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Neurologic aspects of heart transplantation
Alain Heroux1, Salpy V Pamboukian2
1Heart Failure and Heart Transplant Program, Loyola University Medical Center, Maywood, IL, USA.
Insights
Neurologic diseases are common in heart transplant candidates and recipients. Careful pre- and post-transplant neurologic evaluation is crucial for managing risks and optimizing outcomes in these patients.
Area of Science:
- Neurosurgery and Neurology
- Cardiology and Cardiac Surgery
- Transplantation Medicine
Background:
- Cardiac transplantation is the optimal therapy for end-stage heart failure (NYHA class IV) unresponsive to conventional treatments.
- Limited organ donor availability necessitates careful allocation of cardiac allografts.
- Neurologic diseases are prevalent in heart failure patients due to shared risk factors like hypertension, diabetes, and hypercholesterolemia.
Purpose of the Study:
- To highlight the importance of pretransplant neurologic evaluation in identifying contraindications for cardiac transplantation.
- To review common central and peripheral neurologic complications following cardiac transplantation.
- To discuss the neurologic side effects of immunosuppressive therapy in heart transplant recipients.
Main Methods:
- Review of neurologic conditions prevalent in end-stage heart failure patients.
- Analysis of contraindications for cardiac transplantation based on neurologic status.
- Categorization and discussion of early and late post-transplant neurologic complications.
- Examination of neurologic adverse effects associated with immunosuppressive regimens.
Main Results:
- Pretransplant neurologic assessment is vital to detect conditions that may compromise post-transplant survival, such as systemic diseases exacerbated by immunosuppression or dementia.
- Common early post-transplant neurologic complications include ischemic stroke, while long-term issues involve drug toxicities, encephalopathy (e.g., PRES), infections, and malignancies (e.g., PTLD).
- Seizures are the most frequent neurologic complication in pediatric heart transplant recipients, with other complication rates comparable to adults.
Conclusions:
- Comprehensive neurologic evaluation is essential before and after cardiac transplantation to mitigate risks and improve patient outcomes.
- Awareness of potential neurologic complications and the 'double-edged sword' of immunosuppression is critical for managing heart transplant recipients.
- Specific attention to neurologic health is necessary for both adult and pediatric cardiac transplant populations.
Abstract:
Cardiac transplantation remains the best treatment option for patients with end-stage, NYHA class IV heart failure who have failed conventional therapy. However, transplant rates have remained static largely due to limited organ donor supplies. Therefore, appropriate allocation of this precious resource is critical to maximize benefit, both at a patient level and at a societal level. Neurologic diseases, such as cerebrovascular disease and peripheral neuropathy, are prevalent in this patient population, as the major risk factors for heart disease place patients at risk for neurologic disease as well. Examples include hypertension, smoking, hypercholesterolemia, obesity, and diabetes. Pretransplant neurologic evaluation is very important to identify conditions that may limit survival after cardiac transplantation. In general, systemic diseases exacerbated by immunosuppression, conditions limiting ability to rehabilitate, and dementias are considered contraindications. Post-transplant neurologic complications are divided into central versus peripheral, and early versus late. The most common early complication is ischemic stroke. Other serious complications include hemorrhagic stroke, encephalopathy, and critical illness neuropathy. Over the long term, post-transplant immunosuppressive regimens are considered "a double edged sword." Although immunosuppressive medications are critical to preventing rejection and allograft dysfunction, they do have significant risk of morbidity and mortality associated with them, including neurologic side-effects. These include: (1) drug toxicities, such as lowering of seizure thresholds; (2) encephalopathy, such as posterior reversible encephalopathy syndrome (PRES); (3) infections; (4) malignancies, such as post-transplant lymphoproliferative disorder (PTLD). Many of the same considerations discussed in adult heart transplant recipients apply to pediatric heart transplant recipients as well. In children, seizures are the most common neurologic complication, although other neurologic complication rates are comparable.
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