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Chapter: Clinical Anesthesiology: Anesthetic Management: Anesthesia for Cardiovascular Surgery

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Cardiac Transplantation

Cardiac transplantation is the treatment of choice for otherwise healthy patients with end-stage heart disease so severe that they are unlikely to survive the next 6–12 months.

Cardiac Transplantation

Preoperative Considerations

Cardiac transplantation is the treatment of choice for otherwise healthy patients with end-stage heart disease so severe that they are unlikely to survive the next 6–12 months. The procedure is generally asso-ciated with 80–90% postoperative survival at 1 year and 60–90% survival at 5 years. Transplantation improves the quality of life and most patients are able to resume a relatively normal lifestyle. Unfortunately, the number of cardiac transplants performed is limited by the supply of donor hearts, which are obtained from brain-dead patients, most commonly following intracranial hemorrhage or head trauma.Patients with intractable heart failure have an ejection fraction of less than 20% and fall into NYHA functional class IV  and heart failure class D. For most patients, the pri-mary diagnosis is cardiomyopathy. Intractable heart failure may be the result of a severe con-genital lesion, ischemic cardiomyopathy, viral cardiomyopathy, peripartum cardiomyopathy, a failed prior transplantation, or valvular heart dis-ease. Medical therapy should include the standard drugs used for heart failure, including angioten-sin-converting enzyme inhibitors (or angiotensin receptor blockers, or both) and β blockade (usu-ally with carvedilol). Other drugs may include diuretics, vasodilators, and even oral inotropes; oral anticoagulation with warfarin may also be necessary. Patients may not be able to survive without intravenous inotropes while awaiting transplantation. Intraaortic balloon counterpulsa-tion, an LVAD, or even a total mechanical heart may also be necessary.

Transplant candidates must not have suffered extensive end-organ damage or have other major systemic illnesses. Reversible renal and hepatic dysfunction are common because of chronic hypo-perfusion and venous congestion. PVR must be normal or at least responsive to oxygen or vasodi-lators. Irreversible pulmonary vascular disease is usually associated with a PVR of more than 6–8 Wood units (1 Wood unit = 80 dyn·s·cm–5), and is a contraindication to orthotopic cardiac transplan-tation because right ventricular failure is a major cause of early postoperative mortality. Patients with long-standing pulmonary hypertension may, however, be candidates for combined heart–lung transplantation.

Tissue cross-matching is generally not per-formed. Donor–recipient compatibility is based on size, ABO blood-group typing, and cytomegalovirus serology. Donor organs from patients with hepatitis B or C or HIV infections are excluded.

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