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YOUR PATIENT

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A 7-year-old girl presents for her annual heart catheterization with endomyocardial biopsies. She was transplanted 3 years ago for dilated cardiomyopathy.

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PREOPERATIVE CONSIDERATIONS

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After the first year posttransplant, when there are multiple biopsies, most patients undergo biopsies every 6 months and get annual coronary angiography.

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Preoperative evaluation should include review of the electrocardiogram, echocardiogram, and available data from prior catheterizations. Cardiac function, recent labs, and the presence of allograft vasculopathy should be known. Ischemia can be silent because of the surgical denervation.

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Right ventricular failure is seen in the immediate postoperative period for patients who had elevated pulmonary pressures before the transplant. The pretransplant cardiac history typically becomes less relevant as time progresses.

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Kidney failure and hypertension are frequently seen in this population.

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The psychological aspect of having repeated procedures and a life-threatening disease cannot be underestimated. Respecting specific requests for the anesthesiologists gives patients and their families a sense of autonomy and enhances the satisfaction of both.

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ANESTHETIC MANAGEMENT

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  • Most anesthesiologists and patients prefer mask inductions because in this patient group, obtaining intravenous access can be very challenging. If no access is obtainable, one has the option of relying on the access that the cardiologist establishes for the procedure.

  • Sedation is possible with compliant and motivated patients. Normocarbia is desired for hemodynamic measurements, and this often makes general anesthesia with a laryngeal mask airway or an endotracheal tube necessary.

  • The denervated heart relies on an intact Frank-Starling mechanism and circulating catecholamines.

  • Maintenance of anesthesia on room air is preferable to mimic the usual hemodynamic state.

  • Deep extubation is preferred to avoid bleeding from arterial or venous puncture sites from movement during extubation.

  • The transplanted heart is denervated and will not respond to indirectly acting catecholamines.

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POSTOPERATIVE CONSIDERATIONS

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Patients need to keep their leg with the arterial cannulation site straight for up to 6 hours. This is difficult to achieve in smaller children without sedation.

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DOs and DON’Ts

  • ✓ Do treat hypotension with fluid boluses.

  • ⊗ Do not start IVs on extremities that are being cannulated, unless you have to.

  • ✓ Do inform the cardiologist if you are giving vasoactive medications, since this will change the hemodynamic measurements.

  • ⊗ Do not give large amounts of neostigmine—the patient may develop bradycardia or arrest.

  • ⊗ Do not give a stress dose of steroids, unless clinically needed.

  • ✓ Be prepared for cardiac arrest at any time, particularly when the coronaries are manipulated. Manipulation of the coronaries in children can easily lead to vasospasm and ischemia.

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SURGICAL CONCERNS

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About 50% of all retransplantations are for posttransplant coronary vasculopathies. Endomyocardial biopsies are done to screen for rejection. Hemodynamic measurements are changed by acute pulmonary illness, another argument for not undergoing these often elective ...

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