Mod13: Heart Transplant

Question 1

_{Heart Transplant - Indications for Transplant}

What’s the most common indication for heart tpx?

Answer 1

Non-ischemic cardiomyopathy

Historically, ischemic cardiomyopathy was the most common indication for heart tpx

Question 2

_{Heart Transplant - Indications for Transplant}

What are UNOS indications for heart tpx?

Answer 2

Continuous mechanical or ionotropic support

Peak O2 uptake <14 mL/kg/min

LV ejection fraction less than 20%

Inoperable congenital heart disease

Intractable malignant arrhythmias

PVR <2 Wood units

Question 3

_{Heart Transplant - Indications for Transplant}

According to UNOS which Peak O2 uptake value is an indication for heart tpx?

Answer 3

<14 mL/kg/min

Question 4

_{Heart Transplant - Indications for Transplant}

According to UNOS which LV ejection fraction value is an indication for heart tpx?

Answer 4

< 20%

Question 5

_{Heart Transplant - Indications for Transplant}

According to UNOS which PVR value is an indication for heart tpx?

Answer 5

<2 Wood units

Question 6

_{Heart Transplantation - Preop}

Why is a “rapid” H&P of recipient required before Heart tpx?

Answer 6

Time constraints

Short viability period of time from procurement to trasplantation

Estimated at 4 to 5 hours

Question 7

_{Heart Transplantation - Preop}

True or False: Equipment and drugs for heart tpx are similar to those usually used for routine cases requiring CPB.

Answer 7

True

Question 8

_{Heart Transplantation - Preop}

Placement of which invasive lines and monitors is required for Heart Tpx?

Answer 8

PA catheter - Arterial line - TEE

CO - PVR - CVP

Question 9

_{Heart Transplantation - Preop}

Why are Aspiration Precautions necessary in heart Tpx

Answer 9

Short period of time before surgery

NPO status usually not acheived

All aspirations prophylaxis measures and drugs are indicated

Question 10

_{Heart Transplantation - Preop}

What should you communicate to the Blood Bank?

Answer 10

Prepare Blood products

Question 11

_{Heart Transplantation - Preop}

Why must strict aseptic techniques with broad spectrum antibiotics prophylaxis be followed in Heart Tpx procedures?

Answer 11

Concerns for standard infections

Addition of immunosuppressive drugs post op

Question 12

_{Heart Transplantation - Intraop}

What’s a major benefit of using a High dose narcotic with muscle relaxant and benzodiazepines for induction of Anesthesia in Heart Tpx?

Answer 12

Risk of CV collapse limited

Question 13

_{Heart Transplantation - Intraop}

Why is RSI recommended in Heart Tpx? Which drugs would you use?

Answer 13

Most patients called in for transplantation have not fasted and should be considered to have a full stomach

_{Drugs for RSI:}

Etomidate - Succinylcholine - Fentanyl (moderate dose)

Question 14

_{Heart Transplantation - Intraop}

Why should induction in heart Tpx be preformed in the presence of the surgeon, scrub nurse and perfusionist

Answer 14

in anticipation for cardiovascular collapse!!!

Question 15

_{Heart Transplantation - Intraop}

Why do drugs take longer to show effect is these patients?

Answer 15

Low CO

Slow circulation time

Decreased volume of distribution

Allow time for effect before considering a second dose

Question 16

_{Heart Transplantation - Intraop}

Preinduction administration of which drugs optimizes circulation and minimizes transit time of subsequently administered anesthetics?

Answer 16

Inotropic agents or pressors

_{Not a reason to premedicate with these drugs, but benefits are evident}

Question 17

_{Heart Transplantation - Intraop - Maintenance of Anesthesia}

Which cardiac alteration is associated with high dose narcotic?

Answer 17

Ventricular arrhythmias

Question 18

_{Heart Transplantation - Intraop - Maintenance of Anesthesia}

What’s possible cause of pre-CPB hypotension?

Answer 18

Volatile agents

Question 19

_{Heart Transplantation - Intraop - Maintenance of Anesthesia}

True of False: heart Tpx surgery requires OG and foley placement.

Answer 19

True

Question 20

_{Heart Transplantation - Intraop - Maintenance of Anesthesia}

If PA or CVP catheter placed, when must it be withdrawn from the right heart?

Answer 20

Prior to completion of bicaval cannulation

You don’t want it to interfere with surgery

Communicate with surgical team

Question 21

_{Heart Transplantation - Intraop - Maintenance of Anesthesia}

How about cardiac bypass?

Answer 21

Will be discussed extensively next semester

Question 22

_{Heart Transplantation - Intraop - Maintenance of Anesthesia}

What happens in the 1st stage of Heart Tpx surgery?

Answer 22

The donor heart’s left atrium is sewn onto the recipient’s left atrium

Question 23

_{Heart Transplantation - Intraop - Maintenance of Anesthesia}

What happens in the 2nd stage of Heart Tpx surgery?

Answer 23

The donor heart’s right atrium is sewn onto the superior and inferior vena cava

Question 24

_{Heart Transplantation - Intraop - Maintenance of Anesthesia}

What happens in the 3nd and last stage of Heart Tpx surgery?

Answer 24

The donor heart’s other major vessels are sewn onto the recipient’s major vessels

Question 25

_{Heart Transplantation - Intraop - Maintenance of Anesthesia} Why is cardiac bypass required during Heart Tpx?

Answer 25

There would be a significant amount of **blood loss** from major vessels if not bypassed

Question 26

_{Heart Transplantation - Postop} Low CO after transplant may be due to:

Answer 26

Hypovolemia Inadequate adrenergic stimulation Myocardial injury during harvesting or transport Acute rejection Tamponade Sepsis

Question 27

_{Heart Transplantation - Postop} Why shouldn't you treat post op systemic **Hypertension** with vasodilators at 1st?

Answer 27

Because it may be due to **pain** Adequate analgesia is provided before vasodilators

Question 28

_{Heart Transplantation - Postop} Atrial and ventricular tachyarrythmias are common in the immediate postop period. What must be ruled out prior to using antiarrythmics are used for conversion?

Answer 28

**Acute rejection**

Question 29

_{Heart Transplantation - Postop} Why would you consider bringing these pts out of the OR paced?

Answer 29

Many patients require pacing in the immediate postop period

Question 30

_{Heart Transplantation - Postop} What % of patients require permanent pacing following heart Tpx?

Answer 30

**10 - 25%** They will require temporary pacing initially They will be switched to permanent pacing if they remain highly dependent

Question 31

_{Heart Transplantation - Postop} Renal function often improves following transplantation, but which drugs may again impair renal function?

Answer 31

**Immunosuppressants**

Question 32

_{Heart Transplantation - Postop} Which type of infection is very common in the early postop period?

Answer 32

**Bacterial pneumonia**

Question 33

_{Heart Transplantation - Postop} Which type of infections is very common after the first several weeks? and why?

Answer 33

Opportunistic **viral** and **fungal** infections d/t **Immunosuppressants** _{Pts must be advised to consult providers immediately with signs and symptoms}

Question 34

_{Heart Transplantation - Pharmacological Agents After Transplant} Why would agents that act indirectly via the sympathetic or parasympathetic system (Atropine, Ephedrine) be ineffective after heart Tpx?

Answer 34

**The transplanted heart has no autonomic innervation** _Atropine_ will loose its vagolytic property and won't increase HR _Ephedrine_ won't increase HR because of its indirect effect

Question 35

_{Heart Transplantation - Pharmacological Agents After Transplant} Which drugs would you choose to increase HR in a transplanted heart? and why?

Answer 35

Isoproterenol Epinephrine *Because the have direct effect*

Question 36

_{Heart Transplantation - Pharmacological Agents After Transplant} Which modality would you use to increase HR if drugs are inneffective?

Answer 36

Pacing

Question 37

_{Effect of Denervation on Cardiac Pharmacology} How would a recipient react to certain drugs with a denervated heart following transplantation?

Answer 37

Effect of Denervation on Cardiac Pharmacology (See table)

Question 38

_{Effect of Denervation on Cardiac Pharmacology} How would a recipient react to **Digitalis** with a denervated heart following transplantation? *and why?*

Answer 38

_Normal increase_ in **contractility** _Minimal_ effect on **AV node** _d/t: *Direct myocardial effect - Denervation*

Question 39

_{Effect of Denervation on Cardiac Pharmacology} How would a recipient react to **Atropine** with a denervated heart following transplantation? *and why?*

Answer 39

**No reaction** Reason: *Denervation*

Question 40

_{Effect of Denervation on Cardiac Pharmacology} How would a recipient react to **Epinephrine** or **Adrenaline** with a denervated heart following transplantation? *and why?*

Answer 40

Increased **contractility** ^{Reason: Denervation hypersensitivity} Increased **chronotropy**

Question 41

_{Effect of Denervation on Cardiac Pharmacology} How would a recipient react to **Norepinephrine** or Noradrenaline with a denervated heart following transplantation? *and why?*

Answer 41

**Increased contractility** ^{Mechanism: Denervation} **Increased chronotropy** ^{Mechanism: No neuronal uptake}

Question 42

_{Effect of Denervation on Cardiac Pharmacology} How would a recipient react to **Isoproterenol** with a denervated heart following transplantation?

Answer 42

Normal increase in contractility Normal increase in chronotropy

Question 43

_{Effect of Denervation on Cardiac Pharmacology} How would a recipient react to **Quinidine** with a denervated heart following transplantation? *and why?*

Answer 43

**No vagolytic effect** ^{Mechanism: Denervation}

Question 44

_{Effect of Denervation on Cardiac Pharmacology} How would a recipient react to **Verapamil** with a denervated heart following transplantation? *and why?*

Answer 44

**AV block** ^{Mechanism: Direct effect}

Question 45

_{Effect of Denervation on Cardiac Pharmacology} How would a recipient react to **Nifedipine** with a denervated heart following transplantation? *and why?*

Answer 45

**No reflex tachycardia** ^{Mechanism: Denervation}

Question 46

_{Effect of Denervation on Cardiac Pharmacology} How would a recipient react to **Hydralazine** with a denervated heart following transplantation? *and why?*

Answer 46

**No reflex tachycardia** ^{Mechanism: Denervation}

Question 47

_{Effect of Denervation on Cardiac Pharmacology} How would a recipient react to **beta-blocker** with a denervated heart following transplantation? *and why?*

Answer 47

**Increased antagonist effect** ^{Mechanism: Denervation}