Skip to main content
SpringerLink
Log in

Perioperative Management of the Heart Transplant and Mechanical Circulatory Support Device Patient

  • Chapter
  • First Online:
Adult Critical Care Medicine

  • 2143 Accesses

Abstract

The care of patients with end-stage, decompensated heart failure involves a unique mix of medical and surgical interventions designed to prolong life and alleviate symptoms. Currently, heart transplantation and placement of durable mechanical support devices are the treatments of choice for those with end-stage heart failure. As the prevalence of these interventions increases, intensivists need to become more familiar with the core concepts and challenges involved in providing optimal care to these challenging patients. Although by no means comprehensive, the following case-based report is designed to illustrate the most important concepts and most common pitfalls of the perioperative management of the patient with a mechanical circulatory support device or heart transplant.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 89.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Stein A, de Souza LV, Belettini CR, Menegazzo WR, Viégas JR, Costa Pereira EM, Eick R, Araújo L, Consolim-Colombo F, Irigoyen MC. Fluid overload and changes in serum creatinine after cardiac surgery: predictors of mortality and longer intensive care stay. A prospective cohort study. Crit Care. 2012;16(3):R99.

    Article  Google Scholar 

  2. Dang NC, Topkara VK, Mercando M, Kay J, Kruger KH, Aboodi MS, Oz MC, Naka Y. Right heart failure after left ventricular assist device implantation in patients with chronic congestive heart failure. J Heart Lung Transplant. 2006;25(1):1–6.

    Article  Google Scholar 

  3. Kormos RL, Teuteberg JJ, Pagani FD, Russell SD, John R, Miller LW, Massey T, Milano CA, Moazami N, Sundareswaran KS, Farrar DJ, HeartMate II Clinical Investigators. Right ventricular failure in patients with the HeartMate II continuous-flow left ventricular assist device: incidence, risk factors, and effect on outcomes. J Thorac Cardiovasc Surg. 2010;139(5):1316–24.

    Article  Google Scholar 

  4. Fukamachi K, McCarthy PM, Smedira NG, Vargo RL, Starling RC, Young JB. Preoperative risk factors for right ventricular failure after implantable left ventricular assist device insertion. Ann Thorac Surg. 1999;68(6):2181–4.

    Article  CAS  Google Scholar 

  5. Ronco C, Haapio M, House AA, Anavekar N, Bellomo R. Cardiorenal syndrome. J Am Coll Cardiol. 2008;52(19):1527–39. https://doi.org/10.1016/j.jacc.2008.07.051.

    Article  PubMed  Google Scholar 

  6. McKenna DH Jr, Eastlund T, Segall M, Noreen HJ, Park S. HLA alloimmunization in patients requiring ventricular assist device support. J Heart Lung Transplant. 2002;21(11):1218–24.

    Article  Google Scholar 

  7. Drakos SG, Stringham JC, Long JW, Gilbert EM, Fuller TC, Campbell BK, Horne BD, Hagan ME, Nelson KE, Lindblom JM, Meldrum PA, Carlson JF, Moore SA, Kfoury AG, Renlund DG. Prevalence and risks of allosensitization in HeartMate left ventricular assist device recipients: the impact of leukofiltered cellular blood product transfusions. J Thorac Cardiovasc Surg. 2007;133(6):1612–9.

    Article  Google Scholar 

  8. Potapov E, Meyer D, Swaminathan M, Ramsay M, El Banayosy A, Diehl C, Veynovich B, Gregoric ID, Kukucka M, Gromann TW, Marczin N, Chittuluru K, Baldassarre JS, Zucker MJ, Hetzer R. Inhaled nitric oxide after left ventricular assist device implantation: a prospective, randomized, double-blind, multicenter, placebo-controlled trial. J Heart Lung Transplant. 2011;30:870–8.

    PubMed  Google Scholar 

  9. Lahm T, McCaslin CA, Wozniak TC, Ghumman W, Fadl YY, Obeidat OS, Schwab K, Meldrum DR. Medical and surgical treatment of acute right ventricular failure. J Am Coll Cardiol. 2010;56(18):1435–46.

    Article  Google Scholar 

  10. Slaughter MS, Naka Y, John R, Boyle A, Conte JV, Russell SD, Aaronson KD, Sundareswaran KS, Farrar DJ, Pagani FD. Post-operative heparin may not be required for transitioning patients with a HeartMate II left ventricular assist system to long-term warfarin therapy. J Heart Lung Transplant. 2010;29(6):616–24.

    Article  Google Scholar 

  11. Feldman D, Pamboukian SV, Teuteberg JJ, Birks E, Lietz K, Moore SA, Morgan JA, Arabia F, Bauman ME, Buchholz HW, Deng M, Dickstein ML, El-Banayosy A, Elliot T, Goldstein DJ, Grady KL, Jones K, Hryniewicz K, John R, Kaan A, Kusne S, Loebe M, Massicotte MP, Moazami N, Mohacsi P, Mooney M, Nelson T, Pagani F, Perry W, Potapov EV, Eduardo Rame J, Russell SD, Sorensen EN, Sun B, Strueber M, Mangi AA, Petty MG, Rogers J, International Society for Heart and Lung Transplantation. The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary. J Heart Lung Transplant. 2013;32(2):157–87.

    Article  Google Scholar 

  12. Koster A, Huebler S, Potapov E, Meyer O, Jurmann M, Weng Y, Pasic M, Drews T, Kuppe H, Loebe M, Hetzer R. Impact of heparin-induced thrombocytopenia on outcome in patients with ventricular assist device support: single-institution experience in 358 consecutive patients. Ann Thorac Surg. 2007;83(1):72–6.

    Article  Google Scholar 

  13. Schenk S, El-Banayosy A, Morshuis M, Arusoglu L, Eichler P, Lubenow N, Tenderich G, Koerfer R, Greinacher A, Prohaska W. IgG classification of anti-PF4/heparin antibodies to identify patients with heparin-induced thrombocytopenia during mechanical circulatory support. J Thromb Haemost. 2007;5(2):235–41. Epub 2006 Oct 31.

    Article  CAS  Google Scholar 

  14. Alvarez P, Cordero-Reyes AM, Uribe C, De Hoyos P, Martinez D, Bhimaraj A, Trachtenberg BH, Ashrith G, Torre-Amione G, Loebe M, Amione-Guerra J, Rice L, Estep JD. Acquired and hereditary hypercoagulable states in patients with continuous flow left ventricular assist devices: prevalence and thrombotic complications. J Card Fail. 2016;22(7):501–11.

    Article  Google Scholar 

  15. Fried J, Levin AP, Mody KM, Garan AR, Yuzefpolsakaya M, Takayama H, Diuguid DL, Naka Y, Jorde U, Uriel N. Prior hematologic conditions carry a high morbidity and mortality in patients supported with continuous-flow left ventricular assist devices. J Heart Lung Transplant. 2014;33(11):1119–25.

    Article  Google Scholar 

  16. Cowger J, Pagani FD, Haft JW, Romano MA, Aaronson KD, Kolias TJ. The development of aortic insufficiency in left ventricular assist device-supported patients. Circ Heart Fail. 2010;3(6):668–74.

    Article  Google Scholar 

  17. Holtz J, Teuteberg J. Management of aortic insufficiency in the continuous flow left ventricular assist device population. Curr Heart Fail Rep. 2014;11(1):103–10.

    Article  Google Scholar 

  18. Cowger JA, Romano MA, Shah P, Shah N, Mehta V, Haft JW, Aaronson KD, Pagani FD. Hemolysis: a harbinger of adverse outcome after left ventricular assist device implant. J Heart Lung Transplant. 2014;33(1):35–43.

    Article  Google Scholar 

  19. Rao V, Slater JP, Edwards NM, Naka Y, Oz MC. Surgical management of valvular disease in patients requiring left ventricular assist device support. Ann Thorac Surg. 2001;71(5):1448–53.

    Article  CAS  Google Scholar 

  20. Stobierska-Dzierzek B, Awad H, Michler RE. The evolving management of acute right-sided heart failure in cardiac transplant recipients. J Am Coll Cardiol. 2001;38(4):923–31.

    Article  CAS  Google Scholar 

  21. Hosenpud JD, Bennett LE, Keck BM, Boucek MM, Novick RJ. The Registry of the International Society for Heart and Lung Transplantation: seventeenth official report-2000. J Heart Lung Transplant. 2000;19(10):909–31.

    Article  CAS  Google Scholar 

  22. Mentzer RM, Alegre CA, Nolan SP. The effects of dopamine and isoproterenol on the pulmonary circulation. J Thorac Cardiovasc Surg. 1976;71(6):807–14.

    CAS  PubMed  Google Scholar 

  23. Chen EP, Bittner HB, Davis RD, Van Trigt P. Hemodynamic and inotropic effects of milrinone after heart transplantation in the setting of recipient pulmonary hypertension. J Heart Lung Transplant. 1998;17(7):669–78.

    CAS  PubMed  Google Scholar 

  24. Jeevanandam V. Triiodothyronine: spectrum of use in heart transplantation. Thyroid. 1997;7(1):139–45.

    Article  CAS  Google Scholar 

  25. Visweswaran G, Gidea C, Baran D, Cohen M, Zucker M. Acute left ventricular dysfunction complicating pregnancy on ECMO: tri-iodothyronine to the rescue with real time transesophageal echocardiography. J Cardiol Cases. 2016;13:33–6.

    Article  Google Scholar 

  26. Bencowitz HZ, LeWinter MM, Wagner PD. Effect of sodium nitroprusside on ventilation-perfusion mismatching in heart failure. J Am Coll Cardiol. 1984;4(5):918–22.

    Article  CAS  Google Scholar 

  27. Bonet LA, Guillén RV, Lázaro IS, de la Fuente C, Osseyran F, Dolz LM, Hernández MM, Sanz MP, Otero MR, Sanz AS. Intravenous sildenafil in right ventricular dysfunction with pulmonary hypertension following a heart transplant. Heart Int. 2014;9(1):22–5.

    Article  CAS  Google Scholar 

  28. Fernandes AM, Andrade AC, Barroso ND, Borges IC, Carvalho-Andrade D, Rodrigues Junior ES, Guimarães LC, Durães AR, Borges SM, Aras JR. The immediate effect of sildenafil on right ventricular function in patients with heart failure measured by cardiac magnetic resonance: a randomized control trial. PLoS One. 2015;10(3):e0119623.

    Article  Google Scholar 

  29. van Vessem ME, Palmen M, Couperus LE, Mertens B, Berendsen RR, Tops LF, Verwey HF, de Jonge E, Klautz RJ, Schalij MJ, Beeres SL. Incidence and predictors of vasoplegia after heart failure surgery. Eur J Cardiothorac Surg. 2017;51(3):532–8.

    PubMed  Google Scholar 

  30. Levin MA, Lin HM, Castillo JG, Adams DH, Reich DL, Fischer GW. Early on-cardiopulmonary bypass hypotension and other factors associated with vasoplegic syndrome. Circulation. 2009;120(17):1664–71.

    Article  Google Scholar 

  31. Abdelazim R, Salah D, Labib HA, El Midany A. Methylene blue compared to norepinephrine in the management of vasoplegic syndrome in pediatric patients after cardiopulmonary bypass: a randomized controlled study. Egypt J Anaesth. 2016;32:269–75.

    Article  Google Scholar 

  32. Mets B, Michler RE, Delphin ED, Oz MC, Landry DW. Refractory vasodilation after cardiopulmonary bypass for heart transplantation in recipients on combined amiodarone and angiotensin-converting enzyme inhibitor therapy: a role for vasopressin administration. J Cardiothorac Vasc Anesth. 1998;12(3):326–9.

    Article  CAS  Google Scholar 

  33. Shieh JP, Chu CC, Chen JY, Chen YH, Yeh FC, Hsing CH. Acute fatal vasoplegia and asystole induced by intravenous amiodarone after cardiopulmonary bypass in a patient with preoperative cardiogenic shock. Acta Anaesthesiol Sin. 1999;37(4):205–10.

    CAS  PubMed  Google Scholar 

  34. Cooper LB, Mentz RJ, Edwards LB, Wilk AR, Rogers JG, Patel CB, Milano CA, Hernandez AF, Stehlik J, Lund LH. Amiodarone use in patients listed for heart transplant is associated with increased 1-year post-transplant mortality. J Heart Lung Transplant. 2017;36(2):202–10.

    Article  Google Scholar 

  35. Malone DL, Hess JR, Fingerhut A. Massive transfusion practices around the globe and a suggestion for a common massive transfusion protocol. J Trauma. 2006;60(6 Suppl):S91–6.

    Article  Google Scholar 

  36. Andersen ND, Bhattacharya SD, Williams JB, Fosbol EL, Lockhart EL, Patel MG, Gaca JG, Welsby IJ, Hughes GC. Intraoperative use of low-dose recombinant activated factor VII during thoracic aortic operations. Ann Thoracic Surg. 2012;93:1921–9.

    Article  Google Scholar 

  37. Thakar CV, Arrigain S, Worley S, Yared JP, Paganini EP. A clinical score to predict acute renal failure after cardiac surgery. J Am Soc Nephrol. 2005;16(1):162–8.

    Article  Google Scholar 

  38. Smith EP. Hematologic disorders after solid organ transplantation. Hematology Am Soc Hematol Educ Program. 2010;2010:281–6.

    Article  Google Scholar 

  39. Pavri BB, O'Nunain SS, Newell JB, Ruskin JN, William G. Prevalence and prognostic significance of atrial arrhythmias after orthotopic cardiac transplantation. J Am Coll Cardiol. 1995;25(7):1673–80.

    Article  CAS  Google Scholar 

  40. Lushaj EB, Dhingra R, Chindhy S, Akhter S, Kohmoto T, Ulschmid S, Osaki S, Badami A, Lozonschi L. To use or not to use? Amiodarone before heart transplantation. Surgery. 2017;161(5):1273–8.

    Article  Google Scholar 

  41. Cosío Carmena MD, Gómez Bueno M, Almenar L, Delgado JF, Arizón JM, González Vilchez F, Crespo-Leiro MG, Mirabet S, Roig E, Pérez Villa F, Fernández-Yañez JF, Lambert JL, Manito N, Fuente L, Sanz Julve ML, Pascual D, Rábago G, Millán I, Alonso-Pulpón LA, Segovia J. Primary graft failure after heart transplantation: characteristics in a contemporary cohort and performance of the RADIAL risk score. J Heart Lung Transplant. 2013;32(12):1187–95.

    Article  Google Scholar 

  42. Kobashigawa J, Zuckermann A, Macdonald P, Leprince P, Esmailian F, Luu M, Mancini D, Patel J, Razi R, Reichenspurner H, Russell S, Segovia J, Smedira N, Stehlik J, Wagner F, Consensus Conference Participants. Report from a consensus conference on primary graft dysfunction after cardiac transplantation. J Heart Lung Transplant. 2014;33(4):327–40.

    Article  Google Scholar 

  43. Dengler TJ, Zimmermann R, Braun K, Müller-Bardorff M, Zehelein J, Sack FU, Schnabel PA, Kübler W, Katus HA. Elevated serum concentrations of cardiac troponin T in acute allograft rejection after human heart transplantation. J Am Coll Cardiol. 1998;32(2):405–12.

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Cardiothoracic Transplantation Program, Newark Beth Israel Medical Center, Rutgers University – New Jersey Medical School, Newark, NJ, USA

    Mark Jay Zucker

  2. Department of Medicine, Baystate Medical Center, Springfield, MA, USA

    Leeor M. Jaffe

Authors
  1. Mark Jay Zucker
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Leeor M. Jaffe
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mark Jay Zucker .

Editor information

Editors and Affiliations

  1. Newark, NJ, USA

    Jennifer A. LaRosa

Rights and permissions

Reprints and permissions

Copyright information

© 2019 Springer International Publishing AG, part of Springer Nature

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Zucker, M.J., Jaffe, L.M. (2019). Perioperative Management of the Heart Transplant and Mechanical Circulatory Support Device Patient. In: LaRosa, J. (eds) Adult Critical Care Medicine. Springer, Cham. https://doi.org/10.1007/978-3-319-94424-1_3

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-94424-1_3

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-94423-4

  • Online ISBN: 978-3-319-94424-1

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation