Year : 2023 | Volume
: 17 | Issue : 1 | Page : 104--106
Anesthetic considerations for non-cardiac surgeries in orthotopic heart transplant recipients
Vinod Deep, Pujari S Vinayak, Karante Ramachandra
Department of Anaesthesiology, Manipal Hospitals, Bangalore, Karnataka, India
Pujari S Vinayak
Consultant, Department of Anaesthesiology, Manipal Hospitals, Bangalore, Karnataka
The number of heart transplants performed each year is steadily increasing around the world. Anesthesia and perioperative management are different in these cases. For an optimal perioperative management and improved postoperative outcome, a full understanding of the physiology of the denervated heart, post-transplant morbidities, and immunosuppressant pharmacology is required. We hereby discuss the perioperative management of a patient who had undergone orthotopic heart transplant and presented to our setup for left ureteroscopy.
|How to cite this article:|
Deep V, Vinayak PS, Ramachandra K. Anesthetic considerations for non-cardiac surgeries in orthotopic heart transplant recipients.Saudi J Anaesth 2023;17:104-106
|How to cite this URL:|
Deep V, Vinayak PS, Ramachandra K. Anesthetic considerations for non-cardiac surgeries in orthotopic heart transplant recipients. Saudi J Anaesth [serial online] 2023 [cited 2023 Mar 24 ];17:104-106
Available from: https://www.saudija.org/text.asp?2023/17/1/104/364857
According to the annual report of the Indian Heart and Lung Transplant Registry, India as of now has completed 1,113 heart transplants. The anesthesiologist must be aware of the unique anesthetic implications of a transplanted heart.
A 25-year-old male presented to us with complaints of left flank pain and oliguria since two days. Computed tomography (CT) of the abdomen showed an 8-mm stone in the left lower ureter with left hydroureteronephrosis, and he was subsequently scheduled for left ureteroscopy. On pre-anesthetic evaluation, the patient gave history of being diagnosed with congenital heart disease (transposition of great arteries, sub pulmonic VSD with pulmonary stenosis and tricuspid valve aneurysm) at birth. When he was three years old, he underwent atrial septectomy, excision of accessory mitral tissue, and pulmonary artery (PA) banding. At 14 years, he underwent PA de-banding with modified Senning procedure and bidirectional Glenn procedure. An orthotopic heart transplant (OHT) was done when he was 22 years old. The patient was on tab. tacrolimus, tab. prednisolone, and tab. mycophenolate mofetil for immunosuppression.
The patient was diabetic since two years and was on tab. metformin 1 gm BD. The patient had moderate effort tolerance since the heart transplant. His vitals were stable with an increased baseline heart rate of 116 bpm and blood pressure of 102/68 mmHg. Electrocardiography (ECG) showed normal sinus rhythm and 2D echocardiography (echo) showed an ejection fraction of 50% with good left ventricular diastolic function. All blood investigations were within normal limits. An informed consent was obtained and probable need of postoperative intensive care stay in view of OHT was explained.
On arrival at the operation theatre, standard monitoring was applied to the patient. Intravenous balanced salt solution was initiated via a 22-G cannula secured in the left forearm. Antibiotic prophylaxis with inj. cefaperazone sulbactum 1.5 gm and Amikacin 500 mg IV was administered. After preoxygenation for 3 minutes, graded intravenous induction was done using inj. etomidate 20 mg IV, inj. xylocard 20 mg, and inj. fentanyl 100 mcg. Size 4 i-Gel was inserted and ventilation confirmed by auscultation and EtCO2 trace. Anesthesia was maintained with air oxygen mixture and IV propofol infusion at 250 mg/hr. The patient was hemodynamically stable and saturation was maintained throughout the procedure. The surgery lasted for 50 minutes following which the i-Gel was removed once the patient was completely awake and obeying commands. The patient was monitored in the post-anesthesia care unit for an hour and shifted to the ward. He was discharged the next day.
A patient with OHT has unique challenges, and a brief review of the implications of OHT is essential for safe anesthetic management. The transplanted heart has no sympathetic, parasympathetic, or sensory innervation, and the loss of vagal influence results in a higher-than-normal resting heartrate. The denervated heart lacks the ability to respond acutely to hypovolemia or hypotension with reflex tachycardia, unlike the normal heart, which increases cardiac output via sympathetic stimulation causing increased heartrate and contractility. These patients are “preload dependent” as an increase in cardiac output is dependent on venous return, which increases left ventricular end-diastolic volume, which in turn mediates an increase in stroke volume and ejection fraction by the Frank–Starling mechanism. General anesthesia is preferred and central neuraxial blockade is avoided to prevent acute vasodilatation and uncontrolled hypotension.
There were two P-waves on the ECG as the native pacemaker remains intact because cuff of atria is used for surgical anastomosis to the grafted heart. The native P-wave cannot traverse the suture line and thus has no influence on the chronotropic activity of the transplanted heart. Carotid sinus massage and the Valsalva maneuver have no effect on the heart rate. There is a loss of cardiac baroreflexes and loss of sympathetic response to laryngoscopy, tracheal intubation, and inadequate anesthetic depth or analgesia due to denervation. Denervation also alters the pharmacological response to certain drugs. The cardiac vagolytic effect of drugs such as atropine and glycopyrrolate are lost; therefore, isoprenaline and adrenaline should be readily available to manage bradycardia and hypotensive emergencies. Digoxin is ineffective as an anti-arrhythmic while there is marked sensitivity to adenosine (denervation supersensitivity). Bradycardia followed by asystole after administration of neostigmine/glycopyrrolate have been reported in heart transplant recipients. The underlying mechanisms are not exactly known; it may be due extreme sensitivity to acetylcholinesterase inhibitors as a result of denervation and/or abnormal reinnervation and also may be due to direct action on the muscarinic receptors. Neuromuscular blocking agents should be avoided when muscle relaxation is non-essential for surgery, thus avoiding the need for reversal.
We avoided neuromuscular blockade and an i-Gel was used for airway management. Advantages of i-Gel includes high success rate at first attempt, easy insertion and shorter time to achieve effective airway. The soft, non-inflatable cuff made from a thermoplastic elastomer fits snugly onto the perilaryngeal space.
Post-transplant patients are started on immunosuppressive therapy to prevent organ rejection. The most common drug regimen includes tacrolimus, mycophenolate, and prednisone. Tacrolimus and prednisone can cause hypertension, diabetes, neurotoxicity, and renal insufficiency. Mycophenolate mofetil may result in anemia, leukopenia, and thrombocytopenia. We ensured that immunosuppressants were continued throughout his admission to reduce the risk of organ rejection. Transplant patients are considered at risk of infection because of immunosuppression. Antimicrobial coverage need not be expanded to include atypical or opportunistic organisms as long as active infection with such an organism is not present or suspected. Prophylaxis with broad spectrum antibiotic should be administered one hour before surgical incision (depending on hospital protocol).
Post-OHT patients presenting for non-cardiac procedures present unique challenges to an anesthesiologist. It is imperative to have a thorough understanding of the implications when taking care of these patients. i-Gel can safely be used in OHT patients for short procedures with advantages of avoiding muscle relaxants and adequate ventilation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
|1||Annual report of the Indian Heart and Lung Transplant Registry. J Pract Cardiovasc Sci 2021;7:175-7.|
|2||Choudhury M. Post-cardiac transplant recipient: Implications for anaesthesia. Indian J Anaesth 2017;61:768-74.|
|3||Swami AC, Kumar A, Rupal S, Lata S. Anaesthesia for non-cardiac surgery in a cardiac transplant recipient. Indian J Anaesth 2011;55:405.|
|4||Kostopanagiotou G, Smyrniotis V, Arkadopoulos N, Theodoraki K, Papadimitriou L, Papadimitriou J. Anesthetic and perioperative management of adult transplant recipients in nontransplant surgery. Anesthesia Analgesia 1999;89:613-22.|
|5||Morgan-Hughes NJ, Hood G. Anaesthesia for a patient with a cardiac transplant. BJA CEPD Reviews 2002;2:74-8.|
|6||Cachemaille M, Olofsson M, Livio F, Pascale P, Zingg T, Boegli Y. Recurrent asystole after neostigmine in a heart transplant recipient with end-stage renal disease. J Cardiothoracic Vasc Anesth 2017;31:653-6.|
|7||Kannaujia A, Srivastava U, Saraswat N, Mishra A, Kumar A, Saxena S. A preliminary study of I-gel: A new supraglottic airway device. Indian J Anaesth 2009;53:52.|
|8||Ejtehadi F, Carter S, Evans L, Zia M, Bradpiece H. General anaesthesia and emergency surgery in heart transplant recipient. Case Rep Surg 2015;2015. doi: 10.1155/2015/256465.|
|9||Brusich, K. T. , Acan, I. Anesthetic Considerations in Transplant Recipients for Nontransplant Surgery. In: Tsoulfas, G. , editor. Organ Donation and Transplantation - Current Status and Future Challenges [Internet]. London: IntechOpen; 2018 [Last accessed on 2022 Aug 22].|
|10||Navas-Blanco JR, Modak RK. Perioperative care of heart transplant recipients undergoing non-cardiac surgery. Ann Cardiac Anaesth 2021;24:140-8.|