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Postoperative Care of Adult Cardiac Transplant Patients

  • Paul A. Perry
  • Fardad Esmailian
Chapter

Abstract

Cardiac transplantation remains the definitive therapy for end-stage heart failure. Meticulous postoperative management is essential for optimizing successful outcomes in this relatively complex patient cohort. While the critical care considerations of heart transplant recipients are largely similar to that of other cardiac surgery patients, there exist important transplant-specific factors which require attention.

This chapter provides a concise overview of post-transplant critical care. Key topics include initial evaluation, operative considerations, post-transplant physiology, hemodynamic management, dysrhythmias, immunosuppression, and organ-system based assessment and optimization.

Keywords

Transplant Immunosuppression Endomyocardial Orthotopic heart transplantation Donor Organ Considerations Posttransplant monitoring Primary graft dysfunction Rhythm disturbances Coagulopathy Hemorrhage Heart and kidney transplantation Hepatotoxicity Infection Outcome 

References

  1. Barnard CN. A human cardiac transplant: an interim report of a successful operation performed at the Groote Schuur Hospital, Cape Town. S Afr Med J. 1967;41:1271.PubMedGoogle Scholar
  2. Bechstein W. Neurotoxicity of calcineurin inhibitors: impact and clinical management. Transpl Int. 2000;13(5):313–26.CrossRefPubMedGoogle Scholar
  3. Bexton RS, Nathan AW, Hellestrand KJ, Cory-Pearce R, Spurrell RA, English TA, Camm AJ. Electrophysiological abnormalities in the transplanted human heart. Br Heart J. 1983;50(6):555–63.CrossRefPubMedPubMedCentralGoogle Scholar
  4. Cannon RM, Hughes MG, Jones CM, Eng M, Marvin MR. A review of the United States experience with combined heart-liver transplantation. Transpl Int. 2012;25(12):1223–8.CrossRefPubMedGoogle Scholar
  5. Caves PK, Stinson EB, Billingham ME, et al. Percutaneous endomyocardial biopsy in human heart recipients. Experience with a new technique. Ann Thorac Surg. 1973;16:325.CrossRefPubMedGoogle Scholar
  6. Costanzo MR, Dipchand A, Starling R, et al. The International Society of Heart and Lung Transplantation guidelines for the care of heart transplant recipients. J Heart Lung Transplant. 2010;29(8):914–56.CrossRefPubMedGoogle Scholar
  7. Crow S, Chen D, Milano C, Thomas W, Joyce L, Piacentino V 3rd, Sharma R, Wu J, Arepally G, Bowles D, Rogers J, Villamizar-Ortiz N. Acquired von Willebrand syndrome in continuous-flow ventricular assist device recipients. Ann Thorac Surg. 2010;90(4):1263–9.CrossRefPubMedGoogle Scholar
  8. Davies RR, Russo MJ, Morgan JA, Sorabella RA, Naka Y, Chen JM. Standard versus bicaval techniques for orthotopic heart transplantation: an analysis of the United Network for Organ Sharing database. J Thorac Cardiovasc Surg. 2010;140(3):700–8.CrossRefPubMedGoogle Scholar
  9. Dhital KK, Chew HC, Macdonald PS. Donation after circulatory death heart transplantation. Curr Opin Organ Transplant. 2017;22(3):189–1978.CrossRefPubMedGoogle Scholar
  10. Freimark D, Aleksic I, Trento A, Takkenberg JJ, Valenza M, Admon D, Blanche C, Queral CA, Azen CG, Czer LS. Hearts from donors with chronic alcohol use: a possible risk factor for death after heart transplantation. J Heart Lung Transplant. 1996;15(2):150–9.PubMedGoogle Scholar
  11. From AM, Maleszewski JJ, Rihal CS. Current status of endomyocardial biopsy. Mayo Clin Proc. 2011;86(11):1095–102.CrossRefPubMedPubMedCentralGoogle Scholar
  12. Goodroe R, Bonnema DD, Lunsford S, Anderson P, Ryan-Baille B, Uber W, Ikonomidis J, Crumbley AJ, VanBakel A, Zile MR, Pereira N. Severe left ventricular hypertrophy 1 year after transplant predicts mortality in cardiac transplant recipients. J Heart Lung Transplant. 2007;26(2):145–51.CrossRefPubMedGoogle Scholar
  13. de Groote P, El Asri C, Fertin M, Goéminne C, Vincentelli A, Robin E, Duva-Pentiah A, Lamblin N. Sildenafil in heart transplant candidates with pulmonary hypertension. Arch Cardiovasc Dis. 2015;108(6–7):375–84.CrossRefPubMedGoogle Scholar
  14. Hosenpud JD, Bennett LE. Mycophenolate mofetil versus azathioprine in patients surviving the initial cardiac transplant hospitalization: an analysis of the Joint UNOS/ISHLT Thoracic Registry. Transplantation. 2001;72(10):1662–5.CrossRefPubMedGoogle Scholar
  15. Hsu RB, Lin FY, Chen RJ, Chou NK, Ko WJ, Chi NH, Wang SS, Chu SH. Incidence, risk factors, and prognosis of postoperative hyperbilirubinemia after heart transplantation. Eur J Cardiothorac Surg. 2007;32(6):917–22.CrossRefPubMedGoogle Scholar
  16. Kittleson MM, Patel JK, Moriguchi JD, Kawano M, Davis S, Hage A, Hamilton MA, Esmailian F, Kobashigawa JA. Heart transplant recipients supported with extracorporeal membrane oxygenation: outcomes from a single-center experience. J Heart Lung Transplant. 2011;30(11):1250–6.CrossRefPubMedGoogle Scholar
  17. Kobashigawa J, Miller L, Renlund D, Mentzer R, Alderman E, Bourge R, Costanzo M, Eisen H, Dureau G, Ratkovec R, Hummel M, Ipe D, Johnson J, Keogh A, Mamelok R, Mancini D, Smart F, Valantine H. A randomized active-controlled trial of mycophenolate mofetil in heart transplant recipients. Mycophenolate Mofetil Investigators. Transplantation. 1998;66(4):507–15.CrossRefPubMedGoogle Scholar
  18. Kobashigawa J, Zuckermann A, Macdonald P, et al. Report from a consensus conference on primary graft dysfunction after cardiac transplantation. J Heart Lung Transplant. 2014;33(4):327–40.CrossRefPubMedGoogle Scholar
  19. Koul A, Ferraris V, Davenport DL, Ramaiah C. The effect of antifibrinolytic prophylaxis on postoperative outcomes in patients undergoing cardiac operations. Int Surg. 2012;97(1):34–42.CrossRefPubMedPubMedCentralGoogle Scholar
  20. Kubo SH, Naftel DC, Mills RM Jr, O’Donnell J, Rodeheffer RJ, Cintron GB, Kenzora JL, Bourge RC, Kirklin JK. Risk factors for late recurrent rejection after heart transplantation: a multiinstitutional, multivariable analysis. Cardiac Transplant Research Database Group. J Heart Lung Transplant. 1995;14(3):409–18.PubMedGoogle Scholar
  21. La Villa G, Gentilini P. Hemodynamic alterations in liver cirrhosis. Mol Asp Med. 2008;29(1–2):112–8.CrossRefGoogle Scholar
  22. Leuchte HH, Schwaiblmair M, Baumgartner RA, Neurohr CF, Kolbe T, Behr J. Hemodynamic response to sildenafil, nitric oxide, and iloprost in primary pulmonary hypertension. Chest. 2004;125(2):580–6.CrossRefPubMedGoogle Scholar
  23. Listijono DR, Watson A, Pye R, Keogh AM, Kotlyar E, Spratt P, Granger E, Dhital K, Jansz P, Macdonald PS, Hayward CS. Usefulness of extracorporeal membrane oxygenation for early cardiac allograft dysfunction. J Heart Lung Transplant. 2011;30(7):783–9.CrossRefPubMedGoogle Scholar
  24. Livio M, Mannucci PM, Viganò G, Mingardi G, Lombardi R, et al. Conjugated estrogens for the management of bleeding associated with renal failure. N Engl J Med. 1986;315:731–5.CrossRefPubMedGoogle Scholar
  25. Louie CY, Pham MX, Daugherty TJ, Kambham N, Higgins JP. The liver in heart failure: a biopsy and explant series of the histopathologic and laboratory findings with a particular focus on pre-cardiac transplant evaluation. Mod Pathol. 2015;28(7):932–43.CrossRefPubMedGoogle Scholar
  26. Lund LH, Edwards LB, Kucheryavaya AY, Benden C, Christie JD, Dipchand AI, Dobbels F, Goldfarb SB, Levvey BJ, Meiser B, Yusen RD, Stehlik J, International Society of Heart and Lung Transplantation. The registry of the International Society for Heart and Lung Transplantation: thirty-first official adult heart transplant report—2014; focus theme: retransplantation. J Heart Lung Transplant. 2014 Oct;33(10):996–1008.CrossRefPubMedGoogle Scholar
  27. Lund LH, Edwards LB, Ms YK, et al. The Registry of the International Society for Heart and Lung Transplantation: 32nd official adult heart transplantation report—2015. J Heart Lung Transplant. 2015;34(10):1244–54.CrossRefPubMedGoogle Scholar
  28. Mehaffey JH, Johnston LE, Hawkins RB, Charles EJ, Yarboro L, Kern JA, Ailawadi G, Kron IL, Ghanta RK. Methylene blue for vasoplegic syndrome after cardiac operation: early administration improves survival. Ann Thorac Surg. 2017;104(1):36–41.CrossRefPubMedPubMedCentralGoogle Scholar
  29. Moazami N, Sun B, Feldman D. Stable patients on left ventricular assist device support have a disproportionate advantage: time to re-evaluate the current UNOS policy. J Heart Lung Transplant. 2011;30(9):971–4.CrossRefPubMedGoogle Scholar
  30. Mohan R, Patel J, Kittleson M, Chang D, Aintablian T, Czer L, Esmailian F, Kobashigawa J. Liver evaluation for heart transplantation: which is better, noninvasive scans or liver biopsy? Am J Transplant. 2016;16(Suppl 3)Google Scholar
  31. Nalli N, Stewart-Teixeira L, Dipchand AI. Amiodarone-sirolimus/tacrolimus interaction in a pediatric heart transplant patient. Pediatr Transplant. 2006;10(6):736–9.CrossRefPubMedGoogle Scholar
  32. Nielsen FT, Leyssac PP, Kemp E, Starklint H, Dieperink H. Nephrotoxicity of FK-506: a preliminary study on comparative aspects of FK-506 and cyclosporine nephrotoxicity. Transplant Proc. 1994;6:3104–5.Google Scholar
  33. Oyer PE, Stinson EB, Jameison SA, et al. Cyclosporine a in cardiac allografting: a preliminary experience. Transplant Proc. 1983;15:1247.Google Scholar
  34. Pope SE, Stinson EB, Daughters GT, Schroeder JS, Ingels NB Jr, Alderman EL. Exercise response of the denervated heart in long-term cardiac transplant recipients. Am J Cardiol. 1980;46(2):213–8.CrossRefPubMedGoogle Scholar
  35. Randhawa PS, Starzl TE, Demetris AJ. Tacrolimus (FK506)-associated renal pathology. Adv Anat Pathol. 1997;4(4):265–76.CrossRefPubMedPubMedCentralGoogle Scholar
  36. Russo MJ, Chen JM, Sorabella RA, Martens TP, Garrido M, Davies RR, George I, Cheema FH, Mosca RS, Mital S, Ascheim DD, Argenziano M, Stewart AS, Oz MC, Naka Y. The effect of ischemic time on survival after heart transplantation varies by donor age: an analysis of the United Network for Organ Sharing database. J Thorac Cardiovasc Surg. 2007;133(2):554–9.CrossRefPubMedGoogle Scholar
  37. Schaffer JM, Chiu P, Singh SK, Oyer PE, Reitz BA, Mallidi HR. Heart and combined heart-kidney transplantation in patients with concomitant renal insufficiency and end-stage heart failure. Am J Transplant. 2014;14(2):384–96.CrossRefPubMedGoogle Scholar
  38. Semigran MJ, Cockrill BA, Kacmarek R, Thompson BT, Zapol WM, Dec GW, Fifer MA. Hemodynamic effects of inhaled nitric oxide in heart failure. J Am Coll Cardiol. 1994;24(4):982–8.CrossRefPubMedGoogle Scholar
  39. Taylor DO, Barr ML, Radovancevic B, Renlund DG, Mentzer RM Jr, Smart FW, Tolman DE, Frazier OH, Young JB, VanVeldhuisen P. A randomized, multicenter comparison of tacrolimus and cyclosporine immunosuppressive regimens in cardiac transplantation: decreased hyperlipidemia and hypertension with tacrolimus. J Heart Lung Transplant. 1999;18(4):336–45.CrossRefPubMedGoogle Scholar
  40. Uber WE, Self SE, Van Bakel AB, Pereira NL. Acute antibody-mediated rejection following heart transplantation. Am J Transplant. 2007;7(9):2064–74.CrossRefPubMedGoogle Scholar
  41. Wademan BH, Galvin SD. Desmopressin for reducing postoperative blood loss and transfusion requirements following cardiac surgery in adults. Interact Cardiovasc Thorac Surg. 2014;18(3):360–70.CrossRefPubMedGoogle Scholar
  42. Yildiz Y, Salihoglu E, Celik S, Ugurlucan M, Caglar IM, Turhan-Caglar FN, Isik O. The effect of postoperative positive end-expiratory pressure on postoperative bleeding after off-pump coronary artery bypass grafting. Arch Med Sci. 2014;10(5):933–40.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.University of California, DavisDavisUSA
  2. 2.Department of SurgeryCedars-Sinai Heart InstituteLos AngelesUSA
  3. 3.Heart TransplantationCedars-Sinai Heart InstituteLos AngelesUSA

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