Transplant Support- Lung, Heart/Lung, Heart

Evaluation and Candidacy

The evaluation process is a stressful time for the patient and family. Below is some information about what the "typical" evaluation may include and what makes a good candidate.

Also, a very special "Dr. Joel Cooper Says" about evaluation and working in a doctor/patient relationship.

Dr. Joel Cooper Says:

These ideas are from Dr. Joel Cooper, who of course is known for doing the first successful lung transplant and is now at Barnes Jewish in St. Louis Missouri. Listen up, this is great advice.

Ask questions, like:

How many patients have undergone transplant at this center?
What were the results?
What is the hospital survival rate?
What is the one year survival rate?
How long has follow-up been done on these patients?
What percentage of the patients have been tracked for follow-up (25% is not good enough Dr. Cooper says)
How long has the transplant team been together?
What did the members of the team do before teaming up?
How many transplants does the team do a year?

He also says that you should not be afraid to deman numbers. Numbers should be available from the doctor, hospital or for experimental protocols they sponsor, from the National Institute of Health.

Additional Questions You May Want to Ask:

What is the patient survival rate for my type of transplant, with my lung illness at this hospital?
Can I tour the transplant center before my surgery?
Are there any visitor restrictions?
Is there a social worker on the team who can help me prepare?
Will someone from the team help me with insurance issues?
Who will be in charge of my care after transplant?
How long does someone stay in the hospital after transplant?
What are the primary medications I will take after my transplant?
Do I have any choices?
What side effects can I expect?
What should I do to prepare for transplant?
Will I have any food restrictions after transplant?
What is the usual cost for a transplant, including care before and after the transplant?

Evaluation

The following tests may be part of the evaluation process.

Arterial Blood Gases(ABG) - An arterial blood gas measures the amount of oxygen that your blood is able to carry to your body tissues. This is performed by placing a needle into an artery in your wrist. Approximately 3cc off blood is required. This procedure take about 5 minutes. Any discomfort at the site where the needle was inserted will go away within a few minutes.
Pulmonary Function Tests (PFT) -Pulmonary Function Tests measure lung volume and the rate of air flow through your lungs. Pulmonary function tests require that you perform a variety of breathing exercises by blowing into a tube. The results of these exercises measure the progress of your lung disease.
Radionuclide Ventriculography (RVG) - Radionuclide ventriculography is a test that evaluates the performance of both the right and left ventricles, the two many pumping chambers of your heart. Specifically, it records the volume of blood your heart pumps in one heart beat, as well as other information about the chambers of the heart. This test requires that you receive an injection of radioactive material. Sequential pictures are then taken of your heart.
Radiographic Studies (X-Rays) - A radiographic study requires the use of x-rays. The most common is the chest x-ray. A chest x-ray (CXR) is a painless, three minute procedure which takes an interal picture of your chest including the lungs, ribs, heart, and the contours of the great vessels of your chest. A chest x-ray can aid in diagnosing infection, collapsed lung, hyperinflation, or tumors. You will require frequent chest x-rays during your initial evaluation and waiting period, daily chest x-rays once your transplant has occurred, and regular follow up chest x-rays at almost every clinic visit thereafter.
Computerized Tomography(CT Scan) - A chest CT is a picture taken of horizontal slices of your chest and the computer projection of these pictures. The chest CT provides detailed images of the structure of you r chest. These images are compared to your chest x-ray. Chest CT assists with detection of problems of the chest not easily found on chest x-ray.
Ventilation Perfusion Scan (Lung Scan, V/Q Scan) - A ventilation perfusion scan is a test that compares right and left lung function. You will need to be injected with a small amount of radioactive material and will then be asked to inhale (through a mask) a radioactive gas which is distributed throughout the lungs. The gas is exhaled normally.
Electrocardiogram (EKG)- An EKG is a ten-minute procedure which is performed by placing six electrodes on your chest and one electrode on each of your four limbs. A recording of the electrical activity of your heart is obtained which provides information about the rate and rhythm of your heart beat, how your heart is situated in your chest, and assesses any damage to your heart.
Echocardiogram (ECHO) - An echocardiogram is an ultrasound of the heart. It is performed to evaluate the impact of lung disease on the mechanics of your heart. It examines the chambers valves, aorta and the wall motion of your heart. This testing can also provide information concerning the pressure in the pulmonary ariteries. This information is important in planning the exact approach during the transplant operation.
Blood Specimens - Blood samples are required for both routine and specialized testing. Specimens are sent for blood chemistries, including potassium, sodium, cholesterol, triglycerides, liver function tests and other electrolytes. A complete blood count is obtained to determine whether you have an infection or anemia. Blood levels are obtained for information on whether you have been infected with a variety of diseases, including herpes simplex, HIV, and other viruses.
Cardiac Catherterization - To determine heart blood supply and pressure (test requires a catheter to be threaded through a large vein into your heart and dye into the heart through the catheter while an x-ray picture is taken.)
6 minute walk - To measure exercise capacity
MUGA heart imaging - To determine heart function( requires injection of a dye-like substance to "tag" red blood cells.)
Bone Density Scan - To check for osteoporosis

CANDIDACY

Emphysema - FEV1 - <25% predicted

Restrictive (IPF, Sarcoidosis) - TLC or VC <70% predicted

Cystic Fibrosis - FEV1 - <30% predicted

Psycho/Social Criteria

It is of utmost importance to determine which patients will benefit most from transplantation. The selection process should not only be based on medical criteria, but should also focus on psychosocial and behavioral criteia because there is growing evidence that these factors will also determine the success of the transplant procedure.

Supports - This means having family members, significant others, friends and or neighbors who are invested in the candidates life. The center wants to know that the candidate has one or more people who know him/her well enough to see significant changes in the candidate that s/he may not see in him/herself.
Compliance with Medication - The candidate must be able to understand and comply with the post transplant medication regime.
Substance and Alcohol abuse - The candidate msut be alcohol and drug-free - including tobacco for a minimum of six months. If they are not, the candidate will not be considered until the time that they are.
Adequate Resources - This is the candidate's insurance coverage or ability to pay for the transplant and post transplant care and lifetime of medication.
Overall Mental Health - Is the candidate being treated for any mental illnesses, and if so, how successful is the treatment? Many candidates go through some kind of depression due to being ill and needing a transplant.

Recipient Selection

The evaluation of potential lung transplant recipients is fairly standardized among centers and is focused on ensuring that the patient has disease of sufficient severity to warrant lung transplantation, that there are no other potential therapies available, and that the patient has no contraindications to transplant.

Contraindications - Systemic Disease - Most programs will perfrom transplantation in patients with a systemic disease if it is otherwise quiescent and there is no significant extrapulmonary dysfunction.