All heart and/or lung transplantations are considered emergency operations. As a result, the anesthetic preparation and management should reflect a consideration of the risks inherent in such a patient population.
The most common indications for adult cardiac transplantation are ischemic and idiopathic dilated cardiomyopathies, congenital heart disease, and viral myocarditis. The most common indications for adult lung transplantation are chronic obstructive pulmonary disease (particularly emphysema and α1-antitrypsin disease) followed by idiopathic pulmonary fibrosis.
Acute rejection after lung transplantation occurs with greater frequency compared with transplantation of other solid organs, particularly during the first 6 months after surgery. Thus timely administration of immunosuppressants is believed to be of key importance in lung transplantation.
Although immunosuppressant agents have dramatically reduced the incidence of acute rejection after cardiac transplantation, these drugs have been implicated in cardiac allograft vasculopathy, which remains a leading cause of morbidity and mortality among heart transplant recipients.
Patients with primary pulmonary hypertension may have an exacerbation and incremental increase in pulmonary vascular resistance caused by anxiety and agitation. Sedation with minimal respiratory depression is the goal in the lung transplantation population.
Typically, aortic cross-clamping of the donor coincides with induction of general anesthesia in the recipient. This coordinated event across centers is intended to achieve arrival of the donor organ at the recipient's operating room at the time when the recipient has been prepared for receiving the new organ. Delay in implantation of the transplanted organ leads to increased organ ischemia and may increase the risk for early postoperative allograft failure.
The anesthetic management of end-stage lung disease patients is aimed at minimizing further increases in pulmonary vascular resistance, as the patient is transitioned from awake and spontaneously breathing to anesthetized, paralyzed, and mechanically ventilated.
Familiarity and appreciation of pulmonary allograft physiology is imperative for ventilation of the new lung. Native lung explantation and subsequent allograft implantation results in denervated lungs and airways, loss of a functional pulmonary lymphatic system, and loss of bronchial artery blood flow.
Right heart failure can be precipitated by increased pulmonary vascular resistance in the cardiac recipient. Treatment includes inotropes and pulmonary vasodilators, as well as hyperventilation, increasing oxygen tension, decreasing positive end-expiratory pressure, and decreasing lung water.
In patients with end-stage heart and/or lung disease, transplantation often represents the last resort for an improved quality of life. The perioperative care of patients undergoing lung and heart transplantation challenges even the most experienced anesthesiologists, surgeons, and intensivists, and dedicated teams are devoted to this high-risk procedure despite its relative low volume. Understanding the anesthetic implications and underlying pathophysiology is necessary for a successful outcome. This chapter reviews heart and lung transplantation, with an emphasis on intraoperative anesthetic management and postoperative care. The first section reviews the history of lung and heart transplantation. The following section discusses surgical alternatives to transplantation. The third section reviews the immunobiology of transplantation, an area in which much research has been devoted. The fourth section reviews methods of organ procurement and ...