, if there is any evidence of CAV by
angiography
o Combined Tacrolimus and Rapamycin goal of 8-10, with Rapamycin goal >6
 Reassess concurrent contributing factors including statin, antihypertensive, diet/weight
management
o Start low dose Aspirin at time of CAV diagnosis
 Assess frequency of follow-up
o Grade 1 CAV: Reassess at annual cardiac catheterization
o Grade 2/3: Reassess in 3 months and if unchanged may go back to annual cardiac
catheterizations.
 Consider formal re-transplant evaluation
 Assess possible catheter intervention (stenting)
o If stented patient needs to be rediscuss as may need re-listing

Anticoagulation Following Stents

SVC/IVC: ASA 81 mg daily for 6 months minimum assuming no other complicating features

(clot, thrombolysis at time of stent, etc.). Consider low dose ASA indefinitely.

PA: ASA 81 mg daily for 6 months

Coronary: Typically use DES (drug eluting stents) therefore need dual antiplatelet therapy for
12 months (ASA + plus either Plavix or Brilinta) followed by ASA 81 mg indefinitely

Updated November 9, 2017 28