686 Section III / Subspecialty Surgery

HEART TRANSPLANT

Who performed the first	Christiaan Barnard (1967)
heart transplant?
What are the indications?	Age birth to 65 years with terminal
	acquired heart disease—class IV of
	New York Heart Association classification
	(inability to do any physical activity
	without discomfort 10% chance of
	surviving 6 months)
What are the	Active infection
contraindications?	Poor pulmonary function
	Increased pulmonary artery resistance
What are the tests for	ABO, size
compatibility?
What is the placement?	Orthotopic anastomosis of atria, aorta,
	pulmonary artery
What is sewn together in a	Donor heart atriums, pulmonary artery,
heart transplant?	and aorta are sewn to the recipient
	heart atriums, pulmonary artery, and
	aorta
	Left atrium

	Donor	Recipient
What are the red flags of	Fever, hypotension or hypertension,
rejection?	increased T4/T8 ratio
What is coronary artery	Small vessel occlusion from chronic
vasculopathy?	rejection—often requires retransplant

What are the tests for rejection?

What are survival statistics for:

1 year?

5 years?

Chapter 73 / Transplant Surgery 687

Endomyocardial biopsy—much more important than clinical signs/symptoms; patient undergoes routine biopsy

85%

65%

INTESTINAL TRANSPLANTATION

What is it?

What types of donors are there?

Anastomosis:

Living donor?

Deceased donor?

What are indications?

Transplantation of the small bowel

Living donor, deceased donor

Ileocolic artery and vein

SMA, SMV

Short gut syndrome, motility disorders, and inability to sustain TPN (liver failure, lack of venous access, etc.)

What is a common postoperative problem other than rejection?

CMV status of donor?

What is the most common cause of death postoperatively?

GVHD (Graft-Versus-Host Disease) from large lymphoid tissue in transplanted intestines

Must be CMV negative if recipient is CMV negative

Sepsis

How is rejection surveillance	Endoscopic biopsies
conducted?
What is the clinical clue to	Watery diarrhea
rejection?

688 Section III / Subspecialty Surgery

LUNG TRANSPLANT

Who performed the first	James Hardy (1963)
lung transplant?
What are the indications?	Generally, a disease that substantially
	limits activities of daily living and is likely
	to result in death within 12 to 18 months:
		Pulmonary fibrosis
		COPD
		Eosinophilic granuloma
		Primary pulmonary HTN
		Eisenmenger’s syndrome
		Cystic fibrosis
What are the	Current smoking
contraindications?	Active infection
What tests comprise the	1.	Pulmonary—PFTs, V/Q scan
pretransplant assessment of	2.	Cardiac—Echo, cath, angiogram
the recipient?	3.	Exercise tolerance test
What are the donor	1.	55 years of age or younger
requirements?	2.	Clear chest film
	3.	PA oxygen tension of 300 on 100%
		oxygen and 5 cm PEEP
	4.	No purulent secretions on
		bronchoscopy
What are necessary	Bronchi, PA, pulmonary veins
anastomoses?	(Bronchial artery is not necessary)
What are the postop	Bronchial necrosis/stricture, reperfusion,
complications?	pulmonary edema, rejection
What are the red flags of	1.	Decreased arterial O2 tension
rejection (4)?	2.	Fever
	3.	Increased fatigability
	4.	Infiltrate on x-ray
What is chronic lung	Obliterative Bronchiolitis (OB)
rejection called?

		Chapter 73 / Transplant Surgery 689
What are the survival rates:
1 year?	80%
3 yrs?	70%
TRANSPLANT COMPLICATIONS
What are four major	1.	Infection
complications?	2.	Rejection
	3. Post-transplant lymphoproliferative
		disease
	4.	Complications of steroids
INFECTION
What are the usual agents?	DNA viruses, especially CMV, HSV, VZV
When should CMV infection	21 days post-transplant
be suspected?
What is the time of peak	4 to 6 weeks post-transplant
incidence of CMV infections?
What are the signs/	Fever, neutropenia, signs of rejection
symptoms of CMV?	of transplant; also can present as viral
	pneumonitis, hepatitis, colitis
How is CMV diagnosed?	Biopsy of transplant to differentiate
	rejection, cultures of blood, urine
What is the treatment of	Ganciclovir, with or without
CMV?	immunoglobin; foscarnet
What are the complications	Bone marrow suppression
of ganciclovir?
What are the signs/	Herpetic lesions, shingles, fever,
symptoms of HSV?	neutropenia, rejection of transplant
What is the treatment of HSV?	Acyclovir until patient is asymptomatic
MALIGNANCY
What are the most common	Skin/lip cancer (40%), B-cell cancer,
types?	cervical cancer in women, T-cell
	lymphoma, Kaposi’s sarcoma