**6. Management of patients following re-transplantation**

Many studies have highlighted the high early mortality seen after ReTx and patient factors that might be driving this observation. This may reflect the increased complexity of the surgical operation as well as medical frailty in patients undergoing ReTx, but highlights the importance of careful early management. As mentioned previously, the most important aspect of patient management is careful selection of patients who are likely to benefit from ReTx. However, once an appropriate patient has been selected, it is important to optimize the perioperative care in order to attain the best possible outcomes.

From a surgical perspective, it is important to identify the surgical technique used in the initial transplant. It may be especially pertinent to determine if the patient underwent bicaval or bi-atrial anastomosis as well as the level of anastomosis of the pulmonary artery and aorta. Dedicated thoracic imaging, either computed tomographic or magnetic resonance, may help identify anastomotic sites and areas with significant fibrotic tissue. It is not clear if it is necessary to completely excise all of the tissue from the initial cardiac transplant and no guidelines exist to advise clinical practice. Theoretically, it may help to reduce the potential for immunogenicity in those patients; however, this benefit needs to be weighed against increasing the complexity of the operation, which could potentially prolong bypass time and increase peri-operative complications. Finally, careful attention to hemostasis is important as always, but may be particularly important in ReTx patients in whom peri-operative bleeding is more frequent.

There are no clear guidelines on the post-operative care for patients undergoing ReTx. Theoretically, it may not be necessary to add induction therapy if patients have been maintained on high doses of immunosuppression, since their immune response is already significantly blunted. This is not the case for patients undergoing ReTx for refractory rejection or patients who are highly sensitized. However, most transplant centers have used similar induction and immunosuppressive regimens for their primary transplant and ReTx patients. Following induction, it may be reasonable to de-escalate immunosuppression more quickly than would be typical after initial transplantation in order to reduce the long-term risks associated with malignancy and infection.

**9. Conclusions**

**Conflict of interest**

**Author details**

**References**

Robert JH Miller\* and Kiran Khush

Palo Alto, California, United States

2017;**36**:1037-1046

The authors have no relevant conflicts of interest to declare.

\*Address all correspondence to: rjhmille@stanford.edu

Lung Transplantation. 2016;**35**:1158-1169

ReTx represents a small proportion of heart transplant procedures today; however, survival following cardiac transplantation has improved dramatically and more patients are surviving until they develop late complications such as CAV or graft failure. ReTx is the only therapy that offers meaningful improvement in survival to these patients. Survival after ReTx seems to be reduced, but may be acceptable in appropriately chosen patients. Tailored surgical and post-operative care is critical to improving patient outcomes in those accepted for ReTx.

Cardiac Re-Transplantation: A Growing Indication with Unique Considerations

http://dx.doi.org/10.5772/intechopen.74585

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Department of Medicine, Stanford University, Division of Cardiovascular Medicine,

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