Page 6 - Heart Transplant Protocol

Heart Function Service: Heart Transplant Protocols

Listed Status 2 ..................................................................................................................................... 43

Cardiac Catheterization ....................................................................................................................... 43
Infectious Disease Work Up ................................................................................................................ 44

Post-transplant Follow-up: Infant (< 1yr age at transplant) ................................................................... 45

Day of Transplant – 2 months (POD 60) ............................................................................................. 45
Month 2-4 Post Transplant (POD 120) ................................................................................................ 45

Month 4-6 months Post Transplant .................................................................................................... 45
Months 7-11 ........................................................................................................................................ 45

Month 12 following transplant ........................................................................................................... 45
Years 2-5 following transplant: ........................................................................................................... 46

>5 years following transplant: ............................................................................................................ 46
Post-transplant Follow-up: Child (> 1yr age at transplant) ..................................................................... 47

Day of Transplant – 2 months (POD 60) ............................................................................................. 47
Month 2-4 Post Transplant (POD 120) ................................................................................................ 47

Month 4-6 months Post Transplant .................................................................................................... 47

Months 7-11 ........................................................................................................................................ 47
Month 12 following transplant ........................................................................................................... 47

Years 2-5 following transplant: ........................................................................................................... 48
>5 years following transplant: ............................................................................................................ 48

Shared Care Arrangements ..................................................................................................................... 49
SOTP Policies in Policy Tracker ................................................................................................................ 50

Consent for Evaluation Form .................................................................................................................. 51

High Risk Donor Disclosure/Consent Form ............................................................................................. 55
HLA Requisition Form ............................................................................................................................. 59

C1Q Form ................................................................................................................................................ 61
Immunization Letter for Providers .......................................................................................................... 62

Drug Protocols ............................................................................................................................................ 63
Protocol for Administration of Anti-thymocyte Globulin (Thymoglobulin) ............................................ 63

Premedication: .................................................................................................................................... 63
Dosing: ................................................................................................................................................ 63

IV Infusion: .......................................................................................................................................... 63
Anaphylaxis: ........................................................................................................................................ 63

Updated November 9, 2017 6