• Heart transplant is the gold standard for the treatment of end-stage heart failure. Mechanical ventricular assist devices may be used as a "bridge to transplant."
• Indications for cardiac transplant include (1)
  • Severe, end stage disease that is refractory to surgical or medical therapy
  • NYHA Class III–IV despite maximum therapy
  • Compliant, motivated patient <70 years old
  • Heterotopic transplant is indicated for severe pulmonary hypertension and extreme donor/recipient size discrepancy.
• Contraindications for cardiac transplant (1)
  • Fixed pulmonary vascular resistance (PVR) >5 Wood units
  • Active tobacco, alcohol, or drug use
  • Active neoplasm. Oncology consult regarding risk of recurrence for previous neoplasm
  • Major debilitating disease
  • Patient non-compilance
  • Relative contraindications: BMI>30, diabetes with end organ
• Requires full cardiopulmonary bypass; cannula are inserted in the normal fashion (venous drainage from the IVC and the SVC and return via the aortic canula). Surgeons may use either a (2)
  • Biatrial technique (traditional): The recipient's ventricles are removed, while leaving the right and left atrium and great vessels in place. The atrial cuffs of the transplanted heart are sewn onto the recipient's.
  • Bicaval technique: The recipient's ventricles and right atrium are excised while the left atrium and great vessels are left in place. The transplanted IVC and SVC are sewn to the free edges of the recipient's SVC and IVC.

Supine-careful attention to padding

• Sternotomy
• Prepare for possible groin cannulation, especially if previous sternotomy.

• 6–8 hours. Repeat sternotomy patients require longer dissection time.
• Preparation of the recipient must be carefully timed with donor organ harvest; the recommended ischemic time is <4 hours.

• Frequent postbypass coagulopathy requiring antifibrinolytic agents and transfusion of pRBCs, FFP, platelets, and cryoprecipitate. Coagulopathy generally occurs as a result of cardiopulmonary bypass, as well as preoperative anticoagulation and liver dysfunction.
• Common surgical complications
  • Cardiac dysfunction of left, right, or both ventricles
  • Coagulopathy
  • Organ failure (kidneys, lungs)
  • Arrhythmias
  • Rejection

Typical ICU discharge by POD #3 but may have protracted hospital course.

• Full cardiopulmonary bypass machine
• Pacing capability
• Availability of ventricular assist devices or intra-aortic balloon pumps

Incidence

• In the US, ~2,000 heart transplants are performed each year.
• The most frequent indications are idiopathic or ischemic cardiomyopathy.

Prevalence

Approximately 35% of patients listed for heart transplant will actually receive a transplant.

• Early: Graft failure
• Intermediate: Acute rejection or infection
• Late: Allograft vasculopathy, lymphoproliferative disease, chronic rejection.

• 1 year survival: 80–90%
• Additional mortality: 4% per year.
• Approximately 20–30% of patients on the transplant list will die from cardiac causes before a donor is found.

History

• Assessment is often limited because of urgent surgery, but full transplant evaluation should be available.
• Evaluate current symptoms, any changes in ischemic threshold or cardiac function, and NPO status.

Signs/Physical Exam

Evaluate volume status and signs of pulmonary vascular congestion

• Lung auscultation
• JVD
• Peripheral edema
• Poor perfusion or cyanosis

Labs/Studies

• Electrolytes are often altered due to diuretics or excessive fluid retention.
• Liver function tests may reflect hepatic venous congestion.
• Coagulation studies
• EKG: Dysrhythmias are common.
• CXR to evaluate pulmonary venous congestion.
• Echocardiography to assess right and left heart function, valvular abnormalities, and the presence of pericardial or pleural effusion.
• Left and right heart catheterization.
• Evaluation of pulmonary hypertension is critical.

• Patients usually have elevated levels of catecholamines and are dependent on high preload (2).
• Small doses of sedation may result in severe hemodynamic changes.
• Patients are generally anxious but are very well informed about their care.

• Postoperative intubation and mechanical ventilation
• Transfusion of blood products

• Patients will be immunosuppressed so meticulous attention to aseptic technique is vital.
• Use blood products free of cytomegalovirus for patients lacking antibodies to this organism.

• General endotracheal anesthesia (2)
• Timing coordinated with donor heart availability

• Arterial line (preinduction)
• Central venous catheter – Right IJ access may be utilized, although concern for access for future biopsies.
• PA catheter – Insertion may be difficult in the dilated heart. Full insertion could possibly wait until after the donor heart implantation.
• TEE
• Large bore access
• Repeat sternotomy: Consider placement of defibrillator pads and cross-matched and checked pRBCs in the room prior to sternotomy.

• Concern for "full stomach," preoxygenation, +/– rapid sequence induction with cricoid pressure, unexpected difficult airway equipment readily available.
• Very sensitive to hemodynamic changes. Goal is to maintain heart rate, preload, contractility, and afterload. Continue inotropic support if the patient was reliant on it.
• for induction, opioids and benzodiazepines are commonly used for hemodynamic stability. Some patients may tolerate low volatile agent.

• Standard concerns for cardiopulmonary bypass.
• Insulin infusion will likely be necessary given the administration of steroids.
• Weaning from bypass
  • The newly transplanted heart is preload dependent so special care should be given to maintain adequate filling pressures.
  • Particular attention should be paid to right ventricle function; it is the most common etiology of failure to wean.

• Patients remain intubated with sedation
• Complications
  • Primary allograft failure secondary to inadequate myocardial protection, prolonged ischemic time, and reperfusion injury.
  • Right ventricle dysfunction
    • Etiology may be secondary to residual pulmonary hypertension, air in the right coronary artery, valve insufficiency, or prolonged ischemic time.
    • Increases in PVR can result from hypoxemia, hypercarbia, acidemia, and excessive tidal volumes and should be avoided.
    • Treat with aggressive inotropic therapy and selective pulmonary vasodilators (inhaled nitric oxide, prostaglandins).
  • Coagulopathy, especially in patients with prior sternotomy.