Page 1583 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1102 PART 10: The Surgical Patient

complications such as pneumonia. Identifying and correcting factors
that may be contributing to venous admixture is important. Misc.
While pleural effusions are the most common postoperative pul- 0%
monary complication, mortality rate is highest among those who Valvular
develop hospital-associated pneumonias compared to other pulmonary CAD 4%
complications. A meta-analysis of the use of selective digestive decon- 44%
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tamination in the liver transplant population to minimize the risk of
bacterial infections showed the available literature supports a beneficial ReTX
effect of SDD on reducing gram-negative pneumonias. However, larger 2%
randomized trials looking at its impact on infection, mortality, and anti- Congenital Myopathy
microbial resistance are needed. 113 2% 48%
More information on the infectious disease complications can be
found in the section “Infectious Complications” below.
Neurologic Complications: Mental status changes, delirium, seizures, and
coma are not uncommon following liver transplant. Neurologic compli- 1/1982-6/2011
cations have been described in 8% to 40% of patients who undergo liver FIGURE 115-5. Indications for heart transplantation (Stehlik et al ).
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transplant. Hepatic encephalopathy that is present pretransplant can
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persist posttransplant particularly in the setting of delayed graft func-
tion. Seizures can complicate the early postoperative course and may be
due to calcineurin inhibitors, posterior reversible encephalopathy, meta- between the recipient atria and great vessels and the atria and great
bolic disturbances, ischemic events, hemorrhagic central nervous events vessels of the donor heart (the biatrial technique). There has been renewed
in the setting of coagulopathy, or central nervous system infection. interest in bicaval and pulmonary vein to pulmonary vein anastomoses,
Intensive care–associated delirium is not uncommon in the setting of and the bicaval technique has now been recommended by many
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a prolonged intensive care stay, which could be exacerbated by steroids experts. As a general rule, ischemic times should be less than 4 hours
and immunosuppressive medications. as more prolonged times are associated with a higher incidence of reper-
fusion injury.
HEART TRANSPLANTATION ■ POSTOPERATIVE MANAGEMENT
■ INTRODUCTION Hemodynamic Monitoring and Support: Standard monitoring following

Heart transplantation has become the treatment of choice for many heart transplant includes standard ECG, arterial line, and pulmonary
arterial catheter to assist in guiding hemodynamic support therapies.
patients with end-stage heart disease. The initial enthusiasm following An intraoperative transesophageal echocardiogram is performed at
the first transplant in Cape Town in 1967 was blunted by the high rate the end of the case and if tricuspid regurgitation (TR) is seen intra-
of postoperative complications. However, over the past 30 years, with operatively a follow-up echocardiogram is necessary within 24 hours.
advancements in the operative technique, immunosuppression, unique If TR persists, an annuloplasty of donor tricuspid valve can be
bridging strategies, and a more meticulous selection of donors and considered depending on the severity. Pericardial effusions are not
recipients, outcomes have improved substantially. Despite these signifi- uncommon after surgery and can be followed with serial echocardio-
cant advancements, survival remains limited by allograft dysfunction in grams. Drainage of the effusion is necessary if evidence of hemodynamic
the form of cardiac allograft vasculopathy as well as the adverse impact compromise or if there is suspicion of an infectious etiology.
of immunosuppressive medications. Intravenous fluids are used sparingly and aggressive diuresis is con-
■ INDICATIONS AND OUTCOMES tinued postoperatively. However, the denervated heart will not be able

Heart transplant is the optimal treatment for patients with end-stage heart to respond acutely to hypovolemia with reflex tachycardia, and adequate
preload must be present to maintain stroke volume and preserve blood
disease who remain symptomatic despite maximal medical therapy or ven- pressure. A decreased cardiac output from left ventricular dysfunction
tricular assist devices. According to the International Society for Heart and can be treated with inotropes (dobutamine or milrinone). In more
Lung Transplantation, (2002-2012) primary indications included dilated severe cases, transient support with intra-aortic balloon counterpulsa-
cardiomyopathy, coronary artery disease, valvular heart disease, and con- tion may be required. If this fails, mechanical circulatory support may
genital heart disease. Other less common indications include intractable need to be pursued and a diagnosis of primary heart graft failure should
arrhythmias, intractable angina not amenable to bypass or percutaneous be considered (see below). In most cases, inotropic support is weaned
interventions, and hypertrophic cardiomyopathy with persistent symptoms as tolerated over first 3 to 5 days. α-Adrenergic agonists can be added
despite maximal treatment and interventions. Figure 115-5 demonstrates to maintain adequate mean arterial pressures if the systemic vascular
the primary indications for heart transplant over the past decade. resistance is low secondary to a systemic inflammatory response from
The projected median survival has improved to 11 years, with the cardiopulmonary bypass or if there is presence of vasoplegia. Methylene
greatest impact in survival coming from improvements in immunosup- blue is sometimes used at certain institutions for refractory shock felt to
pressive treatment in the first 6 to 12 months. Factors associated with be secondary to vasoplegia. A central venous pressure of 5 to 12 (or a
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worse prognosis at 1 year included the need for short-term ECLS prior level that will provide adequate cardiac filling without leading to right
to transplant, congenital heart disease, insulin-dependent diabetes, or ventricular overload) is targeted postoperatively. These goals should be
the requirement of dialysis or mechanical ventilation prior to transplant. individualized, and the management should be guided by the clinical
Donor age and ischemia are also found to have an impact on 1-year picture and not purely based on hemodynamic measurements.
mortality. The most common causes of death after heart transplanta- If the cardiac output acutely deteriorates, urgent echocardiography
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tion include acute allograft rejection, infections, allograft vasculopathy, should be obtained to exclude the possibility of tamponade and to evaluate
and lymphoma and other malignancies. left and right ventricular function. Left ventricular function of the allograft
■ TRANSPLANT PROCEDURE may be reduced and a restrictive physiology observed if there has been pro-
longed ischemic time and poor myocardial preservation. Other causes of
Although other variations have been described, the standard approach for ventricular dysfunction should be sought such as acidemia, hypovolemia,
heart transplantation involves the creation of four separate anastomoses hypoxemia, and medications with negative inotropic properties.

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