**4.1. Heart transplant recipients**

Transplanted heart is completely denervated, meaning it lacks neural regulating mechanisms [65]. Even though, it has the ability to adjust with compensatory mechanisms to the increased demands in stress returning the recipients to an active life. Transplanted heart has no sensory sympathetic and parasympathetic innervation. Therefore, it has a higher resting heart rate of 90–110 bpm secondary to the loss of vagal tone. The resting ECG is commonly altered showing two P waves: one is from the recipients' own SA node and the other is the donors' SA node. Patients are at higher risk of developing atrial flutter or atrial fibrillation. The transplanted heart is "preload dependent." Cardiac output becomes dependent on venous return. Therefore, it is important to maintain a sufficient systolic pressure and prevent hypovolemia [66].

Although the cardiac index of the transplanted heart is lower than that of normally innervated control hearts, it remains in the normal range. The catecholamine response is different from that of normal heart because intact sympathetic nerves are required for the normal uptake and metabolism of catecholamines. The receptor density, however, remains unchanged, and the transplanted heart can respond to direct-acting drugs (adrenaline and noradrenaline) [67]. Isoprenaline and dobutamine have similar effects in both transplanted and normal heart. Because atropine has no effect on a transplanted heart, isoprenaline and adrenaline should be readily available to manage bradycardia and hypotensive emergencies. In recent years, milrinone and levosimendan, inotropic vasodilators, have been included in the pharmacological arsenal. These drugs increase myocardial contractility without myocardial oxygen consumption (unlike catecholamines). In addition, they lead to arterial and venous vasodilatation and afterload decrease [68, 69]. **Table 6** summarizes the hemodynamic response of some commonly used drugs for resuscitation.

ischemia. Instead of invasive monitoring, intraoperative transesophageal echocardiography may be considered [72, 73]. All preoperative drug therapy should be continued during the perioperative period. If a pacemaker is in place, its proper function should be confirmed.

Anesthetic Considerations in Transplant Recipients for Nontransplant Surgery

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Denervation of the lungs after transplantation is associated with a lack of cough reflex below the tracheal anastomosis level and are unable to clear secretions unless they are awake. Therefore, they are prone to retention of secretions and silent aspiration [74]. These conditions may lead potential hazardous conditions especially in general anesthesia, such as bronchoconstriction and the increased risk of chest infection. In light of potential complications, it is preferable to perform a regional anesthesia whenever possible and if there is no contraindication [75].

Before elective surgery patients should undergo chest radiograph and spirometry to exclude chronic rejection and infection [76]. If allograft rejection or infection is suspected, elective sur-

Altered lymphatic drainage in the transplanted lung may cause interstitial fluid accumulation. It has been recommended that these patients be treated with diuretics and limited crystalloid infusion [77, 78]. Invasive hemodynamic monitoring is often required in heart-lung transplant recipients since there is a narrow line between the pulmonary edema occurrence and maintain-

Kidney transplant recipient have high incidence of cardiovascular diseases, especially elderly patients with diabetes and after years of dialysis procedures. Spectrum of disease can range from hypertension to severe coronary disease. It is wisely to approach them with caution. Cardiovascular complications are the leading cause of death in renal transplant recipients,

After successful transplantation, renal function is restored, with no need for renal replacement therapy. Still, beware of prolonged drug action and excretion in kidney transplant recipients, due to the fact that their glomerular filtration rate and effective plasma flow can be

You should suspect at chronic graft rejection when azotemia, proteinuria, and hypertension are seen [82, 83]. One of the important parameters to consider in the prevention of graft failure is the maintenance of appropriate renal perfusion pressure. Perioperative fluid management must ensure restoration and maintenance of intravascular volume, in order to obtain good graft function. Diuretics should not be given without careful evaluation of the patient's

In anesthetic management, it is prudent to choose drugs that do not rely on the kidney for excretion. Nephrotoxic drugs should be avoided [84]. Cardiovascular instability can be present after a recipient has been recently hemodialysed due to hypovolemia and hypokalemia,

causing arrhythmias and increased susceptibility to muscle relaxants [85].

gery should be postponed and appropriate investigations should be performed.

**4.2. Lung transplant recipients**

ing cardiac output with fluid load [79].

**4.3. Kidney transplant recipients**

accounting for 32% of all deaths [80].

volume status.

significantly lower than in healthy subjects [81].

Heart transplant recipients may present with ongoing rejection with myocardial dysfunction, accelerated coronary atherosclerosis, or severe dysrhythmias, all of which must be diagnosed before surgery. Chronic allograft rejection usually presents as accelerated coronary artery disease. Therefore, heart transplant recipients may have significant myocardial ischemia without any clinical symptoms of pain and silent myocardial infarction on the ECG. Severe rejection can lead to significant systolic and diastolic dysfunction [70, 71].

General anesthesia is usually preferred, as there is a possibility of impaired response to hypotension after spinal or epidural anesthesia. A goal of anesthesia in this setting is the avoidance of significant vasodilation and acute decrease of the preload. Invasive hemodynamic monitoring is extremely useful during surgery that involves large volume shifts, due to the fact that these patients are preload-dependent and may be prone to myocardial dysfunction and/or


SA – sinoatrial; V – atrioventricular; SVR – systemic vascular resistance; BP – blood pressure; CO – cardiac output; HR – heart rate; 0 – no effect; and E – equivocal.

**Table 6.** Response of denervated heart to various cardiovascular drugs.

ischemia. Instead of invasive monitoring, intraoperative transesophageal echocardiography may be considered [72, 73]. All preoperative drug therapy should be continued during the perioperative period. If a pacemaker is in place, its proper function should be confirmed.
