Transplanted Heart 

 

 

Considerations  

 

  • Altered physiology of the denervated heart:

    • Preload dependent

    • High resting heart rate & loss of vagal tone

    • Delayed sympathetic response to circulating catecholamines

    • Dysrhythmias & conduction abnormalities → permanent pacemaker in 5%

  • Altered pharmacology of the transplanted heart:

    • Ineffective indirect-acting agents (e.g. ephedrine, atropine)

    • Intact response to direct-acting vasoactive drugs (e.g. epinephrine, isoproterenol)

  • Allograft function:

    • Rejection

    • Arrythmias

    • Coronary vasculopathy (accelerated CAD): silent ischemia secondary to denervation

  • Co-morbidities:

    • Hypertension (90%)

    • Diabetes 

    • Renal dysfunction

    • Malignancy

  • Steroid therapy: will require stress dose

  • Immunosuppressive therapy: 

    • ​↑ risk of infection & need for strict sterile technique

    • Adverse effects: anemia, thrombocytopenia, hepatotoxicity, nephrotoxicity

 

 

Goals 

 

  • Hemodynamic goals:

    • Preload: maintain normal or high (CO increases by increasing stroke volume)

    • Rhythm: avoid pro-arrhythmic states

    • Afterload: maintain perfusion to potentially ischemic myocardium

  • Use direct-acting sympathomimetics (isoproterenol & epinephrine must be available)

  • Avoid infection: strict sterile technique & minimize catheters/invasive devices

  • Thorough review of functional capacity, investigations (echo, biopsies for graft dysfunction)

  • Strongly consider consultation with transplant clinic & cardiology pre-operatively

  • If valvulopathy: needs infective endocarditis prophylaxis 

 

 

Pregnancy Considerations 

 

  • Same goals as above apply 

  • Epidural is very good technique 

  • Ensure adequate intravascular volume 

  • Extra attention to aseptic techniques 

 

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