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Perioperative management of the heart transplant recipient 

Perioperative management of the heart transplant recipient
Perioperative management of the heart transplant recipient

Alan Ashworth

and Andrew Roscoe

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date: 05 August 2020

Heart transplantation (HTx) is the treatment of choice for certain patients with end-stage heart failure, with median survival of approximately 10 years. The yield of transplantable hearts from potential organ donors is low due to left ventricular dysfunction secondary to the ‘catecholamine storm’ produced by brain death. Cardiopulmonary exercise testing and right heart catheterization are the main investigations required to determine candidacy for HTx in patients with end-stage heart failure. Right heart catheterization is very important to assess for the presence of pulmonary hypertension and the transpulmonary gradient.Timing of induction of anaesthesia is crucial to minimize the donor heart ischaemic time, which should be ideally less than 4 hours. Prolongation of the ischaemic time results in reduced function of the donor heart intraoperatively and postoperatively and increases the risk of primary graft dysfunction.Induction of anaesthesia is a particularly hazardous time for the HTx recipient due to the risk of cardiovascular decompensation. The physiological goals of induction are to avoid reductions in preload, increases in afterload, myocardial depression, and bradycardia. During myocardial reperfusion, infusions of inotropes and vasopressors are usually started to aid separation from cardiopulmonary bypass (CPB). The donor heart is denervated, so indirect sympathomimetics will have no effect. The most common reason for failure to separate from CPB is right ventricular (RV) failure.Postoperative complications include pulmonary hypertension and RV failure, bleeding, dysrhythmias, infection, and acute rejection. Induction immunosuppression is an intense course of therapy aimed at reducingthe pretransplant antigenic load and incidence of acute rejection and prolonging graft survival, but the evidence base is poor. Maintenance of immunosuppression can be via monotherapy or combinations of agents. Long-term complications following HTx are frequently related to immunosuppressant therapy but also include arterial hypertension, hyperlipidaemia, diabetes mellitus, renal dysfunction, cardiac allograft vasculopathy, malignancy, infection, rejection, and graft failure.

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