Cardiac transplantation

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Results of heart transplantation

Treatment of patients with end-stage heart failure by heart transplantation is based on the assumption that their survival and quality of life after surgery are better than with conventional treatment. The prognosis of patients with congestive heart failure generally is poor, with the 5-year survival reported in one study [2] to be less than 30%. Nonetheless, significant advances have been made in the medical management of these patients over the past 10 years. As a result, the heart transplant

Recipient selection

Heart transplant recipient selection is based on an extensive multidisciplinary evaluation intended to assess the patients' disability and prognosis without transplantation and their ability to survive the procedure and comply with the required postoperative management. Most patients referred for evaluation have severely impaired left ventricular function, but occasionally patients with good systolic function also are referred for severe, intractable angina, unmanageable arrhythmias, or severe

Donor selection

Candidates who donate their hearts for transplantation must fulfill the criteria for brain death. They should have no known serious cardiac disease or refractory ventricular arrhythmias. Usually candidates are less than 55 years of age, but older hearts are occasionally used because of the shortage of hearts available for transplantation. Assessment of a potential donor heart with echocardiography or angiography can be helpful, especially in older candidates. Donors should not have evidence of

Donor heart harvest

The medical condition or injury causing the brain death of the organ donor can result in significant metabolic and hemodynamic aberrations, making management of the organ harvest challenging for the anesthesiologist attending the procedure [5], [6]. Invasive monitoring may be helpful in guiding fluid therapy and administering vasoactive drugs. In the early days of heart transplantation, the brain-dead donor was transported to the transplant center so that organ harvesting and preparation of the

Anesthetic preparations

Because the timing of heart transplants is determined by donor availability, the procedures occur on an emergency basis at all hours, and the preoperative evaluation and preparation of the recipient must be carried out expeditiously. There needs to be close communication between the team harvesting the donor heart and the team preparing the recipient. Ideally, to minimize the ischemic time, the recipient will be on cardiopulmonary bypass (CPB), with the recipient heart resected when the donor

Previous procedures

Some heart transplant candidates have had previous operations that have an impact on their transplantation. Previous heart surgery, most commonly coronary artery bypass graft, will lengthen the time it takes to prepare the recipient to receive the donor heart and increase the risk of bleeding during and after surgery. The usual precautions and preparations for repeated procedures such as multiple large-bore intravenous access, immediate availability of blood before sternotomy, and the

Induction and maintenance

Ideally, the heart transplant recipient will be in the operating room with hemodynamic monitors in place when the harvesting team sends word to proceed with induction. Which drugs are used is less important than the way they are used, and the same principles apply as with any cardiac case with poor ventricular function. The key is to achieve a stable, sustainable hemodynamic state before starting surgery by adding or adjusting support. Many heart transplant patients will have recently eaten and

Orthotopic heart transplantation

In orthotopic heart transplantation, the recipient's diseased heart is removed, and the donor allograft is inserted anatomically in its place. After the sternotomy, the ascending aorta is cannulated close to the aortic arch, venous return cannulae are inserted into both the superior and inferior cavae, and the patient is placed on CPB. The cavae are encircled with tourniquets to isolate all of the venous return from the heart, the ascending aorta is clamped close to the aortic arch, and the

Heterotopic heart transplantation

Heterotopic heart transplantation is a rarely performed procedure in which the recipient's heart remains in place, and the donor heart is attached to its right side so that the flow in each is in parallel, permitting the recipient's heart to continue to pump blood, particularly through the lungs (Fig. 2). This procedure is primarily reserved for patients with pulmonary hypertension as a strategy to avoid acute right heart failure in the unconditioned donor heart and in cases in which there is a

Weaning from cardiopulmonary bypass

The heart transplant patient is prepared to come off CPB similarly to any other cardiac case. The patient is warmed, and the lungs are suctioned and ventilated. A recent arterial blood gas result is reviewed, and abnormalities are corrected. Caval tourniquets are released, and suture lines are inspected for bleeding. The cardiac chambers are examined with TEE, and air-evacuating maneuvers are performed.

It is important to remember that the implanted donor heart is denervated so that

Right heart failure

Failure to wean a heart transplant patient from CPB is most commonly the result of right heart failure, which is evidenced by low cardiac output in the face of rising central venous pressure [17]. The right heart can be seen in the surgical field to dilate and contract poorly. TEE shows a dilated, poorly contracting right ventricle and an underfilled, vigorously contracting left ventricle. Severe tricuspid regurgitation secondary to dilatation of the tricuspid valve annulus is also often seen

Management after cardiopulmonary bypass

Once the heart transplant patient has been weaned from CPB and the caval and aortic cannulae have been removed, protamine is given to reverse the heparin. Many patients have post-bypass coagulopathy and may require transfusion of platelets, cryoprecipitate, or fresh frozen plasma. Diagnosis and treatment of this condition for heart transplantation is similar to other cardiac surgery procedures. Careful monitoring of the hemodynamics is continued through chest closure, and adjustments are made

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References (34)

Cited by (17)

  • Intraoperative and Early Postoperative Management of Heart Transplantation: Anesthetic Implications

    2020, Journal of Cardiothoracic and Vascular Anesthesia
    Citation Excerpt :

    The primary goals of induction are maintenance of contractility, systemic vascular resistance, and preload while minimizing the negative inotropic effects of induction and preventing aspiration or an acute increase in PVR. Patients with end-stage HF experience downregulation of the β-adrenergic receptors and may require higher doses of β agonist inotropic support to achieve the same clinical response.40 The preoperative inotropic and vasoconstrictor support are continued during induction of anesthesia.

  • Anesthesia for Heart Transplantation

    2017, Anesthesiology Clinics
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    Continuation of all preoperative inotropic and vasoconstrictive agents is essential. Patients with end-stage HF have downregulation of the beta-adrenergic receptors and will require potentially higher doses of beta-agonist inotrope therapy.53 Reduced cardiovascular function may not respond to ephedrine or phenylephrine, and rapid escalation to other medications, such as epinephrine, norepinephrine, or dobutamine, should be expected.

  • Further evaluation of Somah: Long-term preservation, temperature effect, and prevention of ischemia-reperfusion injury in rat hearts harvested after cardiocirculatory death

    2013, Transplantation Proceedings
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    Functional integrity of cardiomyocytes was evaluated by semiquantitative measurement of the quantum yield (photon counts) of calcein fluorescence, indicative of esterase activity, as described.13–17 Cardiomyocytes were labeled with JC-1 dye (Molecular Probes), imaged, and the mitochondrial polarity ratios were determined using multiphoton microscopy as described.13–17 LV tissue (20 mg) was cut into 300 pieces, suspended in 200 mL of Lysis buffer (CellLytic MT; Sigma-Aldrich) with a protease inhibitor cocktail, homogenized for 30 seconds before centrifuging at 16,000g for 10 minutes and the supernatant (total protein) collected and then quantitated using Bio-Rad protein assay kit.

  • A Review of cardiac transplantation

    2013, Anesthesiology Clinics
    Citation Excerpt :

    The right heart can be seen in the surgical field to dilate and contract poorly. TEE shows a dilated, poorly contracting RV as evidenced by measurement of RV fractional area change in the midesophageal 4-chamber view71 and an underfilled vigorously contracting LV.52 Severe tricuspid regurgitation secondary to dilatation of the tricuspid valve annulus might be seen.

  • Assisting the Failing Heart

    2008, Anesthesiology Clinics
    Citation Excerpt :

    If the patient has an ICD, the defibrillator function is inactivated to avoid discharge from surgical cautery [66]. On arrival in the operating room, if the patient is not intubated, a careful induction to minimize hemodynamic instability is necessary with consideration of a full stomach [67–70]. Adequate preoxygenation, judicious use of induction agents (propofol, etomidate, ketamine, narcotics), and additional pressor support (phenylephrine, norepinephrine) frequently is necessary.

  • Cardiology

    2007, Essential Emergency Medicine: For the Healthcare Practitioner
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