Heart Transplant (Orthotopic)
Patient phenotype
End-stage HF (ischemic, dilated, valvular cardiomyopathy). Often LVAD-bridged. EF < 20%, sometimes inotrope-dependent. Pulmonary HTN screened (PVR > 5 Wood units = high RV failure risk). UNOS status determines urgency.
Procedure
Median sternotomy, CPB cannulation, recipient heart excision (atrial cuff vs bicaval), donor heart anastomosed (LA → SVC/IVC → PA → aorta). Cross-clamp + reperfusion. 4-6+ hours.
Anesthetic plan
Cardiac GETA. High-dose opioid induction (fentanyl 20-50 mcg/kg) + etomidate + cisatracurium. TEE mandatory. PA catheter standard. Inotrope/pressor support throughout.
Setup
- ·A-line PRE-induction
- ·Large-bore CVC (introducer + PA catheter)
- ·PA catheter (manage RV/pulm HTN, post-bypass)
- ·TEE
- ·Cell saver
- ·External defib pads
- ·Inotrope infusions: epi, NE, vasopressin, milrinone, dobutamine
- ·iNO or epoprostenol available (RV failure)
- ·Immunosuppression (methylpred, basiliximab, etc.) per protocol — anesthesia gives most
- ·Strict aseptic technique (immunosuppression)
Biggest concerns by phase
End-stage HF physiology + LVAD considerations
LVAD-bridged: assess flow, RPM, PI on monitor; surgeon explants device. Native heart unsuitable for stress. Inotrope-dependent patients arrive on dobutamine/milrinone — continue throughout induction.
Hemodynamic collapse risk
Severe systolic dysfunction = no reserve. High-dose opioid + etomidate + cisatracurium minimizes hemodynamic insult. Preinduction A-line. Pressors drawn + dialed in. Slow titration.
Aspiration risk in HF + ascites
HF + ascites + hepatic congestion = full stomach physiology. Modified RSI considerations. OG suction post-intubation.
Pulmonary HTN + RV failure (post-bypass)
Donor RV not preconditioned to recipient PVR. Post-bypass RV failure leading cause of separation difficulty. iNO 20-40 ppm, milrinone, epi for RV inotropy. Mechanical RV support if refractory.
Denervated donor heart — chronotropic agents
Vagal innervation severed in donor heart. Atropine ineffective for bradycardia. Use direct beta-agonists: epinephrine, isoproterenol. Pacing wires placed (epicardial) for chronotropic backup.
Coagulopathy + bleeding (especially redo)
Long CPB + redo sternotomy + LVAD explant = major coagulopathy. TEG/ROTEM-guided transfusion. Cell saver. PCC, fibrinogen concentrate, factor VIIa for refractory.
ICU disposition + immunosuppression
All transplants go to ICU intubated. Strict aseptic technique throughout (CVC, A-line, etc.). Immunosuppression already started intraop (induction agents per protocol).
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
48-yo M, HeartMate 3 LVAD bridged for 18 months, dilated cardiomyopathy, PVR 4.5 Wood units, status 2. Donor identified, cold time 3.5 hrs anticipated. Plan?
What an examiner probes for
- ▹LVAD-aware preop assessment + induction strategy
- ▹PVR + RV failure prevention/treatment plan
- ▹TEE + PA catheter use
- ▹Pacing + denervated heart pharmacology
- ▹Coagulation + transfusion strategy
- ▹Aseptic technique + immunosuppression timing
Sources
- Kaplan's Cardiac 7e Ch 27
- ISHLT Guidelines for Heart Transplant
Anatomy reference
Sourced reference images. 4 matches for "heart cardiac chambers ventricle".
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