**6. Intensive care management**

Almost 90% of heart transplants are due to ischemic or dilatative cardiomyopathy and men over 40 years of age are the most involved. They all need a special care and a multimodal approach, even because not only cardiovascular balance but also respiratory care, fluid management, and immune system modulation impact on the overall survival.

#### **6.1. ICU admission**

IAS (interatrial septum) or "fluttering" of IVS (interventricular septum) during end-diastole, TAPSE(tricuspid annular plane systolic excursion), and MPI (myocardial performance index).

Inotropic score Dopamine (μg/kg/min) + dobutamine (μg/kg/min) + 100 × epinephrine

IS + 10 × milrinone (μg/kg/min) + 10 × vasopressin (U/kg/

min) + 100 × norepinephrine (μg/kg/min

VIS + 10 × levosimendan (mcg/kg/min)

(μg/kg/min)

Basic ventilation strategies to reduce pulmonary artery resistances such as hyperoxia and

Chest closure can be very critical for hemodynamics. In some rare cases (i.e., 2.5%), primary graft failure can occur [13], and it is responsible for more than 30% of early deaths after cardiac transplantation. Clinical onset of primary graft failure is with hypotension, low cardiac output, high preload pressures (PVC, LAP, and wedge pressure), and biventricular failure. When necessary, a temporary IABP (intra-aortic balloon pump), as first step, and then peripheral (femoral vein-femoral artery) or central (left atrium, right atrium, aorta) VA-ECMO (venousarteriosus extracorporeal membrane oxygenation) should be taken into account, whenever

, 6–8 ml/

O), after recruitment maneuver,

moderate hyperventilation are mandatory. Ventilation should be set at 60–100% FiO<sup>2</sup>

Poor clinical outcome VIS 20–24 (in the first 24 h) + VIS 15–19 (in the subsequent 24 h)

hemodynamics remain unsatisfactory despite high inotropic support (**Table 5**) [14].

adequate plasma oncotic power is ensured by giving the right amount of albumin.

Fluid management should be "goal directed," that is, guided by the above-mentioned hemodynamic and echocardiographic parameters, and with the aim to avoid a fluid overload, which is very harmful for the lungs and the right ventricle, while providing adequate intravascular space filling. This should be done via balanced colloids and crystalloids in order to avoid electrolyte disorders and hyperchloremic hyperkalemic metabolic acidosis. Adequate oxygen delivery is ensured by maintaining the hemoglobin level around 10–11 g/dL and an

To go on CPB, we need to provide an appropriate anticoagulation via unfractionated heparin (300–400 U/kg). A value of ACT at least of 480 s is enough to start the extracorporeal

kg TV (tidal volume), and low-moderate PEEP (5–6 cmH<sup>2</sup>

with the intention to prevent lung atelectasis [12].

Vasoactive inotropic score (modified by Davidson et al. with inclusion of vasoactive

Vasoactive inotropic score plus

**Table 5.** Inotropic score.

medication

140 Heart Transplantation

levosimendan

**4. Fluid management**

**5. Anticoagulation and hemostasis**

Patients incoming from the operating room have to be placed in an isolated single bed room to avoid contamination, since they will undergo immunosuppressive therapy. Everyone in contact with them must wear mask, cup, and sterile gown and do routine sterile hand washing. Invasive hemodynamic monitoring, including systemic arterial pressure, right atrial pressure, pulmonary artery pressure through the PAC, and left atrial pressure, should be immediately reconnected in the room.

Twelve lead ECG at the arrival is mandatory to check heart rhythm disorders. Bradyarrhythmias and supraventricular arrhythmias are the most frequent and should be related to inotropic and chronotropic support, hypovolemia, and electrolyte disorders. If atrial fibrillation occurs, an acute rejection should be considered and a 500 mg bolus of methylprednisolone should be administered, eventually followed by amiodarone (300 mg iv bolus in 30 min) for pharmacological cardioversion and rate control. In case of failure of pharmacological cardioversion, we can try electrical cardioversion. Sinus bradycardia can be treated with low-dose isoprenaline (0.01–0.04 mcg/kg/min), adrenaline (0.01–0.04 mcg/kg/ min), and/or temporary atrial pacing, in order to ensure a heart rate about 100–110 bpm. In case of severe AV block, a sequential pacing is required. Anyway, if the patient is still pacing dependent after 2 weeks from the operation, implantation of a permanent pace maker should be considered. Then, you can proceed to request chest X-ray to check the lungs, endotracheal and nasogastric tube position, chest drains, and intravascular devices (CVP line, PAC, and pacing wires) and send for laboratory tests including standard coagulation, renal and liver function, platelets, red blood cell and white blood cell counts, troponin I, CK, albumin, viral markers, thyroid markers, and glycaemia. Blood samples should be sent for good practice also for coagulation tests (ROTEM or TEG) in case of excessive bleeding. A plan for immunosuppressive therapy (methylprednisolone, thymoglobulins, etc.) must be provided in collaboration with specialist immunologist and cardiologist. Antibiotic therapy must be tailored on the background history of donor and/or recipient.

**7.3. Pharmacological support**

The goal is to ensure adequate CO, avoiding excessive increase of cardiac preload and afterload, while maintaining adequate heart rate. Chronotropic support is achieved through low-moderate dose of isoprenaline or by atrial-sequential external pacing. Inotropic effect is achieved through moderate-high dose of adrenaline and, when necessary, with phosphodiesterase inhibitors as milrinone that also decreases peripheral vascular resistances. Other pharmacological tools that are aimed to control arterial ventricle coupling are nitroglycerin and sodium nitroprusside, very helpful to decrease the afterload of the left ventricle and increase cardiac output, when used together with an inotropic drug. In case of preexistent pulmonary hypertension, inhalation of nitric oxide and imbrication with sildenafil can help to reduce pulmonary vascular resistances [14]. In the further postoperative course, addition of an upstream therapy including

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143

ace inhibitors, b-blockers, or calcium antagonists may be helpful as cardiac protection.

ing and really impacts on the overall survival of transplanted patients [18].

transplanted patients, but literature is still lacking in terms of overall survival [9].

the prostacyclin analog iloprost (6 × 5–10 mcg) can be given.

phodiesterase inhibitors as milrinone (0.2–0.3 mcg/kg/min).

ventricle support via peripheral VA-ECMO.

hypercapnia, maintain adequate lung recruitment by PEEP (not over 6 cmH<sup>2</sup>

The donor heart, particularly the right ventricle, in case of preexisting precapillary or postcapillary pulmonary hypertension, has to fight with high afterload [**Table 6**]. The preexisting conditions may be impaired in case of coexisting hypoxia or hypercapnia, prolonged extracorporeal circulation, and donor ischemia with consequent ischemia-reperfusion injury, blood transfusion, and protamine administration. Right ventricular failure may be challeng-

Early PA pressure monitoring at the time of CPB weaning is fundamental and has to be continued in the early postoperative period. The first aim in hemodynamic management of the graft is to offload the right ventricle, decreasing PA pressures and pulmonary vascular resistances while ensuring an adequate RV contractility. Inhaled nitric oxide at 20–40 ppm is a rapid onset tool to decrease PA pressures. It seems to improve early clinical outcomes in heart

This is the reason why it is often used preventively during weaning from the CPB.Alternatively,

After the very early postoperative period, inhaled nitric oxide can be substituted by the phosphodiesterase-5 inhibitor sildenafil at the dosage of 20 mg × 3/die via NG tube with very small effects on the systemic pressures, avoiding also the rebound phenomena coming from the discontinuation of inhaled nitric oxide therapy. Sildenafil has also been shown to decrease PA pressures during inhalation of nitric oxide, since they seem to activate different regulatory mechanisms of the vascular tone [19, 20]. Inotropic support of the RV should be guaranteed by moderate-high dose of adrenaline (0.05–0.1 mcg/kg/min) or low-moderate doses of phos-

Clearly, while supporting the right ventricle, we need to ensure adequate oxygenation, avoid

a negative fluid balance in order to reduce the preload and optimize the afterload [**Table 6**]. If all these maneuvers are not sufficient, we have to consider a temporary mechanical right

O), and guarantee

**7.4. Support the right ventricle of the donor heart**
