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  • Routine work up including history of previous heart surgeries
  • Presence and status of mechanical assist devices, pacemakers, and automatic internal cardiac defibrillators

  • Pre-induction: insert A-line using local anesthesia and minimal sedation if needed. Patients should receive immunosuppressive therapy, usually consisting of azathioprine and corticosteroids
  • Consider “gentle” rapid sequence based on NPO status
  • Induction should focus on minimizing negative inotropy; usually achieved with a combination of etomidate, opioids, and benzodiazepines
  • Post-induction: Pulmonary artery catheter (prefer left IJ, as right IJ will be used for serial myocardial biopsies, and subclavian lines can kink with sternal retraction) and TEE
  • Maintenance is achieved with a combination of volatile anesthetics on cardiopulmonary bypass (CPB) as tolerated, opioids, and benzodiazepines

  • Orthotopic transplantation: Standard biatrial or bicaval technique followed by end-to-end aortic and pulmonary anastomoses
  • Pacemaker/ICD explanted as part of the surgery
  • Heterotopic transplantation (rare) utilized in donor-recipient size disparity and irreversible pulmonary hypertension

  • Managing right ventricular failure and pulmonary hypertension is the key as the donor right ventricle is very sensitive to increased afterload
    • An inotrope (usually milrinone 0.375 μg/kg/min) is usually started prior to separation from CPB. Based on TEE findings, a second inotrope, such as dobutamine (3–5 μg/kg/min) or epinephrine (1–2 μg/min) might be added
    • If, despite two inotropes, the patient continues to exhibit signs of RV failure (high CVP, low cardiac index, poor RV systolic function, high dose pressors), then pulmonary vasodilators such as inhaled nitric oxide and inhaled iloprost may be needed. The advantage of nitric oxide over iloprost is that it does not cause any systemic vasodilatation
    • Mechanical assist devices may be necessary to augment right heart function, if despite inotropes and pulmonary vasodilators, the patient continues to exhibit signs of RV failure
  • Left ventricular failure can be similarly managed with inotropes and mechanical assist devices. Post-CPB management focuses on maintenance of adequate preload without right ventricular distention and management of coagulopathy

  • Extubation is achieved in the ICU, when hemodynamic stability is established and there is no bleeding requiring reexploration
  • Inotropic support is gradually weaned over days and invasive monitoring withdrawn
  • Antirejection and immunosuppressive regimens are instituted immediately

Triple Therapy

  • Calcineurin inhibitor that blocks interleukin-2 gene transcription (cyclosporine A, Tacrolimus [Prograf])
  • Purine synthesis inhibitor (azathioprine [Imuran] or mycophenolatemofetil [Cellcept])
  • T-cell dependent immunity suppression, inhibition of interleukin-2 production (methylprednisolone)

The adverse effects of these drugs consist of immunodeficiency resulting in infection and malignancy, and nonimmune toxicities such as diabetes, hypertension, and renal insufficiency. Monoclonal antibodies—interleukin-2 receptor blockers (basiliximab [Simulect], daclizumab [Zenapax]) have been used for induction therapy. They appear to decrease the risk of early postoperative rejection without increasing infection.

Grading and surveillance via serial endomyocardial biopsies.

Long-Term Course

  • Median survival after heart transplant is 10 years
  • Mortality risk is the highest in the first 6 months after transplant
  • In the first year the ...

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