Pre-Transplantation
Click on the appropriate step below to learn more about the pre-transplant process:
- Patient Referral and Preliminary Evaluation
- Initial Evaluation
- Comprehensive Work-up
- Collaborative Practice Committee
- Listing
- Waiting Period
- Donor Evaluation
- Transplantation
Patient Referral and Preliminary Evaluation
Patients may be referred to the Heart Transplant Program by their
primary care physician, cardiologist, insurance/case manager, or
may be self-referred. Referrals may be received by mail, fax, e-mail
or by telephone. In the case of a telephone referral, the referring
party is instructed to mail/fax the pertinent patient records. Each
referral is reviewed in detail by the transplant cardiologist and
coordinator. If the patient has an obvious contraindication, this
is communicated to the referring person and no further steps towards
transplantation are undertaken. If the patient has a contraindication,
but there is a chance that another therapy short of transplant may
be offered, then the patient may be seen with this as the goal.
- Telephone:
703-776-2986 or 1-888-677-1778
- Fax:
703-776-2797
- E-mail: transplant.referrals@inova.org
- Mailing Address
Transplant Coordinator
Heart Failure/Transplant Program
Inova Heart and Vascular Institute
3300 Gallows Road
Falls Church, VA 22042-3300
Initial Evaluation
If the patient is deemed a potential candidate, he/she is invited
to the Inova Transplant Center for further assessment and to meet
members of the transplant team. In 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.
In the initial consultation, the transplant coordinator educates the patient about the transplant process. Family members are invited and are strongly encouraged to attend.
At this first visit, the financial coordinator clearly explains the patient's insurance benefits or lack thereof, and provides guidance and structured planning for the patient and their families. A good deal of time is devoted to the pros and cons of heart transplantation.
Heart transplantation is not the panacea for end-stage heart disease. It carries with it a significant potential mortality risk. In a sense, it is like choosing the lesser of two evils. For each individual patient, both the patient and his or her physicians need to weigh the risks and potential benefits of having a transplant versus the risks of not having a transplant. Some of the factors to be considered in this sometimes difficult decision are depicted in the scale below:
The transplant cardiologist reviews the patient's information to ensure that the patient is an appropriate lung transplant candidate. This entails an assessment and confirmation of the patient's underlying disease process and its associated severity. It also involves ensuring that all other potential therapies have been tried or considered. Lastly, patients are closely scrutinized for any potential contraindications. This is further assessed in the Comprehensive Work-up phase of the evaluation process.
Comprehensive Work-up
All patients are seen and evaluated by a transplant surgeon, a
social worker, infectious disease specialist and a psychiatrist.
The patient already has been seen by the transplant cardiologist
and financial coordinator during the initial consultation. Additional
consultations are obtained on an as needed basis.
The following studies are obtained in potential heart transplant candidates. Please note that having all the tests is not a prerequisite for referral. This is a comprehensive list and some of the testing may not be required in all patients.
Cardiac:
- Left and Right Heart Catheterization with Thermodilution Cardiac Outputs
- Cardiopulmonary Stress Test
- Echocardiogram or MUGA Scan
- EKG
Infectious Disease
- PPD
- 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. - Vaccinations:
- Pneumovax (if not previously received)
- Annual influenza vaccine
- Hepatitis B is not immune
- Varicella if not immune
- Tetanus every 10 years
Miscellaneous Tests
- 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
Laboratories
- CBC with differential
- chemistries
- PT/PTT
- 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
Collaborative Practice Committee
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.
Listing
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
- size
- severity of illness
Donated organs always are distributed locally first. 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. Patients also are listed with our local Organ Procurement Organization (OPO), the Washington Regional Transplant Consortium (WRTC). WRTC serves as the vital link between the donor and recipient. They are responsible for the retrieval, preservation, and transportation of organs for transplantation. WRTC works closely with UNOS and the Inova Transplant Center physicians to coordinate and streamline the transplant process.
Waiting Period
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 unavailable for any reason or unreachable
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 the 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.
Donor Evaluation
All potential heart donors are assessed carefully to ensure the
best quality organ for each recipient. Each donor undergoes an evaluation
by a cardiologist including physical examination, echocardiogram,
EKG and a heart catheterization if indicated. A careful medical
and social history is obtained by the organ procurement coordinator.
Each potential donor undergoes laboratory testing to evaluate for
exposure 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 "dry runs" can be an emotional roller coaster for patients and their families, and it is therefore important to be aware of that "dry runs" are possible and even likely during the period before transplantation.
Transplantation
The transplant team works together to coordinate every facet of
the transplant procedure from organ procurement and transport to
the surgical procedure and family support. The team tracks every
aspect of the patient's care throughout the process, and oversees
every strategic detail.
Once a compatible donor organ becomes available, the patient is notified and is admitted to Inova Fairfax Hospital for a stay that lasts an average of about two weeks. Following surgery, the patient is cared for in the 15-bed cardiovascular ICU. Eventually, the patient is transferred to a private room in a unit where staff members are experienced in the care of transplant patients.
During the recovery period, the transplant team teaches the transplant recipient what to expect during the recuperation period and once discharged from the hospital. Teaching includes information about the patient's immunosuppressive medications and how to monitor progress when he/she returns home.
