Page 12 - Heart Transplant Guidelines
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Heart Function Service: Heart Transplant Guidelines

               Criteria for Suitable Recipient:
               No restriction on ABOi is placed by OPTN in infants (<12 months age). For children between 1 and 2
               years of age OPTN allows ABOi transplant provided isohemagglutinin titers are ≤ 1:16. From the clinical
               standpoint titers <1:64 can usually be safely crossed and even higher titers if consideration is given to
               managing the potential antibody mediated rejection (AMR) by measures that may include rituximab
               immediately pre-transplant, plasmapheresis and eculizumab.
               Pre-Transplant Guidelines:

               Isohemagglutinin Assessment
               Assess isohemagglutinin titers (anti-A and anti-B antibodies) in those considered for an ABOi transplant.
               Check at time of listing for status 1A/1B and re-check monthly during waiting period (OPTN
               requirement). Repeat when a potential ABO-incompatible donor becomes available.

               Blood Products While Listed
               For patients who may be suitable for an ABOi transplant in the future and require blood products then
               the following guide (Table 2) regarding transfusion blood group products should be followed:

               Table 2 Transfusion Products
                                                                            1                 2
                         Recipient                  RBCs        FFP, Platelets  or Cryoprecipitate

                         Group O                     O                           AB

                         Group A                   A or O                        AB

                         Group B                   B or O                        AB

                   1.  If there is insufficient availability of group AB platelets, group B or A platelets can be used if saline-washed
                       and concentrated to remove excess antibody (Lori West, Alberta protocol Jan 2006).
                   2.  Any blood type can be given if necessary but preference is given to AB.

               Peri-Transplant Guidelines:
               With Pre-operative labs, obtain isohemagglutinin titers

               If significant isohemagglutinin titers against the donor heart (titers ≥ 1:4) are present plasma exchange
               should be undertaken prior to cross clamp release until titers ≤ 1:4 are achieved.

               Plasma Exchange
               Plasma exchange is performed via CPB circuit immediately after instituting CPB by withdrawing whole
               blood and infusing recipient-type RBCs reconstituted with plasma of the appropriate blood group (Table
               3). Cell saver equipment can be used. The number of plasma volumes required will depend upon the
               initial isohemagglutinin titer. For titers 1:16 or less a 1.5 volume exchange should theoretically remove
               78% of isohemagglutinins. Higher titers may require a 2 volume exchange which should remove up to
               86% of isohemagglutinins .
               Assessment of isohemagglutinins should be done after plasma exchange to ensure that antibody
               removal has been accomplished (< 1:4 is acceptable).

               Updated December 14, 2018                                                                   12
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