Learn more about the pre-transplant experience at the Inova Transplant Center:
If the patient is deemed a potential candidate, he or she is invited to Inova Transplant Center for further assessment and to meet members of the transplant team. During the first visit, the patient is seen by the heart transplant coordinator, the transplant cardiologist and the financial coordinator. Prior to being seen, every attempt is made to obtain and to review the patient's old records, cardiac function studies, heart catheterization, and where appropriate, records relating to other health conditions.
Family members are invited and are strongly encouraged to attend.
A good deal of time is devoted to the pros and cons of heart transplantation. Heart transplantation is not a panacea for end-stage heart disease. It carries a significant potential mortality risk. In a sense, it is like choosing the lesser of two evils. Each patient, along with his or her medical team, must weigh the risks and potential benefits of the procedure.
The transplant cardiologist reviews the patient's information to ensure that the patient is an appropriate heart transplant candidate. This assessment confirms the patient's underlying disease process and its associated severity. It also ensures that all other potential therapies have been tried or considered.
At this first visit, a financial coordinator clearly explains the patient's insurance benefits or lack thereof, and provides guidance and structured planning for the patient and their families.
Transplant candidates are evaluated by a transplant surgeon, a social worker, infectious disease specialist and a psychiatrist. Additional consultations are obtained on an as needed basis.
The following studies are not a prerequisite for referral. This is a comprehensive list and some of the testing may not be required in all patients.
- Left and right heart catheterization with thermodilution cardiac outputs
- Cardiopulmonary stress test
- Echocardiogram or MUGA scan
- Serologies for CMV IgG, VZV Ig, EBV, HTLV, RPR, measles, HIV, Hep B, S Ag, HepB core Ab, Hep B AB, Hep C AB toxoplasmosis titers for heart-lung recipients only.
- Pneumovax (if not previously received)
- Annual influenza vaccine
- Hepatitis B is not immune
- Varicella if not immune
- Tetanus every 10 years
- 24 hour creatine clearance, urinalysis
- PAP smear, mammogram in all females once a year
- Arterial dopplers for candidates with ischemic heart disease or diabetes over the age of 50
- Carotid doppler studies
- Sigmoidoscopy for patients over the age of 50
- Abdominal ultrasound
- Dental clearance
- CBC with differential
- Lipid panel as needed (LDL, HDL, cholesterol, and triglycerides)
- Thyroid function studies
- Stool for occult blood x 3
- PSA in all males over the age of 50
- Toxicology screen if indicated blood type, panel reactive antibody screen
- Hgb AIC/glycohemoglobin
Once the comprehensive work-up has been completed, potential candidates have their cases presented at the weekly heart transplant collaborative practice committee meeting. The Committee consists of the multidisciplinary team that evaluated the patient. The patient's case and transplant work-up are reviewed in detail and discussed by the team. Based on defined selection criteria, the Committee may render one of the following five decisions:
- The patient may be accepted for transplantation
- Further tests may be required to make a determination
- A decision may be made to defer on listing the patient if they are too early or there is a question about some aspect of their case such as compliance, psychosocial support or nutritional status
- A decision may be made to try some other form of therapy or procedure prior to listing
- The patient may be rejected
After patients are accepted for transplantation and insurance approval is obtained, they are listed with the United Network for Organ Sharing (UNOS), the national computerized listing organization that matches transplant recipients with available organs. When a patient is added to the UNOS transplant waiting list, his or her medical profile is entered into the UNOS computerized database. This system adds the patient's name and medical history into a "pool" of patient names. Once an organ donor becomes available, the computer then generates a list of patients who match the donor organ.
Matches are based on the following criteria, and include:
- Locality (where the patient is listed)
- Time spent on the waiting list
- Blood type
- Severity of illness
Donated organs always are first offered to recipients waiting in the local community. If a suitable match for the organ does not exist in the local area, the organ is offered regionally, and then it is offered nationally. The Washington Regional Transplant Community (WRTC) is the organ procurement organization serving the DC and Northern Virginia area. It serves as the vital link between the donor and recipient for local organ donation. They are responsible for the recovery, preservation and transportation of most organs for transplant at Inova. They also work with the local community and other hospitals on organ donation and awareness.
Candidates accepted for listing must either have a pager or cellular telephone so they may be contacted when away from home. It is the patient's responsibility to be available at all times.
Patients need to inform the transplant coordinator when:
- They are sick or hospitalized
- They are going to be unreachable or unavailable
Patients are seen periodically by their transplant cardiologist at a frequency determined by their level of illness. While awaiting transplant, patients may require hospitalization for changes in their medical condition. The addition of intravenous medications or heart assist devices may be necessary to keep candidates stable until a donor heart becomes available.
Patients and their families are encouraged to take advantage of the many resources available at Inova Transplant Center. These include social workers trained in the needs of transplant patients and their families and monthly patient support groups. These resources can be helpful in coping with and alleviating the stress associated with the patient's medical condition.
All donor hearts are assessed carefully to ensure the best quality organ for each recipient. They undergo an evaluation by a cardiologist including physical examination, echocardiogram, EKG and a heart catheterization if indicated. Laboratory testing is done to evaluate for exposure to or presence of infectious diseases.
The ultimate decision of whether a heart is suitable for donation is made by our surgeon, who goes out to the donor hospital to procure the heart. It is not uncommon that a heart that by all parameters appears suitable, turns out to have a problem that is only evident at the time of the surgical procurement.
With all these potential pitfalls, it is not uncommon for any potential heart transplant recipient to have one or more "dry runs," where the patient is admitted for transplantation only to find out subsequently that the donated organs are unsuitable for transplantation. Potential recipients then are discharged. These experiences can be an emotional roller coaster for patients and their families, and it is therefore important to be aware they are possible, even likely, during the period before transplantation.
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