Page 33 - Heart Transplant Protocol

Heart Function Service: Heart Transplant Protocols

4. Pursue biopsy of any suspicious tissue identified by physical exam, imaging studies, or
endoscopy.
5. Continue to trend EBV PCR weekly during evaluation and management phase.
6. Continue close observation for evidence of allograft dysfunction.

B. Confirmed diagnosis of PTLD will require multidisciplinary management including the transplant
team, the Oncology team, the immunocompromised Infectious Disease team, and when necessary
the Surgical team. Treatment will be tailored to the individual patient as determined by the
multidisciplinary team.

References:
1. Webber SA, Naftel DC, Fricker FJ, Olesnevich P, Blume ED, Addonizio L, Kirklin JK, Canter CE; Pediatric
Heart Transplant Study. Lymphoproliferative disorders after paediatric heart transplantation: a multi-
institutional study. Lancet. 2006 Jan 21;367(9506):233-9.
2. Chinnock R, Webber SA, Dipchand AI, Brown RN, George JF; Pediatric Heart Transplant Study. A 16-year
multi-institutional study of the role of age and EBV status on PTLD incidence among pediatric heart
transplant recipients. Am J Transplant. 2012 Nov;12(11):3061-8.
3. Schubert S, Renner C, Hammer M, Abdul-Khaliq H, Lehmkuhl HB, Berger F, Hetzer R, Reinke P.
Relationship of immunosuppression to Epstein-Barr viral load and lymphoproliferative disease in pediatric
heart transplant patients. J Heart Lung Transplant. 2008 Jan;27(1):100-5.
4. Bingler MA, Feingold B, Miller SA, Quivers E, Michaels MG, Green M, Wadowsky RM, Rowe DT, Webber
SA. Chronic high Epstein-Barr viral load state and risk for late-onset posttransplant lymphoproliferative
disease/lymphoma in children. Am J Transplant. 2008 Feb;8(2):442-5.
5. Das B, Morrow R, Huang R, Fixler D. Persistent Epstein-Barr viral load in Epstein-Barr viral naïve pediatric
heart transplant recipients: Risk of late-onset post-transplant lymphoproliferative disease. World J
Transplant. 2016 Dec 24;6(4):729-735.
6. Manlhiot C, Pollock-Barziv SM, Holmes C, Weitzman S, Allen U, Clarizia NA, Ngan BY, McCrindle BW,
Dipchand AI. Post-transplant lymphoproliferative disorder in pediatric heart transplant recipients. J Heart
Lung Transplant. 2010 Jun;29(6):648-57.

Protocols for CMV Prophylaxis and Management of CMV Infection

Rationale: CMV may cause symptomatic disease in post-transplant patients and is also associated with
cardiac allograft vasculopathy. Reducing CMV viral loads is therefore advisable.

Valganciclovir is continued until 6 months post-transplant, for routine CMV prophylaxis unless both D/R
are CMV negative.

 Hold Ganciclovir or Valganciclovir if the ANC is < 500 or decrease to < 30% of pre-treatment values.
 Hold Ganciclovir or Valganciclovir if the platelet count is < 25,000 or decreases to < 30% of pre-
treatment values.

A. Ganciclovir is supplied as 500 mg per 10 ml vials and Valganciclovir is supplied as 450 mg tablets.

 DO NOT BREAK or CRUSH Valganciclovir Pills as it is teratogenic/carcinogenic

Updated November 9, 2017 33