**12. Intraoperative management**

Main preoperative features and examinations that must be considered are:

valvular heart disease

postpartum, etc. Retransplant (RETX) Due to acute rejection, coronary artery disease, etc.

• Numbers and types of previous operations (sternotomy and thoracotomy).

• Right heart catheterization (RHC): pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), pulmonary vascular resistances (PVR), and pulmonary hypertension etiology. Unfortunately, most patients with congenital heart defects have high PVR because of pulmonary vascular disease. However, the presence of systemic-to-pulmonary shunts, intrapulmonary shunting, and caval pulmonary circulation does not allow a correct assessment of PVR. For these patients, RHC should be performed at 3–6 month interval in adult patients but is not advocated as routine surveillance in children unless a clinical change is noted [26].

Other (OTHER) Arrhythmogenic right ventricular dysplasia, cancer, coronary artery disease,

myopathy-ischemia, hypertrophic cardiomyopathy, etc.

Congenital heart defects: HLHS-unoperated, with surgery, without surgery,

Dilated myopathy due to alcohol, familiar, idiopathic, myocarditis, viral,

• Cyanotic congenital heart disease (secondary erythrocytosis, hyperviscosity, and coagula-

• Panel reactive antibody (PRA) identifies sensitized patients. It may be elevated in patients with allograft patch or with multiple redo-operations, due to the multiple transfusions. It

• Variable anatomic substrates (isomerism, issues of situs, MAPCAs, aberrant right or left

• Previous neurological history: syncope, previous stroke, and cerebral arteriovenous

• Respiratory insufficiency: smoke, chronic obstructive pulmonary disease (COPD), anatomical anomalies of the pulmonary vessels, and presence of bronchial or pulmonary stents.

• Liver disease: an evaluation of the patient's liver profile is extremely important. Chronic heart failure and in particular the univentricular heart physiology can lead to a liver

• Previous venous or arterial thromboembolism (central venous catheter thrombosis).

• Type of heart disease (CHD, DCM, RETX, and OTHER)

**Category (abbreviation) Diagnoses in category**

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

Congenital heart disease

148 Heart Transplantation

Dilated cardiomyopathy

(CHD)

(DCM)

may result in an increased risk of acute rejection [27].

• Arrhythmias and previous ICD implantation.

subclavian artery, and persistence of left superior vena cava).

tion deficit).

malformation.

dysfunction.

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 sternotomy can lead to a destabilization of the hemodynamics.

Antibiotic therapy differs according to age and weight and background of both the donor and recipient (**Tables 8** and **9**).

Immunosuppression is started 1 hour before going to the operating room: thymoglobulin 1 mg/kg/12 h and methylprednisolone 7–10 mg/kg (max. 125 mg).

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 consequently hypercapnia.

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 monitoring before starting the drug administration.

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 10–20 mg/kg is infused.

In all patients, regional cerebral monitoring is achieved with the use of near infrared spectroscopy (NIRS).


**12.1. CPB and weaning**

ratio.

DO2 /VO2

CPB management can be extremely complex and differs according to the patient's weight and age. The main aim is to maintain a correct medium arterial pressure (MAP) and a correct

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Sometimes, this is difficult to be achieved, due to the possible presence of anatomical extracardiac shunts. The dose of unfractionated heparin for the CPB is 200 U/kg in newborns and infants or 300 U/kg in the child and adult, in order to have an ACT > 400 s. In case of reduced response to heparin, administration of ATIII at a dose of 100 mg/kg is recommended. Furthermore, in case of HIT or low response to heparin, direct thrombin inhibitors are administered (bivalirudin and argatroban) as in adult patients. After the aortic cross-clamp is removed, methylprednisolone is administered with the dose of 7–10 mg/kg (max. 125 mg/kg). Weaning from CPB always requires inotropic support and the right ventricular failure is a possible complication, characterized by restrictive pattern that can be managed by inhaled nitric oxide (5–40 ppm) and inotropic support (milrinone 0.3–0.75 mcg/kg/min, adrenaline 0.02–0.1 mcg/kg/min, and isoprenaline 0.1–1 mcg/kg/min) in order to vasodilate the pulmonary circulation improving biventricular contractility and providing a chronotropic effect if bradycardia occurs. It is extremely important to keep normal PVR by providing a proper

can monitor the hemody-

ventilation, avoiding hypoxia and maintaining normocapnia.

**12.2. Anticoagulation and hemostasis**

**12.3. Intensive care**

Once the patient has been weaned form CBP, the vigilance or SCvO2

methylprednisolone, thymoglobulin, tacrolimus, and mycophenolate.

namic profile and biventricular function can be evaluated with echocardiogram.

should consider the support via an extracorporeal membrane oxygenation (ECMO).

However, in case of poor CO, despite maximal inotropic support and correct ventilation, we

At the end of CPB, heparin is antagonized with a ratio 2:1 or 1:1 with protamine based on the ACT values. Antifibrinolytic agents are administrated at the dosage of 50 mg/kg (25 mg/kg after general anesthesia induction and 25 mg/kg at the end of CPB). Severe bleeding is not uncommon in pediatric population. Main reasons of postoperative bleeding are previous heart surgery, cyanotic congenital heart disease, immature coagulation system, and excessive hemodilution due to the disproportionate ratio of CPB circuit volume to patient blood volume, especially in newborns and infants. Correct coagulation management is always achieved through ROTEM.

During the postoperative intensive care course, close monitoring of hemodynamic parameters, inotropes, ventilation, and acid base balance is required to predict pulmonary hypertension, biventricular failure, and LCOS. Normalization of the oxygenation and ventilation is the primary goal in these patients and ventilation support must be discontinued as soon as possible. The antibiotic therapy will be set according to microbiological surveillance. Immunotherapy during the postoperative course is managed by the cardiologist as follows:

**Table 8.** Antibiotic therapy (cefazolin).


**Table 9.** Antibiotic therapy (clindamycin).

Different conditions may complicate the venous central catheter placing as: anatomical variables, possible occlusion due to previous repeated catheterizations, and previous positioning of central lines. In these cases, the echo-guided assistance is recommended. In smaller patients or in occluded jugular/subclavian veins, femoral veins can be also used. The sizing of the catheter and the numbers of lumens used depend on the weight and age of the patients. When possible, a pulmonary artery catheter (PAC) must be placed into the superior vena cava and then correctly repositioned by the cardiac surgeon before removing the aortic cross-clamp. In newborns and infants, placing PAC may be problematic or impossible due to the size of the patient. In these cases, it is possible to use the central venous oxygen saturation (SCvO2 ) as a surrogate of SVO2 even if the results are controversial [30].

As an alternative, the left atrial pressure (LAP) can be monitored with the insertion of a catheter through the right superior pulmonary vein.

Transesophageal echocardiography (TEE) is always recommended for a correct evaluation of biventricular function, after the CPB weaning, accordingly with the patient's weight.

After induction of the anesthesia, the ventilation management requires extreme attention since the hypoxia and the hypercapnia can increase PVR leading to a low cardiac output syndrome. In case of hypotension, before infusing, a bolus of colloid is essential to secure the correct ventilation, avoiding respiratory acidosis.

The majority of patients with CHD undergoing cardiac transplantation are reoperation candidates, so it is important to put into account long operative times, due to dissection of the adhesions and complex reconstruction of the anatomy.

#### **12.1. CPB and weaning**

CPB management can be extremely complex and differs according to the patient's weight and age. The main aim is to maintain a correct medium arterial pressure (MAP) and a correct DO2 /VO2 ratio.

Sometimes, this is difficult to be achieved, due to the possible presence of anatomical extracardiac shunts. The dose of unfractionated heparin for the CPB is 200 U/kg in newborns and infants or 300 U/kg in the child and adult, in order to have an ACT > 400 s. In case of reduced response to heparin, administration of ATIII at a dose of 100 mg/kg is recommended. Furthermore, in case of HIT or low response to heparin, direct thrombin inhibitors are administered (bivalirudin and argatroban) as in adult patients. After the aortic cross-clamp is removed, methylprednisolone is administered with the dose of 7–10 mg/kg (max. 125 mg/kg).

Weaning from CPB always requires inotropic support and the right ventricular failure is a possible complication, characterized by restrictive pattern that can be managed by inhaled nitric oxide (5–40 ppm) and inotropic support (milrinone 0.3–0.75 mcg/kg/min, adrenaline 0.02–0.1 mcg/kg/min, and isoprenaline 0.1–1 mcg/kg/min) in order to vasodilate the pulmonary circulation improving biventricular contractility and providing a chronotropic effect if bradycardia occurs. It is extremely important to keep normal PVR by providing a proper ventilation, avoiding hypoxia and maintaining normocapnia.

Once the patient has been weaned form CBP, the vigilance or SCvO2 can monitor the hemodynamic profile and biventricular function can be evaluated with echocardiogram.

However, in case of poor CO, despite maximal inotropic support and correct ventilation, we should consider the support via an extracorporeal membrane oxygenation (ECMO).

#### **12.2. Anticoagulation and hemostasis**

At the end of CPB, heparin is antagonized with a ratio 2:1 or 1:1 with protamine based on the ACT values. Antifibrinolytic agents are administrated at the dosage of 50 mg/kg (25 mg/kg after general anesthesia induction and 25 mg/kg at the end of CPB). Severe bleeding is not uncommon in pediatric population. Main reasons of postoperative bleeding are previous heart surgery, cyanotic congenital heart disease, immature coagulation system, and excessive hemodilution due to the disproportionate ratio of CPB circuit volume to patient blood volume, especially in newborns and infants. Correct coagulation management is always achieved through ROTEM.

#### **12.3. Intensive care**

) as a

Different conditions may complicate the venous central catheter placing as: anatomical variables, possible occlusion due to previous repeated catheterizations, and previous positioning of central lines. In these cases, the echo-guided assistance is recommended. In smaller patients or in occluded jugular/subclavian veins, femoral veins can be also used. The sizing of the catheter and the numbers of lumens used depend on the weight and age of the patients. When possible, a pulmonary artery catheter (PAC) must be placed into the superior vena cava and then correctly repositioned by the cardiac surgeon before removing the aortic cross-clamp. In newborns and infants, placing PAC may be problematic or impossible due to the size of the patient. In these cases, it is possible to use the central venous oxygen saturation (SCvO2

As an alternative, the left atrial pressure (LAP) can be monitored with the insertion of a cath-

Transesophageal echocardiography (TEE) is always recommended for a correct evaluation of

After induction of the anesthesia, the ventilation management requires extreme attention since the hypoxia and the hypercapnia can increase PVR leading to a low cardiac output syndrome. In case of hypotension, before infusing, a bolus of colloid is essential to secure the

The majority of patients with CHD undergoing cardiac transplantation are reoperation candidates, so it is important to put into account long operative times, due to dissection of the

biventricular function, after the CPB weaning, accordingly with the patient's weight.

even if the results are controversial [30].

eter through the right superior pulmonary vein.

Newborn < 1200 g 5 mg q 12 h Newborn = 2000 g < 7 days of life 5 mg q 12 h Newborn = 2000 g > 7 days of life 5 mg q 8 h Newborn > 2000 g < 7 days of life 5 mg q 8 h Newborn > 2000 g > 7 days of life 5 mg q 6 h

Newborn < 1200 g 20 mg q 12 h Newborn ≥ 1200 g < 7 days of life 20 mg q 12 h Newborn ≥ 1200 gr > 7 days of life 20 mg q 8 h

Infants and children 100 mg/kg/24 h in 3 doses

In case of allergy to beta-lactams, clindamycin is administered.

**Table 9.** Antibiotic therapy (clindamycin).

**Table 8.** Antibiotic therapy (cefazolin).

150 Heart Transplantation

Infants and children 15/40 mg/kg/24 h in 3–4 doses

correct ventilation, avoiding respiratory acidosis.

adhesions and complex reconstruction of the anatomy.

surrogate of SVO2

During the postoperative intensive care course, close monitoring of hemodynamic parameters, inotropes, ventilation, and acid base balance is required to predict pulmonary hypertension, biventricular failure, and LCOS. Normalization of the oxygenation and ventilation is the primary goal in these patients and ventilation support must be discontinued as soon as possible. The antibiotic therapy will be set according to microbiological surveillance. Immunotherapy during the postoperative course is managed by the cardiologist as follows: methylprednisolone, thymoglobulin, tacrolimus, and mycophenolate.

#### **12.4. Peculiar problems**

In the postoperative setting, the main problems for pediatric patients are comorbidities related to chronic decompensation and univentricular physiology.

ISVR indexed systemic vascular resistance

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LAP left atrial pressure

NGT nasogastric tube NO nitrogen oxide

OCS organ care system

PPM parts per millions

RAP right atrial pressure

RV right ventricle

TV tidal volume

WU wood unit

**Author details**

VAD ventricular assist device

LVAD left ventricular assist device

PAC pulmonary artery catheter PAP pulmonary arterial pressure

PGD primary graft dysfunction

PVR pulmonary vascular resistance

SVR systemic vascular resistance

TPG transpulmonary pressure gradient TRALI transfusion-associated lung injury

SIRS systemic inflammatory response syndrome

TACO transfusion-associated circulatory overload

Massimo Baiocchi\*, Maria Benedetto, Marta Agulli and Guido Frascaroli

Anaesthesiology and Intensive Care Unit, Cardiothoracic and vascular Department,

\*Address all correspondence to: massimo.baiocchi@aosp.bo.it

Policlinico S. Orsola University Hospital, Bologna, Italy

PCWP pulmonary capillary wedge pressure

PEEP positive end expiratory pressure

LV left ventricle

