A case study on Heart Transplantation

Nalini Sivakumar*

Dietician, Department of Clinical Nutrition & Dietetics, Kauvery Hospital, Chennai

Background

Hypertrophic cardiomyopathy (HCM) is a condition in which the heart muscle becomes thick. Often, only one part of the heart is thicker than the other parts. The thickening can make it harder for blood to leave the heart, forcing the heart to work harder to pump blood. It also can make it harder for the heart to relax and fill with blood.

heart-trans1

Etiology

Cardiomyopathy is most often passed down through families (inherited). It is thought to result from defects in the genes that control heart muscle growth. Younger people are likely to have a more severe form of hypertrophic cardiomyopathy. However, the condition is seen in people of all ages.

Sign & Symptoms

  1. Chest pain, especially during exercise
  2. Fainting, especially during or just after exercise or exertion. Heart murmur, which a health care provider might detect while listening to the heart
  3. Sensation of fast, fluttering or pounding heartbeats (palpitations)
  4. Shortness of breath, especially during exercise.

Common causes of Heart Failure

  1. Heart attack (myocardial infarction or MI)
  2. Viral infection of the heart muscle- Myocarditis
  3. High blood pressure
  4. Heart valve disease (Eg: Rheumatic Heart Disease)
  5. Heart defects present at birth (congenital heart disease)
  6. Irregular heartbeats (arrhythmia)
  7. High blood pressure in the lungs (pulmonary hypertension)
  8. Alcoholism or drug abuse
  9. Heart Disease secondary to Chronic lung diseases, such as emphysema or chronic obstructive pulmonary disease (COPD)
  10. Heart muscle is enlarged, thick, and stiff (cardiomyopathy)

Case scenario

A 35-year-old female, had been diagnosed to have hypertrophic cardiomyopathy. She was experiencing breathlessness on exertion (NYHA-III) from 2017. Echo revealed severe left ventricular dysfunction. Hence patient was worked up and admitted for heart transplant.

  1. Anthropometric data
Height​ 151cm​
Weight​ 53kg​
Body mass index​ 23.2kg/m2 (according to WHO BMI classification​

patient falls under healthy weight category)​
Ideal body weight (IBW)​ {height (m2)x19} to {height (m2x24)} =43 to 55kg​
  1. Biochemical parameters
Parameter​ 4/9/22​ 5/9/22​ 6/9/22​ 7/9/22​ 8/9/22​ 9/9/22​ 10/9/22​ 11/9/22​ 12/9/22​ 13/9/22​
Urea​ 17.5​ 18.4​ 20.7​ 35.9​ 34.9​ 29.8​ 35.6​ 46.7​ 41.4​ 26.1​
Creatinine​ 0.54​ 0.57​ 0.42​ 0.50​ 0.50​ 0.53​ 0.69​ 0.83​ 0.73​ 0.44​
Na​ 135​ 141.7​ 132.7​ 132.8​ 135.5​ 133.5​ 133.5​ 133.8​ 132.7​ 134.1​
Potassium​ 4.21​ 3.94​ 5.04​ 3.91​ 3.84​ 4.15​ 4.23​ 4.32​ 3.91​ 4.47​
Cl 2​ 108.1​ 115.1​ 106.4​ 103​ 103.8​ 103.7​ 104.7​ 102.2​ 102​ 104.8​
HCo3​ 15.6​ 18.5​ 19.8​ 18.3​ 17​ 19.0​ 20.01​ 20.6​ 16.6​ 19.6​
Bilirubin-T​ 0.38​ 1.63​ -​ 0.64​ -​ -​ 0.63​ -​ ​ ​
Bilirubin-D​ 0.16​ 0.41​ -​ 034​ -​ -​ 0.35​ -​ ​ ​
Bilirubin- I​ 0.22​ 0.72​ -​ 0.30​ -​ -​ 0.28​ -​ ​ ​
SGOT​ 24.6​ 103.7​ -​ 31.9​ -​ ​ 19.5​ ​ ​ ​
SGPT​ 15.6​ 27.9​ -​ 22.2​ -​ ​ 23.1​ ​ ​ ​
T. Protein​ 6.84​ 5.60​ -​ 5.30​ -​ ​ 4.79​ ​ ​ ​
Albumin​ 4.19​ 3.84​ 3..77​ 3.55​ 3.23​ 3.09​ 3.05​ 3.43​ 3.44​ ​
Globulin​ 2.65​ 1.76​ ​ 1.75​ ​ ​ 1.74​ ​ ​ ​
Calcium​ 8.47​ 7.62​ ​ 8.32​ ​ ​ 7.73​ ​ 7.99​ 7.71​
Al phosphatase​ 18.0​ 8.3​ ​ 11.5​ ​ ​ 18.0​ ​ ​ ​
Phosphatase​ 4.60​ 1.19​ 3.42​ 1.18​ ​ ​ 1.48​ ​ 2.03​ ​
Hb​ 10.3​ 10​ 9.0​ 8.8​ 8.6​ 8.4​ 7.8​ 9.4​ 11.3​ 10.7​
PCV​ 32.8​ 30.6​ 27.9​ 26.7​ 25.9​ 25.2​ 23.4​ 28.6​ 34.9​ 32.5​
WBC​ 6000​ 15300​ 188001​ 19600​ 12900​ 8800​ 11800​ 11900​ 12700​ 13830​
Platelet count​ 247000​ 164000​ 113000​ 117000​ 118000​ 118000​ 142000​ 138000​ 188000​ 265400​
GGT​ 12.1​ 18.5​ ​ ​ ​ ​ ​ ​ ​ ​
A/G Ratio​ 1.6​ 2.2​ ​ ​ ​ ​ ​ ​ ​ ​

 

Parameters 14/9/22 15/9/22 16/9/22 17/9/22 18/9/22 19/9/22 20/9/22 22/9/22 24/9/22 26/9/22
Urea 31.3 46.4 44.9 49.2 0.47 35.6 46.7 41.4
Creatinine 0.54 0.60 0.62 0.58 0.66 0.69 0.83 0.73
Na 132.8 132.4 132.5 131.0 134.1 133.5 133.8 132.7
Potassium 4.49 4.57 4.51 4.50 103.7 4.23 4.32 3.91
Cl2 103.7 102.6 102.3 101.0 19.6 104.7 102.2 102
HCo3 18 15.9 14.8 17.5 1.76 20.01 20.6 16.6
Bilirubin-T 0.55 0.63 –
Bilirubin-D 0.25 0.35 –
Bilirubin- I 0.30 0.28 –
SGOT 14.0 30.7
SGPT 23.0 157.2 82.2
T. Protein 4.72 5,85
Albumin 36 3.29 2.90 3.85 3.95
Globulin 1.82 1.90
Calcium 7.82 7.94 7.93 7.75 8.21 8.22 8.62 9.14 8.68
Al phosphatase 51.0
Phosphatase 2.72 3.00 2.90 2.67 2.36 2.18 2.20 3.67 3.53
Hb 9.1 8.8 9.6 9.5 9.8 8.6 8.4 8.6
PCV 27.3 27.6 29.7 28.8 29.5 26.6 25.6 26.0
WBC 15900 14800 16800 15000 13700 11200 5900 7200
Platelet count 164000 200000 236000 209000 205000 178000 176000 220000
GGT 58.5 2.1
A/G Ratio

 

  1. Clinical data
Chief complaints  Tiredness, Palpitation, Shortness of breath and fatigue
Diagnosis Hypertrophic cardiomyopathy/ CCF
History of past illness Nil
Plan of treatment Heart transplantation
Nutrition-focused physical findings Appearance (eyes, hair, nails, skin, lips & mouth were found to be normal)

No presence of ascites and edema

 

Dietary Habits – Non-vegetarian

Food Allergy   –   Nil

 

  1. Diet History
SUBJECTIVE GLOBAL ASSESSMENT
Rating B
Category Well nourished but at risk

 

Medical Nutrition Therapy

Energy: To provide adequate amount of energy to meet Post -surgery requirements and to maintain optimal nutrition status.

Carbohydrate: To provide adequate amount of carbohydrates to replenish energy reserves.

Protein: To provide high protein diet for healing and to prevent PEM.

Fat: To provide moderate amount of fat to aid in optimal growth.

Micronutrients:  Micro nutrients are to provided as per RDA to maintain physiological functions and pre operatively we prescribed oral nutrition supplement.

Nutritional plan

ENERGY           :       2000kcals@30kcals/kgIBW

CARBOHYDRATES      :       60% of total calories.

PROTEIN                     :       82g@1.5g/kgIBW

FAT           :       25% From Total calories

SALT                     :       6gms/Day

VITAMINS                     :       As per RDA

MINERALS                     :       As per RDA

POST OPERATIVE NUTRITIONAL INTERVENTION

Days​ Date​ Type of diet​ Energy (kcals)​ Protein (g)​ Remarks​
Day 0​ 4/09/22​ On surgery ​ ​ ​
Day1​ 5/09/22​ NPO​ 0​ 0​ Post operative​
Day 2​ 6/09/22​ RT feed initiated @150ml 3rd hrly –​

total volume:300ml  +oral clear    liquid diet​

 527​ 33​ Pt well tolerated clear      liquids ​
Day 3​ 7/09/22​ RT feed stopped,  oral  High Protein soft diet initiated +1.5lit f/R​ 287​ 28​ Initiated oral nutrition supplement​
Day 4​ 8/09/22​ High Protein soft diet​ 383​ 28​ Intake was poor diet         modified​
Day 5​ 9/09/22​ High Protein soft diet​ 869​ 56​ Intake was getting better​
Day 6​ 10/09/22​ High Protein normal diet diet        initiated​ 1376​ 78​ Intake is improved​
Day 7​ 11/09/22​ Oral high Protein high fibre diet initiated​ 665​ 39​ Intake was poor due   to vomiting & constipation​
Day 8​ 12/09/22​ High Protein soft diet​ 913​ 33​ Diet modified​
Day 9​ 13/09/22​ High Protein normal diet​ 1095​ 58​ Intake is fair​
Day 10​ 14/09/22​ High Protein diet​ 847​ 44​ Intake was poor due   to  vomiting​
Day 11​ 15/09/22​ High Protein diet​ 936​ 49​ NPO,  plan biopsy​
Day 12​ 16/09/22​ High Protein normal diet​ 1185​ 61​ Intake is improved​
Day14​ 17/09/22​ High Protein normal diet​ 1449​ 93​ Intake is improved​
Day 15​ 18/09/22​ High Protein normal diet​ 1141​ 75​ Pt had c/o vomiting, diet modified                  accordingly​
Day 17​ 20/09/22​ High Protein normal​ diet 1221​ 59​ Pt had poor appetite,  compromised and  encouraged to take  ONS​
Day 18​ 21/09/22​ High Protein normal diet​ 1411​ 70​ Intake was getting better​
Day 19​ 22/09/22​ High Protein Normal diet​ 1585​ 79​ Intake was better
Day 20​ 23/09/22​ High Protein normal diet​ 1648​ 93​ Intake improved
Day 21​ 24/09/22​ High Protein normal diet​ 1900​ 113​ Intake improved​
Day 22​ 25/09/22​ High Protein normal​ diet 1857​ 86​ Intake was adequate, pt   took ONS supplements
Day23​ 26/09/22​ High Protein normal diet​ 275​ 5​
heart-trans2

What is Tacrolimus test?

The Tacrolimus test is used to measure the amount of drug in the blood to determine whether the concentration has reached a therapeutic level and it is below the toxic level.

  1. Normal Tac level: 5- 10 ng/ ml

The level of Tacrolimus in the blood must be maintained within a narrow therapeutic range.

  1. If the concentration is too low, organ rejection may occur.
  2. If it is too High then the person may experience symptoms associated with toxicity.

 

POD Tacrolimus

levels ng/ml

 Dosage

(morning) mg

 Dosage

(Evening) mg
Pod 4 4.7 0.5 0.5
Pod 5 4.8 0.5 1
Pod 6 7.7 0.75 1
Pod 7 Not done 0.75 1
Pod 8 7.4 0.75 1
Pod 9 7.2 1.0 1.25
Pod 10 Not done 1.0 1.25
Pod 11 6.9 1.0 1.5
Pod 12 Not done 1.5 1.5
Pod 13 7.6 1.5 1.5
Pod 14 Not done 1.75 2
Pod 15 10.9 1.75 2
Pod 16 Not done 1 75 2
Pod 17 9.4 1.75 2.25
Pod 18 Not done 2.25 2.25
Pod 19 12.1 2.25 2.25
Pod20 Not done 2.25 2.25
Pod 21 18.7 2.25 Not given
Pod 22 Not done 2 2
Pod 23 16.2 2 1.75
Pod 24 Not done 3 Not given

Post operative medications

heart-trans3

Summary

A 35year old female, who was known to have Hypertrophic cardiomyopathy, started experiencing NYHA- III symptoms from 2017.  She completed all her workups for heart and lung transplant on April 2022. Patient got suitable organ alert call on 4/09/2022. Patient underwent Orthotropic heart transplant Surgery on 4/09/2022. After procedure the she was shifted to ICU with minimal inotropic and nitrous oxide support. During the hospital stay the nutritional management was planned according to the patient condition.  Post operatively RT feed was initiated on pod 3, RT feed was stopped and oral liquid diet initiated oral nutritional supplement was prescribed. Patient tolerated oral feeds well and   diet stepped up to high Protein soft diet. Patient had some Gastric issues diet modification was done. Patient intake was gradually improved, on discharge patient and family was educated High Protein, low fat neutropenic diet.

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