Mod13: Heart Transplant Flashcards
Heart Transplant - Indications for Transplant
What’s the most common indication for heart tpx?
Non-ischemic cardiomyopathy
Historically, ischemic cardiomyopathy was the most common indication for heart tpx
Heart Transplant - Indications for Transplant
What are UNOS indications for heart tpx?
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
Heart Transplant - Indications for Transplant
According to UNOS which Peak O2 uptake value is an indication for heart tpx?
<14 mL/kg/min
Heart Transplant - Indications for Transplant
According to UNOS which LV ejection fraction value is an indication for heart tpx?
< 20%
Heart Transplant - Indications for Transplant
According to UNOS which PVR value is an indication for heart tpx?
<2 Wood units
Heart Transplantation - Preop
Why is a “rapid” H&P of recipient required before Heart tpx?
Time constraints
Short viability period of time from procurement to trasplantation
Estimated at 4 to 5 hours
Heart Transplantation - Preop
True or False: Equipment and drugs for heart tpx are similar to those usually used for routine cases requiring CPB.
True
Heart Transplantation - Preop
Placement of which invasive lines and monitors is required for Heart Tpx?
PA catheter - Arterial line - TEE
CO - PVR - CVP
Heart Transplantation - Preop
Why are Aspiration Precautions necessary in heart Tpx
Short period of time before surgery
NPO status usually not acheived
All aspirations prophylaxis measures and drugs are indicated
Heart Transplantation - Preop
What should you communicate to the Blood Bank?
Prepare Blood products
Heart Transplantation - Preop
Why must strict aseptic techniques with broad spectrum antibiotics prophylaxis be followed in Heart Tpx procedures?
Concerns for standard infections
Addition of immunosuppressive drugs post op
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?
Risk of CV collapse limited
Heart Transplantation - Intraop
Why is RSI recommended in Heart Tpx? Which drugs would you use?
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)
Heart Transplantation - Intraop
Why should induction in heart Tpx be preformed in the presence of the surgeon, scrub nurse and perfusionist
in anticipation for cardiovascular collapse!!!
Heart Transplantation - Intraop
Why do drugs take longer to show effect is these patients?
Low CO
Slow circulation time
Decreased volume of distribution
Allow time for effect before considering a second dose
Heart Transplantation - Intraop
Preinduction administration of which drugs optimizes circulation and minimizes transit time of subsequently administered anesthetics?
Inotropic agents or pressors
Not a reason to premedicate with these drugs, but benefits are evident
Heart Transplantation - Intraop - Maintenance of Anesthesia
Which cardiac alteration is associated with high dose narcotic?
Ventricular arrhythmias
Heart Transplantation - Intraop - Maintenance of Anesthesia
What’s possible cause of pre-CPB hypotension?
Volatile agents
Heart Transplantation - Intraop - Maintenance of Anesthesia
True of False: heart Tpx surgery requires OG and foley placement.
True
Heart Transplantation - Intraop - Maintenance of Anesthesia
If PA or CVP catheter placed, when must it be withdrawn from the right heart?
Prior to completion of bicaval cannulation
You don’t want it to interfere with surgery
Communicate with surgical team
Heart Transplantation - Intraop - Maintenance of Anesthesia
How about cardiac bypass?
Will be discussed extensively next semester
Heart Transplantation - Intraop - Maintenance of Anesthesia
What happens in the 1st stage of Heart Tpx surgery?
The donor heart’s left atrium is sewn onto the recipient’s left atrium
Heart Transplantation - Intraop - Maintenance of Anesthesia
What happens in the 2nd stage of Heart Tpx surgery?
The donor heart’s right atrium is sewn onto the superior and inferior vena cava
Heart Transplantation - Intraop - Maintenance of Anesthesia
What happens in the 3nd and last stage of Heart Tpx surgery?
The donor heart’s other major vessels are sewn onto the recipient’s major vessels
Heart Transplantation - Intraop - Maintenance of Anesthesia
Why is cardiac bypass required during Heart Tpx?
There would be a significant amount of blood loss from major vessels if not bypassed
Heart Transplantation - Postop
Low CO after transplant may be due to:
Hypovolemia
Inadequate adrenergic stimulation
Myocardial injury during harvesting or transport
Acute rejection
Tamponade
Sepsis
Heart Transplantation - Postop
Why shouldn’t you treat post op systemic Hypertension with vasodilators at 1st?
Because it may be due to pain
Adequate analgesia is provided before vasodilators
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?
Acute rejection
Heart Transplantation - Postop
Why would you consider bringing these pts out of the OR paced?
Many patients require pacing in the immediate postop period
Heart Transplantation - Postop
What % of patients require permanent pacing following heart Tpx?
10 - 25%
They will require temporary pacing initially
They will be switched to permanent pacing if they remain highly dependent
Heart Transplantation - Postop
Renal function often improves following transplantation, but which drugs may again impair renal function?
Immunosuppressants
Heart Transplantation - Postop
Which type of infection is very common in the early postop period?
Bacterial pneumonia
Heart Transplantation - Postop
Which type of infections is very common after the first several weeks? and why?
Opportunistic viral and fungal infections
d/t
Immunosuppressants
Pts must be advised to consult providers immediately with signs and symptoms
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?
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
Heart Transplantation - Pharmacological Agents After Transplant
Which drugs would you choose to increase HR in a transplanted heart? and why?
Isoproterenol
Epinephrine
Because the have direct effect
Heart Transplantation - Pharmacological Agents After Transplant
Which modality would you use to increase HR if drugs are inneffective?
Pacing
Effect of Denervation on Cardiac Pharmacology
How would a recipient react to certain drugs with a denervated heart following transplantation?
Effect of Denervation on Cardiac Pharmacology
(See table)
Effect of Denervation on Cardiac Pharmacology
How would a recipient react to Digitalis with a denervated heart following transplantation? and why?
Normal increase in contractility
Minimal effect on AV node
d/t:
Direct myocardial effect - Denervation
Effect of Denervation on Cardiac Pharmacology
How would a recipient react to Atropine with a denervated heart following transplantation? and why?
No reaction
Reason: Denervation
Effect of Denervation on Cardiac Pharmacology
How would a recipient react to Epinephrine or Adrenaline with a denervated heart following transplantation? and why?
Increased contractility
Reason: <em>Denervation hypersensitivity</em>
Increased chronotropy
Effect of Denervation on Cardiac Pharmacology
How would a recipient react to Norepinephrine or Noradrenaline with a denervated heart following transplantation? and why?
Increased contractility
Mechanism: <em>Denervation</em>
Increased chronotropy
Mechanism: <em>No neuronal uptake</em>
Effect of Denervation on Cardiac Pharmacology
How would a recipient react to Isoproterenol with a denervated heart following transplantation?
Normal increase in contractility
Normal increase in chronotropy
Effect of Denervation on Cardiac Pharmacology
How would a recipient react to Quinidine with a denervated heart following transplantation? and why?
No vagolytic effect
Mechanism: <em>Denervation</em>
Effect of Denervation on Cardiac Pharmacology
How would a recipient react to Verapamil with a denervated heart following transplantation? and why?
AV block
Mechanism: <em>Direct effect</em>
Effect of Denervation on Cardiac Pharmacology
How would a recipient react to Nifedipine with a denervated heart following transplantation? and why?
No reflex tachycardia
Mechanism: <em>Denervation</em>
Effect of Denervation on Cardiac Pharmacology
How would a recipient react to Hydralazine with a denervated heart following transplantation? and why?
No reflex tachycardia
Mechanism: <em>Denervation</em>
Effect of Denervation on Cardiac Pharmacology
How would a recipient react to beta-blocker with a denervated heart following transplantation? and why?
Increased antagonist effect
Mechanism: <em>Denervation</em>
