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308 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

FIGURE 12.10 IABP during 1 : 2 assist. Late deflation. The late deflation is seen here as the sharp drop-off before systole and a balloon assisted end diastole
that does not fall to below the normal patient end-diastolic pressure.

Patients with certain chronic heart, respiratory and lung
diseases may be referred for organ transplantation assess-
,ĞůŝƵŵ ĚƌŝǀĞ ůŝŶĞ ment when their disease state is such that their life expec-
ĨƵůů ŽĨ ďůŽŽĚ tancy is less than 2 years and quality of life intolerable.
Patients who receive organ transplants are commonly
debilitated and may have an acute on chronic presenta-
tion at the time of surgery. The surgical procedure is
lengthy, up to 12 hours, and involves cardiopulmonary
bypass. The duration and nature of the surgery in patients
ZƵƉƚƵƌĞĚ with severely compromised health status serves to com-
ďĂůůŽŽŶ pound the often critical condition of such patients in the
early postoperative period.
FIGURE 12.11 Intra-aortic balloon rupture and presence of blood in
helium drive line. The immediate period following surgery is commonly the
first contact that critical care clinicians have with trans-
plant recipients and their families. The exception may be
patients awaiting heart transplantation who are sup-
ported by an intra-aortic balloon pump or mechanical
circulation. Small gas losses of helium may or may not circulatory support (MCS) also known as a ventricular
be of clinical significance, but the delivery of sizeable assist device (VAD) as a ‘bridge to transplantation’ (see
helium volumes may behave as gas emboli, and if deliv- Figure 12.12). Ideally, patients with MCS are returned to
ered into the coronary circulation may result in lethal a sound physical, mental and nutritional state prior to
arrhythmias or result in neurological complications if receiving a transplant, and, as part of their recovery, await
delivered into the cerebral circulation. In all gas loss transplantation in the ward or home setting. For specific
alarm states, the helium drive line should be inspected management of patients on MCS, readers are referred to
for the presence of blood to indicate loss of integrity of specific resources (e.g. websites and operating manuals
the balloon. If blood is present in the drive line (Figure for individual MCS: HeartMate, Throratec, VentrAssist
12.11), pumping should be suspended and no attempts and DuraHeart).
at recommencing balloon pumping should be made.
Prompt removal and/or replacement, along with thor- Heart transplantation is a life-saving and cost-effective
ough patient assessment, is essential. form of treatment that enhances the quality of life for
many people with chronic heart failure. Legislation that
defined brain death and enabled beating-heart retrieval
HEART TRANSPLANTATION was enacted in Australia from 1982. This legislation her-
alded the establishment of formal transplant programs.
The ultimate goal of organ transplantation is to provide
an improved quality of life and long-term survival for In Australia, the first heart program commenced in
53,54
patients with end-stage heart disease. To optimise patient 1983. The success of transplantation in the current era
outcomes, the early postoperative management of these as a viable option for end-stage organ failure is primarily
patients requires critical care clinicians with specific due to the discovery of the immunosuppression agent
55
expertise to collaborate with a multidisciplinary team cyclosporin A. In this section, heart transplantation as
of health professionals. In the following sections, the a component of critical care nursing is discussed, with
important management issues in the early postoperative reference to evidence-based practices.
period for heart transplant recipients are discussed. The
major long-term complications of heart transplantation HISTORY
are also discussed briefly as survivors may be readmitted Heart transplant surgery for refractory heart failure was
to critical care with life-threatening complications years first performed in Australia in 1968, only months after
after their transplant. the first heart transplant was performed in South Africa