Anesthesia Following Heart Transplantation

(1)

Anesthesia Following

Heart Transplantation

R1 Minghui Hung

Department of Anesthsiology, NTUH

(2)

Case History

 _{The patient was a male aged 68 yr who}

had received heart transplant 6 years a go due to dilated cardiomyopathy with c ongestive heart failure

 _{In general, his progress following surger}

y had been good with tolerant daily acti vity

 _{Two episodes of graft rejection were not}

(3)

Case History

 _{Gross hematuria was noted this Novem}

ber.

 _{Pelvic CT revealed an infiltrative tumor}

at right bladder wall and a hepatic tumo r

 _{Separate bladder TCC and HCC were c}

onfirmed by pathological results

 _{Combined atypical hepatectomy and ra}

dical cystectomy with ileal conduit was planned, which was estimated to longer than 10 hours

(4)

Case History

 _{preoperative immunosuppressive therapy}

triple-therapy

oral prednisone, azathioprine, cyclosporin keep cyclosporin level at 80-160ng/dL

(5)

Case History

 _{Laboratory studies}

WBC 5720 Anti-HCV negative

Hb 10.4 HBsAg negative

PLT 217K Anti-HBs negative AST 22 Anti-CMV negative ALT 11

T-Bil 0.2

Alb 3.97 ICG test:

PT 12.4 15min 25.3%

PTT 33.8 20min 13.3%

(6)

Case History

 _U/A:

 WBC 1-2 /HPF

(7)

Case History

(8)

Case History

 _{previous cardiac catheterization and en}

domyocardial biopsy

• _{patent coronary vessels} • _{no graft rejection}

 _{cardiac echography}

• _{Normal LV size with good contractility} • _{AR, mild to moderate; Mild MR and TR}

(9)

Anesthetic management

sheet-1

(10)

Anesthetic management

sheet-1

Anesthetic management

sheet-2

(11)

Anesthetic management

sheet-3

(12)

Anesthetic management

sheet-4

(13)

Anesthetic management

sheet-5

(14)

Postoperative course

 _{Weaning and extubated on the next day}

 _{Transfer to general ward on day 3 with stabl}

e hemodynamics

 _{Intravenous cyclosporin as immunosuppress}

ant keep blood level 100-120 ng/dL

 _{Antibiotics use, (Cefmetazone, gentamycin a}

nd metronidazole) for prophylaxis.

 _{Geneally, uneventful postoperative course in}

(15)

朱元璋一聯：「雙手撇開生死路，一刀割斷是非根」不亦快哉。

(16)

1967, first human allograft cardiac transplant carried out by Christian Barnard

“It is infinitely better to transplant a heart than bury it to be devoured by worms.” Time magazine

(17)

(18)

Heart transplantation (HTx)

78%

65% 86%

(19)



_{Denervated donor heart}



_{Immunocompromised on long-term i}

mmunosuppressive therapy

(International Anesthesiology Clinics. 33(2)1-9, 1995 Spring)

(20)

 _{The recipient atrial remnant remains in}

nervated, but no electrical impulses cro ss the suture line.

 _{The donor atrium is responsible for the}

donor heart rate.

 _{EKG: biphasic “P” waves.}

 _{No response to vagal stimulation, the r}

Pathophysiology of the

(21)

 _{Normal impulse formation and conducti}

vity.

 _{No response to vagal stimulation, the r}

esting heart rate is 90-100 bpm .

 _{No beat-to-beat variation in response t}

o respiration.

Pathophysiology of the

(22)

 _{With normal Frank-Sterling law of the h}

eart, the donor heart is “preload-depen dent”.

 _{In the first minutes of stress, stroke vol}

ume is increased instead of elevating h eart rate.

 _{Endogenous catecholamines was elev}

ated after 5-6 minutes and heart rate in

Pathophysiology of the

(23)

 _{Alpha- and beta-adrenergic receptors r}

emain intact but no clinical evidence of denervation hypersensitivity.

Pathophysiology of the

(24)



_{Accelerated coronary atherosclerosis}

chronic rejection

angiographic evidence:

10-20% at 1 year 50% by 5 years

silent myocardial ischemia

only diagnosed by EKG or angiography

Pathophysiology of the

(25)

 Arrhythmias

Most common during the first 3-6 months • lack of vagal tone

• increased level of circulating catecholamines • episodes of rejection

• ischemia secondary to graft CAD

Anti-arrhythmic agents or DC cardioversion should be carried out as normal, but negative inotropic effect should be considered.

Pathophysiology of the

(26)

Drugs in the Transplanted Heart

 _{Diuretics, antihypertensives, antiarrhythmi}

cs, anticoagulants

 _{Immunosuppressive drugs} • _Prednisone

• _Azathioprine • _Cyclosporine

(27)

Immunosuppressive agents

Prednisone

_{insulin antagonism}

_{sodium and fluid retention} _{Cushing’s syndrome}

_{suppression of the hypothalamic-pit}

uitary-adrenal axis

_osteoporosis

(28)

Immunosuppressive agents

Azathioprine

_{an antimetabolite}

_{antagonize competitive neuromuscul}

ar blockade as a phosphodiesterase inhibitor

_{hepatic toxicity}

_{bone marrow toxicity leading to leuk}

(29)

Immunosuppressive agents

Cyclosporine

 suppressing both humoral and cell-mediated immu nity

 unprictable GI absorption, routine blood level meas ures needed

_{Nephrotoxicity}

Avoid anesthetic drugs excreted mainly via the renal route.

_Hypertension

Incidence of 75%, mainstay of treatmen t is calcium channel blockers and angio tensin-converting enzyme inhibitors.

(30)

Immunosuppressive agents

Rejection and Infection

 therapeutic dilemma of immuno-suppressing therapy

 most common causes of mortality and morbi dity

 symptoms of rejection: tiredness, dyspnea, a rrhythmia, transient ischemic attacks

 ECG shows decrease in the QRS voltage

 yearly routine postcardiac transplant follow-u p, which includes echocardiography, cardiac

(31)

Preoperative Assessment

• CBC, urea, creatinine, and electrolyte level, liver fun ction test, pulmonary function test, chest X-ray, EKG • In particular, looking for any features of coronary ath

erosclerosis or graft rejection

• Check pacemaker preoperatively if the patient is fitte d with one

• Review drug history

• Steroid supplements and proper prophylactic antibiot ics

• Coagulation status

Anesthesia for the Patient with a

Denervated Heart

(32)

Monitoring

• Standard monitoring for any safe anesthetic

• Carefully weighed against the

potential risk of infection for invasive monitoring

• Fully aseptic techniques

Anesthesia for the Patient with a

Denervated Heart

(33)

Intraoperative management

• avoid dehydration, volume loss, and perip heral vasodilation, and to maintain preload • in general, geneal anesthesia is preferred

with intravenous induction

• regional anesthesia is problematic and req uire adequate preloading to avoid exagger ated hypotension

Anesthesia for the Patient with a

Denervated Heart

(34)

Intraoperative management

• Bradycardia and hypotension

• Isoprenaline (Isuprel®), _{a direct beta-adrener}

gic agonist, increased heart rate, cardiac output, a nd systolic blood pressure, and a reduced total peri pheral resistance and diastolic blood pressure

• Ephedrine, direct alpha- and beta-adrenergic ag onist, increased systolic and diastolic blood pressu re, increased pulse pressure and pulse rate, increa

Anesthesia for the Patient with a

Denervated Heart

(35)

Postoperative Care

• routine chest physical therapy for possible pulmonary infection

• fluid balance for fluid overload or reduced renal perfu sion

• the polypeptide sequence from amino acids 99-126 of the natriur etic factor (Urodilatin®) have shown to have profound effects on r

enal function

• early postoperative mobilization minimizes the risk of deep venous thrombosis and pulmonary embolism • continue all drug therapy, including immunosuppresa

Anesthesia Following Heart Transplantation