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What is known as a complex clinical syndrome caused by structural or functional cardiac disorder that impairs the ability of the ventricle or ventricles to maintain adequate CO, resulting in hemodynamic changes?
Which stage of heart failure includes:
Hypertension, diabetes, CAD, and hx of cardiomyopathy
A - high risk
Which stage of heart failure includes:
Previous MI, LV dysfunction, valve disease
B - Asymptomatic heart failure
Which stage of heart failure includes:
Structural heart disease, dyspnea and fatigue, impaired exercise
C - symptomatic heart failure
Which stage of heart failure includes:
Marked symptoms at rest despite maximal medical therapy
D - Refractory end-stage failure
Which 5 treatments are usual standard of care for HF patients?
2. beta blockers
Once a heart failure patient reaches category D, they have a ______ year mortality risk greater than ______ %.
2 year mortality risk
greater than 75%
Frequency of transplantation remains limited by ______________ supply
Chronic rejection of heart transplantation is manifested by what?
(inflammation and vasospasm of arteries. little collateral blood flow present)
Will chronic rejection of heart transplantation result in angina?
No, no angina due to denervation
Early graft failure as a result of acute rejection is rare, but late graft failure remains problematic due to what?
Transplant coronary artery disease
What is treatment of choice for patients with end stage heart disease who are unlikely to survive the next 6-12 months?
Candidates for heart transplantation includes intractable heart failure with an ejection fraction less than what?
What is primary diagnosis for cardiac transplant patients?
idiopathic or ischemic cardiomyopathy
The goal for cardiac transplant candidates is diagnosis of Class _____ heart failure that has been maximally treated but will result in death in less than _______ year
Class D heart failure
less than 1 year
What is PVR requirement for cardiac transplant candidates?
PVR normal or responsive to O2 or vasodilators
Donor recipient compatibility is based on what 3 things?
2. ABO blood-group typing
3. distance from donor center
Highest priority of cardiac transplant is given to inpatients with which 4 criteria?
1. mechanical circulatory assist devices
2. assist devices with significant device related complications
3. continuous infusion of inotropic medications
4. life expectancy less than 7 days without transplant
Donor organs from patients with what diseases are excluded?
Hepatitis B or C
Are diabetics considered candidates for recipients/donors?
Are those older than 65 considered candidates for recipients/donors?
What are 3 anesthetic implications for cardiac transplantation?
1. Abnormal contractility
2. Preload dependence
3. afterload sensitivity
For abnormal contractility, patients will have poor tolerance for which agents?
negative inotropes that decrease HR
(Their CO is maintained by HR)
(Their SV is relatively fixed)
For patients with abnormal contractility, will they have a hypertensive response to light anesthesia?
(may respond with rapid decomensation)
Abnormal contractility is associated with:
1. decrease in myocardial catecholamines
2. decrease in beta receptor density
Which drugs may be helpful because of this?
Phosphodiasterase inhibitors (enoximone and milrinone)
These inotropes bypass the beta receptor
(also much higher doses of inotropic agents maybe required)
What are hemodynamic goals for cardiac transplantation:
Systemic BP greater than 100mmHg
CVP 8-12 mmHg
PaO2 greater than 100mmHg
Because cardiac transplant patients are preload dependent, the compensatory mechanism is an increase in _______________ volume
left ventricular end diastolic volume
(they require a higher than normal preload to maintain CO)
What can a sudden decrease in preload cause in a cardiac transplant patient?
decompensation and circulatory collapse
What are 3 ways anesthesia can decrease preload in cardiac patients?
1. anesthetic agents cause venodilation and decrease preload
2. surgery causes volume loss
3. PPV impedes VR to heart
What happens with an increase in afterload or SVR for cardiac transplant patients?
If there is not a corresponding increase in myocardial contractility, it can result in rapid decrease in SV, CO, and systemic perfusion
Small decreases in afterload are associated with _______________ in SV
Large decreases in afterload are associated with what?
significant increases in SV
poorly tolerated and result in hypotension and decreased organ perfusion
What are 2 ways the donor heart must be evaluated prior to transplant?
echo and angiography
Is mild LV hypertrophy and MVP a contraindication for a donor heart?
No, unless it causes severe mitral regurgitation
Explain the steps of procuring donor heart?
1. median sternotomy
2. systemic heparinization (300U/kg)
3. SVC ligated
4. IVC transected
5. aorta cross clamped
6. heart decompressed
7. cold (4 degrees C) cardioplegia infused
8. heart removed
What is the upper time limit between harvesting and reimplantation?
Organ dysfunction in the presence of HF is present in more than ________ % of patients
more than 50%
(orthopnea, renal dysfunction, peripheral edema, liver dysfunction, inotropic support, cardiac dysrhythmia, IABP)
How should recipient be premedicated prior to transplant?
What induction should be used for recipient in heart transplant?
RSI with etomidate/ketamine
(if the patient is uncompensated, receiving inotropic support, and is NPO other than cyclosporin - may use modified RSI with cricoid pressure)
Will recipient transplant patient be NPO more than 6-8 hours?
They rarely know more than several hours in advance
What does excitement and anticipation of transplant do to gastric emptying?
Why should you not hook recipient transplant patient to NG suction in OR?
They take PO cyclosporin with milk/orange juice
If you hook up to suction may remove this drug
Prepping anesthesia equipment for transplant is similar to other open hearts - with an emphasis on what?
(sterile anesthesia bag and circuit, bacterial filter on circuit, sterile intubation tray, sterile monitors, radial art line, CVP/PA catheter, TEE. All invasive lines prepped with iodine and draped with sterile towels and sterile gloves/gown worn with insertion)
Is nasal intubation okay for cardiac transplantation?
No, it predisposes the patient to bacteremia and sinus infection
Which patients should get a PA catheter vs CVP?
In patients without pulmonary hypertension use CVP
In patients with pulmonary hypertension use PA
Premedication with a benzo before surgery is okay, but avoid what?
depressed consciousness, hypoxemia, hemodynamic compromise
How much blood should be available during transplant?
if re-do 4 units
(CMV-free blood products for patients who lack CMV antibodies)
Which medications should be ready for transplant?
Dobutamine, epi, neo, isoproterenol, nipride, NO
Are opioids okay to use on induction?
Use with care fentanyl 5-10mcg/kg
sufentanil (slowing of heart rate!)
What would be an appropriate muscle relaxant for transplant?
Can Ketamine be used for induction for transplant?
Ketamine maintains BP bc of released catecholamines
but these pts are catecholamine depleted so its direct negative inotropic effects may result in significant hypotension
Can Etomidate be used for induction for transplant?
Yes. It is not associated with significant hemodynamic alterations
______________ based anesthesia is used in the majority of transplantations
Narcotic based anesthesia
Is inhalational anesthesia a primary anesthetic used in transplantation?
No. Its use is complicated by hypotension
(only used to supplement narcotic based technique)
(benzos are also used to supplement narcotic technique)
Is N2O recommended in transplant?
No, it depressed myocardial contractility and can exacerbate consequences of air emboli
During mobilization and exposure of the heart, what is common?
hemodynamic instability and cardiac dysrhythmias
What follows exposure of the heart during transplantation?
heparin is administered in preparation for cannulation of the great vessels
After coagulation is verified, the great vessels are cannulated, the donor heart arrives and CPB is initiated
Why should excessive doses of narcotics be avoided?
It causes prolonged ventilatory support, which increases the risk of pulmonary infection postop
Early in CPB, what will ABG reveal?
large O2 deficit in the peripheral tissues
(these should be corrected before attempting to separate from CPB)
What is the most common complication that occurs during weaning from CPB?
RV failure from pulmonary hypertension
The donor's heart is not accustomed to such a high RV afterload found in the recipient
(treatment is with hyperventilation, PGE1, and NO)
What are 6 drugs that should be available during weaning from CPB?
1. Isoproterenol 0.005-0.05 mcg/kg/min. titrate to 90-100 bpm. Decreases PVR, improves filling
2. Dobutamine (similar to Isoproterenol)
4. Phosphodiesterase type III inhibitors. increase cAMP, increase Ca2+, positive inotrope (milrinone amrinone)
5. Prostaglandin E1. Manages pulm htn. Decreases peripheral resistance, increases CO and HR.
6. NO. Decreases PVR without decreasing BP
Which medication should be administered before the removal of aortic cross-clamp and during reperfusion of transplanted heart?
What ventilation techniques should be implemented to minimize pulmonary vasoconstriction?
Hyperventilation with minimal PEEP and correction of acidosis
During CPB, LV dysfunction can occur as the result of....
1. prolonged donor heart ischemia
2. inadequate myocardial protection
3. coronary air embolization
4. inadequate myocardial perfusion during early post CPB period
(High dose inotropics and vasoactive support may be required)
What drug is given after satisfactory weaning from CPB?
Which transplant procedure includes the donor heart being resected so that the posterior atrial walls (including SA node), pulmonary veins, and vena cava are intact?
Orthotopic transplantation procedure
In orthotopic transplantation procedure, where are the great vessels divided above?
Above the semilunar valves
Ideally, when is CPB initiated?
just before arrival of donor heart
Where are the atria resected in orthotopic transplantation?
above the AV grooves
(this leaves the posterior atrial walls and SA node intact)
Where are the 4 major anastomoses in orthotopic transplantation?
Left and right atrium
Aortic and PA
The result of orthotopic transplantation is an implanted heart totally devoid of autonomic innervation and contains _______ SA nodes
Because of slow junctional rhythms common during weaning of CPB, what is used during weaning?
Isoproterenol infusion and placement of pacing wires
What can be used to decrease postoperative bleeding?
What do you do with PA catheter during CPB?
It must be completely withdrawn into the sterile sheath until floated into pulmonary artery after CPB is removed
Which transplant procedure includes a graft placed in the right chest and connects to the circulation in parallel with the recipient heart?
What are the 2 primary indications for heterotopic transplantation?
1. significant irreversible pulmonary hypertension
2. gross size mismatch between donor and recipient
What may be avoided with heterotopic transplantation?
RV failure in the face of acutely elevated RV afterload
In the denervated heart, the heart rate is controlled by which SA node?
Does it respond to direct autonomic nervous system stimulation?
Donor SA node
What is basal heart rate of denervated heart?
90 - 100 bpm
Which nerve does not work in the denervated heart?
Which drugs work directly on the denervated heart and will increase heart rate?
Which drug has no effect on denervated heart?
Glucagon and isoproterenol
What effects does norepinephrine have on the denervated heart?
Increases HR due to beta effect on SA node
(in a normal heart it would slow HR due to reflex bradycardia via baroreceptor mechanism and vagal nerve)
Can denervated heart respond with reflex increases in heart rate in response to vasodilation or sudden blood loss?
Will denervated heart rate respond to inadequate anesthesia?
(any response in heart rate will lag in onset, be minor in magnitude, and lag in termination
In the denervated heart, even though the adrenergic neurotransmission has been permanently disrupted, the receptors are still intact and response to which medications is preserved?
Direct adrenergic agonists
isoproterenol, epi, dobutamine, NE, phenylephrine
What can bradydysrhythmias be treated with in denervated heart?
direct beta adrenergic stimulating agents
(reflex HR changes associated with direct acting agents such as phenylephrine are absent)
What percent of heart transplantation patients will require placement of permanent pacemaker?
How does digoxin work in denervated heart?
Positive direct inotropic action for long term afib control
Little chang ein SA/AV node activity
Not useful for acute control of ventricular rate in atrial fib
How do beta blockers work in denervated heart?
Extremely sensitive in transplant patients so be careful.
They decrease the HR in denervated heart. Also reduce exercise tolerance. The denervated heart's CO is dependent on elevated catecholamine levels.
How does verapamil work in denervated heart?
decreases atrial rate and AV conduction
effective in its direct action on calcium channels in transplanted heart and decreases atrial rate and AV conduction. Used in SVT
How do quinidine and procainamide work in denervated heart?
supresses supraventricular dysrhythmias in denervated heart
Exert both direct and autonomically mediated effects. Increase in HR d/t atropine like effects on SA/AV nodes.
How does lidocaine work in denervated heart?
The effects of lidocaine are completely independent of ANS and are useful for ventricular dysrhythmias in transplant patients
What are 5 potential causes of bleeding in the cardiac transplantation patient?
1. anticoagulation therapy
2. coag deficiency from hepatic dysfunction
3. dilutional coagulopathy
4. thrombocytopenia (secondary to preop heparin therapy)
5. suture line
When is vitamin K administered before surgery effect?
Not effective for at least 24 to 48 hours
Should coagulopathy be corrected preoperatively?
Yes, but not without risk considering 2 units of FFP may precipitate acute heart failure
What is important to consider when ordering any blood products on transplant patients?
What is the number one cause of death in transplant patients?
What infections are most common post-cardiac transplant?
(most bacterial and fungal)
What is the 2nd most common cause of death in the 1st 2 years after transplant?
(tachycardia, fever, dysrhythmias, heart failure)
(surgery during the acute rejection period puts the patient at high risk of death. Get cardiac cath and endomyocardial biopsy prior to elective surgery)
Post transplant avoid:
1. rapid ____________ in filling pressures
2. rapid ____________ in heart rate
3. Significant ____________ in SVR
Post transplant :
1. maintain _____________ filling pressures
2. use ____________ drugs
3. perioperative _______________ coverage
4. strict ____________ technique
2. direct-acting vasoactive
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