**2. Monitoring and induction of general anesthesia**

Timing to get the patient ready to receive the new organ is crucial because the ischemia of the donor heart should be as short as possible to avoid the ischemia-reperfusion injury.

besylate (0.15–0.2 mg/kg for induction and 1–2 mcg/kg/min for continuous iv infusion during surgery) is a good alternative since it is metabolized by ester hydrolysis and Hofmann reaction, so the duration of block is not affected by renal or hepatic function. During induction of general anesthesia, severe hypotension can occur, so that a fluid iv bolus ad availability of rapid onset vasoconstrictors as metaraminol, phenylephrine, noradrenaline should be ensured. Cardioplegia is not administered in the recipient during heart transplantation, so that the risk of related hemodilution is less than routine cardiac surgery. On pump, sevoflurane or iv 2% propofol infusion (4 mg/kg/h) are the options for maintenance of general anesthesia. Monitoring the depth of anesthesia with bispectral index (BIS) should be routinely adopted in order to decrease the risk of awareness. Once having put the patient asleep, central lines must be placed (queen central venous pressure [CVP] line and 8 Fr line for the pulmonary artery catheter [PAC]). The ideal site for puncture (blind or ultrasound-guided) is the left internal jugular vein (IJV), since the right one can be reserved for eventual postoperative biopsy (necessary to evaluate the level of graft rejection). When this is not possible (presence of ICD on the left side), we can adopt the right subclavian vein. Sometimes, when the preoperative renal function is really compromised, we can already place into the femoral or subclavian vein a catheter for continuous renal filtration afterwards. The PA catheter is flown through the 8 Fr line up to the right atrium, and then, once the new heart is placed, it will be advanced by the cardiac surgeon up to the superior right pulmonary artery. Vigilance calibration will be done

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If the graft is not carried out into the organ care system (OCS), the ischemic time is crucial and the risk of ischemic/reperfusion injury is proportionally high, with possible dramatic increase of blood lactate levels and decrease of the graft global function. This is the reason why we must ensure adequate glycemia control, urine output, and, in general, an optimal tissue

means to keep MAPs about 60–80 mmHg and Hb levels at least about 8–9 mg/dL. When the aorta is unclamped, VF can occur (50% of patients). A shock delivery (10–30 J) followed by lidocaine bolus (when VF is refractory to electrical therapy) will take to resolution of the arrhythmia and return to sinus rhythm. In case of sinus bradycardia, temporary epicardial pacing will ensure adequate heart rate (100–110 bpm). Due to limited muscular mass, the ability of the right ventricle (RV) to increase contractility is limited and a temporary pacing at about 110 bpm will increase RV output and will overpace possible arrhythmias. Surgeons will also place a left atrial catheter for continuous measurement of the left atrial pressure (LAP) as an indicator of the left ventricle performance and stiffness. This value, together with CVP, PAPs, MAPs, and SvO2, will influence the posttransplantation hemodynamic management. Throughout this period, it will be mandatory to ensure adequate MAPs and diastolic pressure to allow adequate coronary perfusion, while maintaining medium-low preload pressures (CVP < 12 mmHg, LAP/PCWP < 12 mmHg). The biventricular assessment with transesopha-

), which

perfusion during CPB. This means to guarantee an adequate oxygen delivery (DO2

Pharmacological tools for CPB weaning will include the following [**Tables 3** and **4**]:

immediately before weaning from the CPB.

geal echocardiography should be done simultaneously.

**3. CPB and weaning**

Everyone in the theater should wear sterile surgical gown, hat, mask, and sterile gloves for any procedure on the patient especially because he will go under immune deficiency. Once the patient is in the theater, he will be connected to multiparametric monitor, with the 12 lead ECG and oximetry probe. Two peripheral venous lines are placed (generally 18G for iv sedation and 14G for rapid fluid infusion), and an arterial catheter, generally 20G, is placed into the radial or humeral artery. When the patient is very unstable, an arterial catheter is placed in the left femoral artery, to estimate central to peripheral arterial pressure gradients. Placement of an arterial line can be very difficult in patients with previous implantation of LVADs as bridge to transplant, due to the absence of arterial pulse. In such situations, ultrasound guidance can be very helpful (see **Table 2**).

Induction of general anesthesia usually starts just with the final acceptance of the donor organ. Drugs used for general anesthesia should impact the less possible on hemodynamics. A rapid sequence induction is preferred since recipients are always very stressed and sometimes not present with an empty stomach [6].

Midazolam (10–15 mg) or etomidate (20 mg) are preferred to propofol for hypnosis, due to the less impact on hemodynamics. Opioids like fentanyl or sufentanil are preferred for the same reason ("stress-free anesthesia"), with an induction dose of 0.2–0.4 mcg/kg for sufentanil and 2–4 mcg/kg for fentanyl. Continuous infusion analgesia remifentanil is preferable for the less impact on renal function since it is metabolized by plasmatic esterase. This is particularly important in patients with low cardiac output and preexisting renal failure. Remifentanil will be turned off and replaced by morphine or tramadol (30 mg/die and 300 mg/die, respectively), before moving to the intensive care unit. Mean term muscle relaxant rocuronium (1 mg/kg) is usually the first choice for rapid sequence induction. Sometimes short-term cisatracurium


**Table 2.** Standard monitoring.

besylate (0.15–0.2 mg/kg for induction and 1–2 mcg/kg/min for continuous iv infusion during surgery) is a good alternative since it is metabolized by ester hydrolysis and Hofmann reaction, so the duration of block is not affected by renal or hepatic function. During induction of general anesthesia, severe hypotension can occur, so that a fluid iv bolus ad availability of rapid onset vasoconstrictors as metaraminol, phenylephrine, noradrenaline should be ensured. Cardioplegia is not administered in the recipient during heart transplantation, so that the risk of related hemodilution is less than routine cardiac surgery. On pump, sevoflurane or iv 2% propofol infusion (4 mg/kg/h) are the options for maintenance of general anesthesia. Monitoring the depth of anesthesia with bispectral index (BIS) should be routinely adopted in order to decrease the risk of awareness. Once having put the patient asleep, central lines must be placed (queen central venous pressure [CVP] line and 8 Fr line for the pulmonary artery catheter [PAC]). The ideal site for puncture (blind or ultrasound-guided) is the left internal jugular vein (IJV), since the right one can be reserved for eventual postoperative biopsy (necessary to evaluate the level of graft rejection). When this is not possible (presence of ICD on the left side), we can adopt the right subclavian vein. Sometimes, when the preoperative renal function is really compromised, we can already place into the femoral or subclavian vein a catheter for continuous renal filtration afterwards. The PA catheter is flown through the 8 Fr line up to the right atrium, and then, once the new heart is placed, it will be advanced by the cardiac surgeon up to the superior right pulmonary artery. Vigilance calibration will be done immediately before weaning from the CPB.
