Cardiac transplant, pediatric

• Heart transplant

• V42.1 Heart replaced by transplant

• Z94.1 Heart transplant status

Pattern 6C: Impaired ventilation, respiration/gas exchange, and aerobic capacity/endurance associated with airway clearance dysfunction

Description

• Diseased or defective heart is partially (heterotopic transplant)1 or completely (orthotopic transplant) removed due to heart failure and a healthy donor heart from a deceased person is implanted.

Essentials of Diagnosis

• Severity of heart failure classification2
  • Stage A: at risk for heart failure
  • Stage B: abnormal structure or function but no heart failure
  • Stage C: abnormal structure or function and history of or current heart failure
  • Stage D: abnormal structure or function resulting in ventilator or cardiac support

General Considerations

• The heart is considered denervated (due to severing of thoracic and vagus nerves3) following transplantation
  • As a result, pulse rate can no longer be utilized as the primary method of assessing intensity of exercise
  • Circulating catecholamines regulate heart’s response to exercise
  • As a result, a warm-up period prior to exercise and a cool down period following exercise are crucial to any active exercise program

Demographics

• 5,000 heart transplants/year including adults and children

Signs and Symptoms

• Cyanosis
• Tachycardia
• Tachypnea
• Syncope

Possible Contributing Causes

• Four primary reasons2
  • Congenital heart defects such as hypoplastic left heart syndrome or cardiomyopathy
  • Tumors
  • Infections
  • Toxins

Differential Diagnosis

• Cytomegalovirus (CMV)
• Human Immunodeficiency Virus (HIV)

Functional Implications

• Denervated heart
• Developmental delay
• Deconditioned
• Immunosuppression
• 92% have no functional loss 10 years following transplant3

Laboratory Tests

• Complete blood count (CBC)
• Immunosuppressant trough
• CMV test
• HIV test
• Immunoglobulin G levels
• Isotopic glomerular filtration rate

Imaging

• Fetal ultrasound
• Echocardiography
• Renal ultrasound
• Electroencephalogram (EEG)
• Electrocardiogram (EKG)
• CT scan
• MRI
• Chest radiograph
• Kidney radiograph

Medical Procedures

• Cardiac catheterization
• Endomyocardial biopsy
• Coronary angiography
• Sternotomy as part of heart transplant

Medication4

• Immunosuppresants (e.g., cyclosporine)
• Corticosteroids (e.g., methylprednisolone)
• Vasodilators (e.g., Nitropress)
• Inotropic agents (e.g., dopamine)
• Pulmonary vasodilators (e.g., nitric oxide)
• Immune globulins (e.g., IVIG)

• May be admitted for infection due to cardiac catheterization, cardiac biopsy, immunosuppression, rejection, or pulmonary hypertension
• Cardiology
• Pulmonology
• Nephrology
• Occupational therapy
• Speech therapy

• Decreased strength
• Decreased endurance
• Limited active range of motion
• Unable to ambulate independently
• Dependent for transfers

• Bayley scale of infant development
• Peabody development motor scales-2
• 6 minute walk test
• Goniometric measurements

• Borg Rating of Perceived Exertion (RPE) or modified Borg scale to monitor intensity of ...