**11. Graft dysfunction**

An international consensus conference in 2014 has classified the graft dysfunction into primary graft dysfunction (PDG) and secondary graft dysfunction (SGD). The first one occurs 24 h from heart transplant and can involve the left, the right ventricle, or both, with different degrees of dysfunction. Typical signs are severe deficit of systolic function, low cardiac output, and high filling pressures without evidence of acute graft rejection or cardiac tamponade. The SGD has a specific reason such as acute rejection, pulmonary hypertension, or surgical complications. Risk factors to develop PGD may be related to the recipient, donor, or technical factors [22].

Donor-related risk factors may be:


Recipient-related risk factors may be:


Technical risk factors are:

**9. Infection control**

146 Heart Transplantation

**10. Immunosuppressive therapy**

mycophenolate.

cal factors [22].

**11. Graft dysfunction**

Donor-related risk factors may be:

• Age (increased risk of 20% every decade)

• Sex (nearly doubled risk with female)

Standard prophylaxis is due to cefuroxime 2 g iv every 6 hours in the first 24 hours from heart transplantation (the first two boluses are given in the operating room, at the induction of general anesthesia and once CPB is started). The amount of antibiotic given in the ICU should be tailored for the patient's creatinine clearance, especially if the patient is not under renal filter. Further extension and change of antibiotic therapy should depend on microbiological results of the donor and on microbiological samples of the recipient once admitted in the ICU. Furthermore, in case of redo-operation with existing wound infection, the patient will receive vancomycin and meropenem as standard medication and vancomycin plasma levels should be tested daily. Obviously, due to the immunosuppressive therapy, transplanted patients are very prone to infections. Delivery of care should be done in sterile conditions and, besides standard iv antibiotic therapy, topical antifungal medications should be given in the early postoperative period.

A specific team is taking care of immunosuppressive therapy. It starts with 500 mg iv bolus of solumedrol at the CPB weaning. Once admitted in the ICU, the patient will receive 125 mg

Antithymocyte globulines (1.5 mg/kg iv) are usually given 4, 24, and 48 hours after the end of the transplantation. They will be adjusted based on eventual presence of high body temperature, bleeding, and thrombocytopenia. There are several possible immunosuppressive agents that will be tailored for the patient such as tacrolimus, cyclosporin A, everolimus, and

An international consensus conference in 2014 has classified the graft dysfunction into primary graft dysfunction (PDG) and secondary graft dysfunction (SGD). The first one occurs 24 h from heart transplant and can involve the left, the right ventricle, or both, with different degrees of dysfunction. Typical signs are severe deficit of systolic function, low cardiac output, and high filling pressures without evidence of acute graft rejection or cardiac tamponade. The SGD has a specific reason such as acute rejection, pulmonary hypertension, or surgical complications. Risk factors to develop PGD may be related to the recipient, donor, or techni-

bolus of solumedrol every 8 hours, with a specific descending dose scheme.


All these factors can increase the ischemic-reperfusion injury and the overall mortality [23].

The first step to treat a PDG is vasoactive and inotropic support. If it were not sufficient, an intra-aortic balloon pump (IABP) placement may help.

In case of very severe PGD, an extracorporeal membrane oxygenation (ECMO) becomes the only emergency treatment.

#### **11.1. Anesthesia and intensive care management**

#### *11.1.1. For cardiac transplantation in pediatrics*

Pediatric heart transplant represents a small subgroup (14%) of total cardiac transplant where the differences in anatomy and physiology make the surgical procedure and the management more complex and creates a unique scenario [24].

The management of pediatric patients undergoing cardiac transplantation differs from the adult patients because it requires a specific knowledge of physiology and physiopathology at different stages of growth, from the newborns through childhood up to adulthood.

This heterogeneous population with a wide range of age, genetic disorders, anatomical anomalies, and symptoms can be classified in four different groups based on the different etiology: 1—CHD (congenital heart disease); 2—DCM (dilated cardiomyopathy); 3—RETX (retransplant); 4—OTHER (**Table 7**) [25]; each of these has specific features.

#### *11.1.2. Preoperative evaluation*

The preoperative evaluation is an essential step in order to better analyze both the cardiac pathology and the possible related comorbidities.


Fontan-associated liver disease (FALD) is a liver dysfunction due to a chronic elevated central venous pressure, low cardiac output, persistent hypoxemia, and intrahepatic venous thrombosis. FALD can be expressed in different stages, from moderate hepatic congestion up to liver cirrhosis with portal hypertension. In several cases, liver function is preserved or is only slightly altered, with high international normalizer ratio (INR), low factor V levels, and

Anesthesia and Intensive Care Management for Cardiac Transplantation

http://dx.doi.org/10.5772/intechopen.79837

149

• Coagulation anomalies may be present as result of chronic anticoagulation, liver disease, or as a result of cyanotic congenital heart disease (reduced levels of coagulation factors II,

• Gastrointestinal disorders: necrotizing enterocolitis in newborns or protein losing enteropathy (PLE), which is an excessive protein loss through the gastrointestinal tract that can

The anesthetic management should consider that these patients have a poor cardiac reserve and that the premedication, general anesthesia, and the surgical manipulation after the ster-

Antibiotic therapy differs according to age and weight and background of both the donor and

Immunosuppression is started 1 hour before going to the operating room: thymoglobulin

Premedication is performed, according to clinical condition, with low doses of benzodiazepines (midazolam 0.3–0.5 mg/kg orally or rectal in neonate) avoiding excessive sedation and

It is well known that in newborns and infants, placing an invasive monitoring before induction of anesthesia is not always possible; therefore, it is essential to have a noninvasive moni-

General anesthesia is induced by inhalation of sevoflurane/desflurane in newborns and infants and by intravenous injections of midazolam 0.3–0.5 mg/kg, fentanyl 2–4 mcg/kg, rocuronium 1 mg/kg, and propofol 2–4 mg/kg in adults and children. Moreover, for continuous infusion of the anesthesia, propofol 4–6 mg/kg/h in adults, while midazolam 0.2 mg/kg/h and fentanyl 2 mcg/kg/h in newborns and children are recommended. After induction, hydrocortisone

In all patients, regional cerebral monitoring is achieved with the use of near infrared spectros-

be present after Fontan operation (even if its origins are poorly understood) [29]

elevated factor VIII levels [28].

**12. Intraoperative management**

recipient (**Tables 8** and **9**).

consequently hypercapnia.

10–20 mg/kg is infused.

copy (NIRS).

toring before starting the drug administration.

• Kidney disease: acute or acute-on-chronic renal dysfunction.

notomy can lead to a destabilization of the hemodynamics.

1 mg/kg/12 h and methylprednisolone 7–10 mg/kg (max. 125 mg).

V, VII, IX, and X, accelerated fibrinolysis, and fibrinogen alterations).

**Table 7.** Diagnosis for pediatric heart transplant.

Main preoperative features and examinations that must be considered are:


Fontan-associated liver disease (FALD) is a liver dysfunction due to a chronic elevated central venous pressure, low cardiac output, persistent hypoxemia, and intrahepatic venous thrombosis. FALD can be expressed in different stages, from moderate hepatic congestion up to liver cirrhosis with portal hypertension. In several cases, liver function is preserved or is only slightly altered, with high international normalizer ratio (INR), low factor V levels, and elevated factor VIII levels [28].

