Page 14 - Heart Transplant Guidelines
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Heart Function Service: Heart Transplant Guidelines

                   •  Every 3 months until 1 year post-transplant
                   •  Annually

               Management of Rising Isohemagglutinins against the Graft:
               Note that if a significant rise is seen in the postoperative period then a repeat later that day is
               appropriate as sometimes if a secondary immune response is occurring it can be very rapid.
               An urgent echo should be undertaken to establish graft function. If function poor and the titers are
               significantly raised then consideration should be given to eculizumab or initiating plasmapheresis.
               Rituximab may be required.

               If the incompatibility becomes a problem it usually arises around the 4  postoperative day and if severe
               may last a month or so but usually settles within a week with appropriate treatment.

               Management of rising Isohemagglutinin titers:

                   •  <1:16 – Repeat titers next day
                   •  1:16 – Evaluate allograft function (echo, exam, end-organ labs)
                   •  1:32 – Consider treatment with Rituximab 375 mg/m2
                   •  >1:32 – Rituximab 375 mg/m2 and consider plasmapheresis +/-Bortezomib if change in clinical

               Breastfeeding for Potential ABO-Incompatible Recipients
               Breastfeeding is not a contraindicated for infants pre or post-transplant.


                   1.  West LJ, Pollock-Barziv SM, Dipchand AI, et al. ABO-incompatible heart transplantation in
                       infants. N Engl J Med. 2001;344(11):793-800. doi:10.1056/NEJM200103153441102.
                   2.  Urschel S, Larsen IM, Kirk R, et al. ABO-incompatible heart transplantation in early childhood: an
                       international multicenter study of clinical experiences and limits. JHLT. 2013;32(3):285-292.
                   3.  Irving C, Gennery A, Kirk R. Pushing the boundaries: The current status of ABO-incompatible
                       cardiac transplantation. JHLT. 2012;31(8):791-796. doi:10.1016/j.healun.2012.03.007.
                   4.  Winters J, King K, eds. Therapeutic Aphereis: A Physicians Handbook. 4th ed. AABB/ASFA; 2013.

               HLA-Incompatible Heart Transplantation

               When a patient produces alloantibody to human leukocyte antigen (HLA), it is called an HLA antibody.
               HLA antibodies develop when a patient is exposed to extraneous human tissues – eg homograft, blood
               transfusions, pregnancy or organ transplant. Sensitization can occur when no known sensitizing events
               have occurred and it is postulated that this is due to cross reactive antibodies with pathogens eg viral
               coats. Sensitized patients are at risk of severe rejection and poor graft outcomes. Their options are to
               wait for a heart which doesn’t have the HLA they have antibodies to. This may be almost impossible if
               the patient is highly sensitized and leads to high waitlist mortality. An alternative is desensitize the
               patient prior to transplant by removing the antibodies and preventing new ones from being produced or

               Updated December 14, 2018                                                                   14
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