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Cardiac Surgery and Transplantation 311

The average costs associated with heart transplantation can be configured to support biventricular function
are high, at approximately $A35,000 for the first year and (BiVAD configuration). The LVAD configuration for
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$A15,000 for each ongoing year. However, the high heterotopic heart transplantation is illustrated in
incidence of chronic heart failure and associated hospi- Figure 12.15.
talisation costs are also considerable. During 2000, it was
estimated that over half a million Australians had chronic
heart failure (CHF), with 325,000 patients per annum CLINICAL PRACTICE
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experiencing symptoms. Hospital admissions for heart Postoperative nursing and collaborative management of
failure were estimated at 100,000, totalling more than 1.4 orthotopic heart transplant recipients involves full hae-
million days, figures that represent prevalence rates of modynamic monitoring with a pulmonary artery catheter
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526 hospitalisations and 7400 days per 100,000/annum. (PAC), a triple- or quad-lumen central venous catheter
The cost of a single hospital admission for CHF in Aus- (CVC), arterial line, indwelling urinary catheter, and
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tralia is currently approximately $A6000. In 2006, 5-lead cardiac monitoring to assist in dysrhythmia dis-
approximately 263,000 Australians experienced chronic crimination. A 12-lead ECG is also recorded. If the ortho-
heart failure, with 2350 dying from end-stage heart topic transplant is performed with the standard technique,
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disease. In New Zealand, hospital admissions for heart a remnant P wave from the native heart may be visible
failure consume approximately 1% of the healthcare on the ECG or cardiac monitor (see Figure 12.16). As
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budget. In the context of a 50% mortality rate within 4 the native sinus node cannot conduct across the right
years of being diagnosed with chronic heart failure, a atrial suture line, the recipient’s heart rate is determined
50% mortality rate within 1 year for patients with severe by the conduction system of the donor heart, not the
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heart failure, and the burden of care associated with native heart. Of interest, it is possible for the native heart
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heart failure exceeding that of all types of cancer, trans- to generate a P wave while the donor heart is in atrial
plantation for end-stage heart failure is actually a viable fibrillation or other dysrhythmia. (More detailed discus-
and economical treatment option for individuals and sion of cardiac monitoring and haemodynamic manage-
society; it is, however, a limited resource, available to only ment of patients with a heterotopic heart transplant
a few recipients. is available. 78,86 ) Monitoring data are combined with
physical assessment information from all body systems
to determine nursing and collaborative interventions.
FORMS OF HEART TRANSPLANT SURGERY Intensive continuous monitoring and assessment of
The most common heart transplant surgery is orthotopic haemodynamic parameters according to evidence based
transplantation, with two surgical techniques used: the practices 87-89 and overall clinical status allows nurses to
standard or bicaval approaches. The standard technique detect and subsequently respond to emergent postopera-
has been used since the 1960s and involves anasto moses tive complications.
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of the donor and native atria. Complications associ- Full ventilatory support is required until the patient’s
ated with the standard technique can include abnormal haemodynamic status is stable. Respiratory status is mon-
atrial contribution to ventricular filling, and tricuspid itored via clinical, radiological and laboratory-derived
and mitral valve insufficiency. 80,81 Since the mid-1990s, data (see Chapter 13). Enteral feeding is usually com-
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the bicaval technique as described by Dreyfus et al. menced on the day of admission. Renal and neurological
has gained favour. The main advantage of the bicaval function are closely monitored, as cyclosporin has a del-
approach is the maintenance of atrial conducting path- eterious effect on renal function and can lead to failure
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ways and the likelihood of promoting sinus rhythm as well as neurotoxicity. For the small number of patients
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and its associated superior atrial haemodynamics (see who develop allograft dysfunction requiring mechanical
Figure 12.13). Reported potential disadvantages include circulatory support (i.e. IABP, ECMO or Thoratec LVAD),
stenoses in the inferior and superior vena cava at the or acute renal failure requiring haemofiltration, hospitali-
anastomosis sites. 82
sation in the critical care unit tends to last weeks rather
The second form of heart transplant surgery is hetero- than days.
topic transplantation, although these account for less
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than 0.5% of heart transplants in Australasia. In this The immediate period after transplantation can be a time
procedure, the donor heart is implanted in the right side of great hope and joy for recipients and their family and
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of the chest next to the native heart to augment native friends; however, complications and setbacks can make
systolic function. Figure 12.14 illustrates a chest X-ray of the path to recovery prolonged, unpredictable and diffi-
the donor heart next to the native heart. cult. The provision of psychosocial support by all
members of the transplant/critical care team to family
Heterotopic heart transplantation is primarily indicated members and friends is an important part of patients’
in patients with pulmonary hypertension refractory to recovery from organ transplantation. Meetings with
pulmonary vasodilator therapies. It may also be con- family that convey honest and open information about
sidered in patients with a large body surface area that patient progress need to be conducted regularly. Support-
are unlikely to receive a suitably large-sized donor heart ing and managing patient and families following trans-
to enable an orthotopic procedure to take place, 79,85 or plant is consistent with support provided to other critically
when the donated organ is unsuitable as an orthotopic ill patients (see Chapter 8). In addition, there is the issue
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graft. Heterotopic transplantation is usually performed of dealing with lost hope if the transplant fails; a very
to support the left ventricle (LVAD configuration), but distressing time for all involved. In the immediate