Cardiac II Transplant

Question 1

What factors indicate priority to receive a heart transplant?

Answer 1

Priority status
ABO compatibility
Body size match
Distance from donation center
Class IV w/ predicted life-expectancy < 1yr
EF < 20%

Question 2

What is the most common indication for heart transplant?

Answer 2

Idiopathic cardiomyopathy

Question 3

Heart

Cold Ischemic Time

Answer 3

4-6 hours

Question 4

Patient contraindications to receive heart transplant include:

Answer 4

> 70yo
Chronic renal dysfunction
Obesity

Question 5

Heart Transplant

Preop Anesthetic Management

Answer 5

Consider current cardiac support & infusions (VAD, IABP, ICD, inotropes)
Line patient prior to induction
Set-up & program all pump infusions

Question 6

Heart Transplant

Induction

Answer 6

GOAL to start cardio-pulmonary bypass as soon as possible
Full stomach → RSI
Slow IV administration to prevent rapid hemodynamic changes
Smooth, rapid airway control
Maintain HR & intravascular volume
Avoid ↓SVR

Question 7

Heart Transplant

Intraop

Answer 7

Immunosuppression protocol
High-dose steroid & immunosuppressants
Drugs available: Epi, Isoproterenol, PDEi (Milrinone), NO, inhaled prostaglandins
Vasopressin to preserve SVR w/o impact on PVR

Question 8

POST

Heart Transplant

Answer 8

Donor heart denervation Ø responsive to autonomic system
Loss PSNS tone ↑baseline HR (no response to anticholinergics)
DIRECT-acting myocardial adrenergic receptors
DIRECT-acting vasoactive agents (inotropes & vasoconstrictors to treat HR, BP, & CO)
Volume/preload dependent
Intrinsic mechanisms remain intact (Frank-Starling)

Question 9

How does accelerated atherosclerotic disease present in patients after receiving a heart transplant?

Answer 9

No angina

Arrhythmias indicate ischemic changes

Question 10

OFF Pump CABG

Answer 10

Heart immobilization achieved w/ compression and/or suction directly on vessels
Anesthetic goals: Prevent HoTN & ↓coronary artery perfusion d/t impaired contractility
Volume load
Head down positioning ↑VR
Pressors
R ventricle thin-walled & prone to compression

• TEE
• Heparin
• Bypass on standby

Question 11

Minimally Invasive Direct Coronary Artery Bypas

Answer 11

Grafting single vessel
L internal mammary artery → LAD
Lung isolation w/ DLT
OFF pump case
L anterior thoracotomy incision

• Place defibrillation pads before prep & drape
• Bypass on standby

Question 12

Minimally Invasive Aortic & Mitral Valve Replacement

Approaches

Answer 12

Partial hemi-sternotomy
Parasternal incision
R thoracotomy

*Morbidity & mortality comparable to full sternotomy

Question 13

Minimally Invasive Aortic & Mitral Valve Replacement

Anesthetic Considerations

Answer 13

Cardio-pulmonary bypass via femoral artery & vein bypasses heart
Lung isolation w/ DLT
Transvenous pacing
Defibrillation pads on
Central venous access
↓bleeding
Robotic option

Question 14

Transcatheter Aortic Valve Replacement or Implantation

Answer 14

IV sedation or GETA
Approach via femoral artery or transapical (L ventricle apex)
PIV, A-line, central access
TEE (general) or transthoracic echo (sedation)
Place external defibrillator (R2) pads on
Vasopressors
Fluoroscopy - lines to place valves

*Bypass on standby

Question 15

Transcatheter Aortic Valve Replacement or Implantation

Complications

Answer 15

• Stroke
• Renal failure
• Cardiac tamponade

Question 16

CABG

Answer 16

Coronary artery bypass graft

Question 17

Blood Conservation Strategies

Answer 17

• Antifibrinolytics
• Minimize hemodilution
• Cell saver
• Retrograde pump priming
• Normovolemic hemodilution
• POC to evaluate Hgb/Hct

Question 18

What impacts platelet function?

Answer 18

Hemodilution
Hypothermia
Contact with bypass circuit

Question 19

What precipitates R ventricular dysfunction or failure after bypass?

Answer 19

Inadequate myocardial protection or revascularization

Contract w/ the cardio-pulmonary bypass circuit

Question 20

Clinical approaches to measurably reduce the inflammatory response in cardiac surgical patients:

Answer 20

Surgical & perfusion techniques
Circuit components
Pharmacological strategies

Question 21

CNS Insult Causes

Answer 21

< 2%

Micro-emboli
Cerebral hypoperfusion
Systemic inflammatory response

Question 22

What increase postop renal dysfunction risk?

Answer 22

Renal insufficiency
Type 1 diabetes
Vascular pathology
Nephrotoxic agents

Question 23

ON vs. OFF pump CABG

Answer 23

No evidence to support one approach over another

Morbidity & mortality

Question 24

Midline Sternotomy or Thoracotomy →

Answer 24

Significant reduction in TLC, VC, & FEV