55 - Management after heart transplant

Summary

Introduction

The immediate postoperative course after a heart transplant has a profound effect on long-term outcome. This chapter deals with the management of heart transplant recipients in the first 48 to 72 hours in the critical care unit.

The heart transplant recipient has had, above all, a major cardiac procedure on cardiopulmonary bypass (CPB). The main principles in dealing with the postoperative course of any open heart operation, as detailed elsewhere in this book, also apply to heart transplantation. Nevertheless, there are areas where transplantation differs from standard open heart surgery, and these are specifically addressed in this chapter.

Baseline factors

Recipient factors

Before the transplant, the recipient will have undergone thorough assessment and rigorous waiting list surveillance to identify clinical features that may have an impact on both the operation itself and the postoperative course. Two important such features can substantially affect the postoperative course: pulmonary vascular resistance and renal function.

An absolute contraindication to heart transplantation is fixed severely elevated pulmonary vascular resistance. The new heart has a right ventricle (RV) that has never seen pulmonary artery pressure greater than 20 mmHg; it cannot be expected to pump against very high pulmonary artery pressure owing to elevated pulmonary vascular resistance. Many heart transplant recipients have a small degree of elevated pulmonary vascular resistance and, if more than 5 Woods units, this can compromise donor RV function. Such recipients often need perioperative pulmonary vasodilators.