ANZCA Final
Cardiac Surgery
Cardiothoracic Anaesthesia
Transplantation
High Evidence

Anaesthesia for Heart Transplantation

Heart transplantation is the gold standard treatment for end-stage heart failure refractory to medical/device therapy. Indications : Dilated cardiomyopathy (50-60%), ischemic cardiomyopathy (25-35%), congenital heart...

Updated 3 Feb 2026
28 min read
Citations
88 cited sources
Quality score
56 (gold)

Clinical board

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Urgent signals

Safety-critical features pulled from the topic metadata.

  • Cardiac arrest during induction (severe cardiomyopathy)
  • Unable to wean from bypass after transplant
  • Severe pulmonary hypertension with right heart failure
  • Hyperacute rejection (immediate graft dysfunction)

Exam focus

Current exam surfaces linked to this topic.

  • ANZCA Final Written
  • ANZCA Final Clinical Viva

Editorial and exam context

ANZCA Final Written
ANZCA Final Clinical Viva
Clinical reference article

Quick Answer

Heart transplantation is the gold standard treatment for end-stage heart failure refractory to medical/device therapy. Indications: Dilated cardiomyopathy (50-60%), ischemic cardiomyopathy (25-35%), congenital heart disease (5-10%), valvular heart disease (3-5%), retransplantation (2-4%). Key challenges: Severely depressed LV/RV function, elevated PVR (predicts post-transplant RV failure), potential for arrhythmias, coagulopathy (liver congestion), prior sternotomy (adhesions, redo risk). Monitoring: Arterial line, central venous catheter, PA catheter (essential for PVR monitoring), TEE (essential for all phases). Induction: Hemodynamic stability (avoid myocardial depression, maintain coronary perfusion), etomidate or ketamine preferred (avoid propofol), high-dose opioid (blunt stress response). Bypass strategy: Bicaval cannulation (preserves right atrial anatomy), mild hypothermia (32-34°C), cardioplegia for donor heart preservation. Post-bypass: Denervated heart physiology (no vagal tone, high resting HR 90-110 bpm), direct acting chronotropes needed (isoprenaline, adrenaline), temporary pacing common, inhaled NO for PHT, RV support if needed (milrinone, inotropes). [1-15]

Pathophysiology

Indications and Recipient Selection

Dilated Cardiomyopathy (50-60%):

  • Pathophysiology: LV dilation and systolic dysfunction (EF <25-30%), often idiopathic, viral, genetic, or toxin-related
  • Clinical features: Biventricular failure, low cardiac output, elevated filling pressures
  • Timing: INTERMACS profile 1-4 (inotrope dependence, declining status)
  • Outcomes: Good survival, lowest post-transplant PHT risk

Ischemic Cardiomyopathy (25-35%):

  • Pathophysiology: Prior MI → LV remodeling, aneurysm formation, global hypokinesis
  • Clinical features: Angina (if viable territories), heart failure symptoms
  • Considerations: Prior CABG (sternotomy redo), ventricular arrhythmias (ICD often present), PHT from chronic elevation of LVEDP
  • Outcomes: Similar survival to dilated CM

Congenital Heart Disease (5-10%):

  • Types: Single ventricle physiology (Fontan failure), complex cyanotic lesions, Eisenmenger syndrome (now more often lung or heart-lung)
  • Challenges: Complex anatomy, prior multiple surgeries (adhesions), unusual venous anatomy, PHT
  • Outcomes: Higher early mortality, good long-term if survive first year

Valvular Heart Disease (3-5%):

  • Causes: Rheumatic disease (developing world), endocarditis destruction, prosthetic valve degeneration
  • Considerations: Prior valve surgery, calcified annulus, cardiac chambers often small (especially if severe AS)
  • Approach: Often combined with other indications

Restrictive/Infiltrative Cardiomyopathy (2-5%):

  • Causes: Amyloidosis (systemic AL amyloid), sarcoidosis, hemochromatosis, radiation
  • Features: Severe diastolic dysfunction, normal/near-normal EF, biatrial enlargement
  • Challenges: Small stiff ventricles (donor heart may not fit), PHT, multi-organ involvement

Retransplantation (2-4%):

  • Indications: Allograft vasculopathy (CAV), severe acute rejection, graft failure
  • Outcomes: Worse than primary transplant (patient selection critical)

Contraindications:

  • Active infection, malignancy <5 years, severe irreversible PVR >5-6 Wood units (or >3 Wood with vasodilator unresponsive), severe comorbidities (renal, hepatic), active substance abuse, psychosocial unsuitability

Denervated Heart Physiology

Autonomic Denervation:

  • Surgical transection: Vagal and sympathetic nerves cut during explantation
  • Result: No autonomic innervation of donor heart

Resting Heart Rate:

  • Intrinsic SA node rate: 90-110 bpm (higher than normal 60-80 due to absence of vagal tone)
  • No rate variation: Heart rate does not increase with exercise (no sympathetic response) or decrease with sleep (no vagal tone)
  • Delayed response: Circulating catecholamines (slow) rather than neural (fast) control
  • Maximal HR: Blunted compared to normal (reduced cardiac reserve)

Hemodynamic Response:

  • Exercise: Cardiac output increases primarily by increasing stroke volume (not HR), venous return dependent
  • Position changes: Minimal HR change (no vagal reflex)
  • Stress/Valsalva: No reflex bradycardia after strain release

Pharmacology:

  • Direct-acting agents required: Isoprenaline, adrenaline, dobutamine, dopamine (β-agonists work directly)
  • Indirect agents ineffective: Atropine (no vagal tone to block), glycopyrrolate (no effect), edrophonium (no effect)
  • Denervated supersensitivity: Exaggerated response to catecholamines and digoxin (reduced uptake/storage)

Diagnosis of Rejection:

  • Cannot rely on HR: No vagal response to inflammation
  • Biopsy surveillance: Endomyocardial biopsies gold standard
  • Other signs: Decreased exercise tolerance, arrhythmias, low-grade fever, graft dysfunction on echo

Pulmonary Hypertension and Right Ventricular Dysfunction

Pathophysiology:

  • Chronic LV failure: Elevated LVEDP → elevated LA pressure → elevated PAP (passive PHT)
  • PVR elevation: If chronic, can lead to fixed (arterial) PHT with vascular remodeling
  • Reversibility: Critical to test (vasodilator challenge during cardiac catheterization)

Risk Assessment:

  • PVR: <2.5 Wood units (ideal), 2.5-5 (acceptable), >5 (high risk), >6-8 (contraindicated)
  • Transpulmonary gradient (TPG): Mean PAP - PCWP; >15 mmHg concerning
  • Vasodilator response: If PVR falls to <2.5 with nitric oxide or epoprostenol, acceptable

Post-Transplant RV Failure:

  • Mechanism: Donor RV (normal) cannot overcome recipient PVR (high)
  • Timing: Immediate post-bypass most common
  • Consequences: Low cardiac output, elevated CVP, hepatorenal dysfunction
  • Risk factors: Pre-op PVR >5 Wood units, TPG >15, long-standing LV failure

Management of Elevated PVR:

  • Preoperative: Optimize (diuretics, inotropes), test vasodilator responsiveness
  • Intraoperative: Inhaled NO, IV epoprostenol, milrinone (inotrope + vasodilator)
  • Postoperative: Continue pulmonary vasodilators, RV support (inotropes)
  • Mechanical support: ECMO or RVAD if refractory

Graft Dysfunction and Rejection

Hyperacute Rejection:

  • Timing: Minutes to hours post-reperfusion
  • Mechanism: Preformed anti-HLA antibodies (ABO incompatibility, prior sensitization)
  • Manifestation: Immediate severe graft dysfunction (cyanosis, arrhythmias, hypotension)
  • Prevention: Crossmatch negative, ABO compatible

Acute Cellular Rejection:

  • Timing: Weeks to months (most common first year)
  • Mechanism: T-cell mediated immune response
  • Diagnosis: Endomyocardial biopsy (ISHLT grading Grade 0R-3R)
  • Treatment: High-dose corticosteroids, thymoglobulin if severe

Antibody-Mediated Rejection (AMR):

  • Timing: Anytime, increasingly recognized
  • Mechanism: Donor-specific antibodies (DSA), complement activation
  • Diagnosis: Biopsy (C4d staining), rising DSA titers, graft dysfunction
  • Treatment: Plasmapheresis, IVIG, rituximab, bortezomib

Chronic Allograft Vasculopathy (CAV):

  • Timing: Months to years (major cause of late mortality)
  • Mechanism: Accelerated coronary artery disease (intimal proliferation), immune-mediated
  • Diagnosis: Coronary angiography (diffuse disease), IVUS, stress testing
  • Treatment: Statins, immunosuppression optimization, retransplantation
  • Challenge: Denervated heart → silent ischemia, no angina warning

Clinical Presentation

Preoperative Recipient Evaluation

Cardiac Assessment:

  • LV function: EF (typically <25-30%), stroke volume, cardiac output
  • RV function: Critical (echocardiography, catheterization)
  • Hemodynamics: RHC essential (PVR, TPG, PCWP, cardiac output, index)
  • Arrhythmias: ICD present? (should be deactivated before surgery)
  • Coronary angiography: If age >40 or risk factors (ischemic CM usually known)

Pulmonary Vascular Assessment:

  • PVR: As above, reversibility testing
  • Ventilation/perfusion scan: If suspected chronic thromboembolic PHT
  • Echo: Estimate PAP, assess RV

Other Organ Systems:

  • Renal: Creatinine clearance (renal dysfunction predicts post-op renal failure, may need simultaneous kidney transplant)
  • Hepatic: Congestion from RV failure (elevated bilirubin), cirrhosis (contraindication)
  • Coagulation: INR often elevated (liver congestion), platelet dysfunction
  • Diabetes: Common, affects immunosuppression dosing, wound healing
  • Infection screening: CMV, EBV, HIV, hepatitis (donor/recipient matching)

Nutritional/Cachexia:

  • Cardiac cachexia: Common in severe HF (worse outcomes)
  • BMI: <18 or >35 associated with worse outcomes
  • Optimization: Enteral nutrition pre-transplant if possible

Sensitization:

  • Panel reactive antibody (PRA): Screen for anti-HLA antibodies
  • Virtual crossmatch: Predict compatibility
  • Desensitization: If highly sensitized (IVIG, plasmapheresis, rituximab)

Psychosocial:

  • Compliance: History of medication adherence critical
  • Support: Family/friend support for postoperative care
  • Substance use: Tobacco, alcohol, drug use (must be abstinent)

Donor Heart Assessment

Selection Criteria:

  • Age: Ideally <55 years (up to 65 in selected recipients)
  • Size match: Donor weight ±20-30% of recipient (small donors don't fill pericardial well, large donors may not fit)
  • Function: EF >50% (TTE), no wall motion abnormalities
  • Ischemic time: <4 hours ideal (up to 6 hours acceptable)
  • ECG: No ischemia, acceptable rhythm
  • Cause of death: Trauma (preferred), intracranial hemorrhage (acceptable), medical causes (selective)
  • Infection: No systemic infection, negative HIV, hepatitis B/C (unless recipient already positive)
  • Malignancy: No active malignancy (except low-grade CNS tumors)
  • Hemodynamics: Minimal inotrope requirement

Marginal/Extended Criteria Donors:

  • Older age (55-65)
  • Mild LV dysfunction (improves after transplant)
  • Mild coronary disease (may be acceptable for older recipient)
  • Hepatitis C positive (now treatable)
  • Higher inotrope use
  • Can increase donor pool by 20-30%

Donor Management (Before Procurement):

  • Hemodynamic optimization: Maintain MAP >60 mmHg, CVP 8-12 mmHg
  • Hormonal resuscitation: T3, vasopressin, methylprednisolone (improves organ function)
  • Goal: Optimize donor heart to improve post-transplant function

Management

Preoperative Preparation

Recipient Optimization:

  • Inotropes: Often already on (milrinone, dobutamine, adrenaline)
  • Mechanical support: If INTERMACS 1-2 (IABP, ECMO, Impella, LVAD)
  • ICD: Deactivate (shock during surgery dangerous)
  • Anticoagulation: Stop warfarin (bridge with heparin if needed), stop aspirin
  • Immunosuppression: Induction agent ordered ( basiliximab, ATG, alemtuzumab)

Blood Products:

  • Cross-matched: 6-10 units PRBC, FFP, platelets
  • Cell saver: Available (though limited utility given heparinization)
  • Recombinant Factor VII: Available if massive bleeding

Equipment:

  • TEE probe: Multiplane, sterilized
  • PA catheter: 7-8.5 Fr (some centers use continuous cardiac output/PVRI monitoring)
  • Pacing wires: Temporary epicardial (atrial and ventricular)
  • Defibrillator: Internal paddles

Communication:

  • Procurement team: Coordinate timing (donor heart arrives ready for bypass)
  • OR setup: Two teams (procurement and implantation may be simultaneous in different rooms)

Induction and Monitoring

Monitoring Setup:

  • Arterial line: Radial (often pre-induction given hemodynamic instability risk)
  • Central line: 8.5 Fr introducer (for PAC, volume, drugs)
  • PA catheter:
    • Controversial (some centers routine, others selective)
    • Benefits: Continuous CO, PVR monitoring, RV function assessment
    • Risks: Arrhythmia, PA rupture (in PHT), infection
    • Alternative: TEE-based monitoring (most information)
  • TEE: Essential for all phases (baseline function, de-airing, post-transplant function)
  • Temperature: Nasopharyngeal + bladder

Induction Strategy:

  • Pre-oxygenation: 100% O₂, 3-5 minutes
  • Etomidate: 0.2-0.3 mg/kg (hemodynamically stable, good for poor LV)
  • Ketamine: Alternative (sympathomimetic, maintains BP)
  • Avoid propofol: Vasodilation, myocardial depression (contraindicated in severe HF)
  • Opioid: High-dose (fentanyl 10-20 μg/kg or remifentanil)
    • Blunts sympathetic response to intubation and sternotomy
    • Reduces stress-induced arrhythmias
  • Muscle relaxant: Rocuronium or vecuronium

Intubation:

  • Gentle laryngoscopy: Avoid sympathetic surge (can precipitate VT/VF in cardiomyopathy)
  • Airway: ETT 8.0-8.5 mm
  • Ventilation: 100% O₂ initially

Lines Before Sternotomy:

  • Large-bore IVs: Running (volume available)
  • Blood products: In room, verified
  • Emergency drugs: Drawn up (atropine, adrenaline, amiodarone)

Surgical Phases

Sternotomy and Dissection:

  • Prior sternotomy:
    • Risk of RV/graft injury (adhesions)
    • Femoral cannulation backup ready
    • Cell saver for shed blood
  • Pericardial opening: Careful (dilated heart adherent)
  • Aortic and caval dissection: For cannulation
  • Aortic assessment: If prior root surgery, may need modification

Cardiopulmonary Bypass:

Cannulation:

  • Bicaval technique (preferred):
    • SVC and IVC cannulated separately
    • Preserves right atrial anatomy (important for suture lines)
    • Caval snares for occlusion
  • Alternative: Right atrial single cannula (less ideal, RA scarred post-transplant)
  • Aortic cannulation: High ascending aorta (usual)
  • Vent: Via right superior pulmonary vein or PA

Bypass Initiation:

  • ACT: >480 seconds
  • Flow: 2.0-2.4 L/min/m²
  • Temperature: Mild hypothermia (32-34°C) - reduces metabolic demand, myocardial protection
  • MAP: 50-70 mmHg
  • Cooling: Gradual to target temperature

Native Cardiectomy (Heart Removal):

  • Timing: Donor heart nearly arrived
  • Aorta cross-clamped: After venting LV
  • Cardioplegia: Antegrade (sometimes retrograde) for myocardial protection of donor heart
  • Excision:
    • Aorta transected above sinotubular junction
    • PA transected at bifurcation
    • Atrial cuffs: Leave RA cuff around cavae, LA cuff behind (posterior LA wall with PV orifices)
  • Preserve: Posterior pericardial space for hemostasis later

Donor Heart Preparation:

  • Inspection: Assess for injury, atherosclerosis
  • Trimming: Shorten aorta, PA to appropriate length
  • Anastomosis order (surgeon preference, common sequence):
    1. Left atrium (largest anastomosis, posterior)
    2. Aorta (restore coronary perfusion)
    3. PA
    4. Right atrium (or bicaval: SVC, IVC separately)

Implantation:

  • LA anastomosis: Running suture, posterior aspect (patient supine, donor heart held)
  • De-airing: Critical before aortic anastomosis completed
  • Aortic anastomosis: Complete, remove aortic cross-clamp
  • Reperfusion: Donor heart reperfuses (warm blood cardioplegia if needed)
  • PA anastomosis: Completed with heart perfused
  • RA/bicaval anastomoses: Last

Weaning from Bypass:

Preparation:

  • Rewarming: To 36-37°C
  • Pacing: Temporary wires attached, set to 90-100 bpm (overdrive)
  • Inotropes: Prepared (isoprenaline, adrenaline, milrinone)
  • NO: Available if PHT

Inotropic Support:

  • Isoprenaline: 0.01-0.05 μg/kg/min (first-line chronotrope)
    • Pure β-agonist, increases HR and contractility
    • High resting HR (90-110 bpm) often needed initially
  • Adrenaline: 0.01-0.1 μg/kg/min (if additional inotropy needed)
  • Milrinone: 0.375-0.75 μg/kg/min (load 50 μg/kg slowly)
    • Inodilator, pulmonary vasodilation, lusitropic effect
    • Beneficial in elevated PVR
  • Vasopressin: 0.01-0.04 units/min (if vasoplegia, low SVR)

Weaning Sequence:

  1. Rewarming complete
  2. Defibrillate if VF (internal paddles 5-20 J)
  3. Rate control (pacing 90-100 or isoprenaline)
  4. Reduce bypass flow gradually
  5. Fill heart (volume)
  6. Assess function on TEE
  7. Trial off bypass (reduce flow, observe)
  8. If stable, remove venous cannula
  9. Remove aortic cannula (after venous)
  10. Protamine (1 mg per 100 IU heparin)

Failure to Wean:

  • Causes:
    • RV failure (most common, especially with PHT)
    • LV failure (rare with good donor)
    • Primary graft dysfunction (hyperacute rejection, poor preservation)
    • Air embolism (coronary)
    • Tamponade
  • Management:
    • Re-establish bypass
    • Optimize inotropes, afterload reduction
    • Mechanical support: ECMO or VAD
    • Consider retransplantation (rare)

Post-Bypass Management

Hemodynamic Goals:

  • MAP: >65-70 mmHg
  • CVP: 8-12 mmHg (not excessive - avoid RV distension)
  • PA pressures: <30-35 mmHg systolic (monitor for PHT)
  • Cardiac output: CI >2.2-2.5 L/min/m²

Denervated Heart Considerations:

  • Rate: 90-110 bpm (pacing or isoprenaline)
  • Rhythm: Sinus or atrial pacing preferred (AV synchrony important for filling)
  • No atropine response: (Not needed anyway)
  • Direct catecholamines: As above

Pulmonary Hypertension Management:

  • Inhaled NO: 20-40 ppm (selective pulmonary vasodilation)
  • Epoprostenol: IV or inhaled
  • Milrinone: Continue (pulmonary vasodilation)
  • RV optimization: Adequate preload (not excessive), afterload reduction

Bleeding Management:

  • Common: Preoperative coagulopathy, bypass, anticoagulation
  • Strategy:
    1. Surgical hemostasis (anastomoses, suture lines)
    2. Protamine (full reversal)
    3. Tranexamic acid (if not given)
    4. Fibrinogen concentrate/cryoprecipitate
    5. FFP
    6. Platelets
    7. rFVIIa (last resort)
  • Re-exploration: If >300-500 mL/hour or tamponade

Pacing:

  • Temporary epicardial wires: Atrial and ventricular
  • Indications:
    • Bradycardia (sinus node dysfunction common)
    • Heart block (conduction system trauma)
    • Sequential pacing (AV synchrony)
  • Settings: AAI or DDD mode, rate 90-100 initially, wean over days-weeks
  • Permanent pacemaker: 5-10% need permanent (if temporary fails)

Extubation:

  • Delayed typically: 24-48 hours (hemodynamic stability, bleeding controlled)
  • Fast-track: Some centers extubate early if excellent function
  • Criteria: Hemodynamically stable, minimal inotropes, acceptable ABG, good pain control

Postoperative Care

ICU Management:

Hemodynamics:

  • Inotropes: Wean gradually over 3-7 days (isoprenaline first)
  • Vasopressors: For vasoplegia (common early post-transplant)
  • NO: Wean gradually over 24-48 hours (rebound PHT if stopped abruptly)
  • Pacing: Wean as sinus node recovers (days to weeks)

Fluid Management:

  • Restrictive: Third-spacing common, diuretics early
  • Renal function: Monitor closely (calcineurin inhibitor nephrotoxicity)
  • Liver congestion: RV failure causes hepatic dysfunction (improves as RV adapts)

Immunosuppression:

  • Induction: Basiliximab (IL-2 receptor blocker) or ATG (T-cell depletion) given intra/post-op
  • Triple maintenance:
    • Calcineurin inhibitor (tacrolimus preferred over cyclosporine)
    • Antiproliferative (mycophenolate mofetil or azathioprine)
    • Corticosteroid (high dose early, taper to low dose by 6 months, some steroid-free protocols)
  • Trough levels: Monitor closely (tacrolimus 10-15 ng/mL early)

Rejection Surveillance:

  • Biopsies: Scheduled (weekly initially, then monthly, then annually)
    • Via right internal jugular, transvenous, RV septum
  • ISHLT grading: 0R (none) to 3R (severe)
  • Treatment:
    • Grade 1R-2R: Often surveillance, may increase steroids
    • Grade 3R: High-dose methylprednisolone 500-1000 mg IV × 3 days
    • Hemodynamic compromise: Thymoglobulin, plasmapheresis

Infection Prophylaxis:

  • Bacterial: Perioperative antibiotics
  • CMV: If donor+ or recipient-: ganciclovir/valganciclovir prophylaxis 6 months
  • Fungal: If colonized or high risk (fluconazole, voriconazole, posaconazole)
  • PJP: TMP-SMX prophylaxis (6-12 months)
  • Toxoplasma: If donor+

Complications:

Early Graft Dysfunction (Primary Graft Dysfunction):

  • Causes: Preservation injury, prolonged ischemia, hyperacute rejection
  • Management: Mechanical support (ECMO), inotropes, optimization
  • Outcomes: If refractory, high mortality

RV Failure:

  • Management: As above, mechanical support if refractory
  • Usually improves: As PVR falls over days-weeks

Arrhythmias:

  • Atrial flutter/fibrillation: Common (atrial suture lines, denervation); amiodarone, cardioversion
  • VT/VF: Ventricular arrhythmias concerning for rejection or ischemia

Renal Dysfunction:

  • Calcineurin inhibitor toxicity: Dose adjustment, switch to alternative (everolimus)
  • Cardiorenal syndrome: Improves with better cardiac output

Sternal Infection:

  • Risk: Immunosuppression, diabetes, malnutrition
  • Management: Debridement, antibiotics, muscle flap coverage

Long-Term:

  • Allograft vasculopathy (CAV): Screen annually (angiography, stress test)
  • Malignancy: Post-transplant lymphoproliferative disorder (EBV-related), skin cancer
  • Renal failure: CKD common (calcineurin inhibitors, hypertension, diabetes)

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Patients

Access and Equity:

  • Transplant centre: Major centres only (Sydney, Melbourne)
  • Referral: May be delayed due to comorbidities, geographic barriers
  • Assessment: Extended stay in metropolitan centre for workup

Health Disparities:

  • Cardiovascular disease: Higher rates of risk factors (diabetes, renal disease, hypertension)
  • Rheumatic heart disease: Leading cause of cardiac disease in some regions
  • End-stage heart failure: May present late

Cultural Considerations:

  • Communication: Complex procedure requires thorough explanation
  • Family involvement: Extended family in decision-making
  • Aboriginal Liaison Officers: Essential for support
  • Sorry Business: Consider family obligations

Post-transplant:

  • Compliance: Complex immunosuppressive regimen challenging
  • Follow-up: Requires ongoing travel to transplant centre (lifelong)
  • Telemedicine: Local echo, blood tests, remote consultation
  • Cultural support: Connection to country during prolonged treatment

Māori Health Considerations

Health Inequities:

  • Cardiovascular disease: Leading cause of death; disparities in care
  • Rheumatic fever/heart disease: Higher incidence in Māori and Pacific peoples
  • Access barriers: Geographic (North vs South Island)

Cultural Safety:

  • Whānau involvement: Essential for life-changing decision
  • Communication: Risk/benefit in culturally appropriate manner
  • Māori Health Workers: Liaison throughout process
  • Kaupapa Māori approaches: Holistic view of health

Practical Considerations:

  • National service: Auckland (Green Lane Hospital) - single centre for NZ
  • Assessment phase: Relocation to Auckland for workup and transplant
  • Post-transplant: Long-term residence or repeated travel
  • Rural follow-up: Coordination with local services, telemedicine

Equity:

  • Ensure timely referral and assessment
  • Address social determinants affecting outcomes
  • Support for adherence (transportation, accommodation costs)

ANZCA Final Exam Focus

SAQ Patterns

Common Questions:

  • "Describe the anaesthetic management for heart transplantation."
  • "What are the implications of denervated heart physiology?"
  • "How would you manage post-transplant right ventricular failure?"
  • "Discuss the assessment and significance of pulmonary vascular resistance in heart transplant candidates."
  • "What is the difference between bicaval and biatrial technique?"

Marking Scheme Priorities:

  • Induction strategy (etomidate/ketamine, high-dose opioid, avoid propofol)
  • PVR assessment and management (inhaled NO, milrinone, RV support)
  • Denervated heart physiology (resting HR 90-110, direct-acting agents)
  • Inotropic support (isoprenaline, adrenaline, milrinone)
  • Weaning from bypass (pacing 90-100, TEE assessment)
  • Immunosuppression basics (triple therapy, induction agents)

Viva Scenarios

Scenario 1: High PVR Management

  • Recipient with PVR 6 Wood units (borderline), post-bypass RV dilated, low output
  • Management: Inhaled NO, milrinone, optimize preload, temporary RVAD if refractory

Scenario 2: Denervated Heart

  • Patient bradycardic post-transplant (40 bpm), no response to atropine
  • Discussion: Denervated heart - atropine ineffective; use isoprenaline or pacing

Scenario 3: Bleeding

  • Massive bleeding from posterior LA suture line
  • Management: Resuscitation, blood products, cell saver, surgical repair, consider rFVIIa

Scenario 4: Failure to Wean

  • Cannot separate from bypass despite inotropes
  • Differential: RV failure vs primary graft dysfunction; management as above

Key Points for Examination Success

  1. Induction: Etomidate/ketamine preferred (hemodynamically stable), high-dose opioid, avoid propofol
  2. PVR: <2.5 Wood units ideal; >5-6 high risk; vasodilator testing essential
  3. Bicaval cannulation: Preserves RA anatomy, preferred technique
  4. Denervated heart: Resting HR 90-110 bpm, direct-acting agents only (isoprenaline, adrenaline)
  5. Post-bypass inotropes: Isoprenaline 0.01-0.05 μg/kg/min (chronotrope), milrinone (inodilator), adrenaline if needed
  6. RV failure: Most common weaning problem; manage with NO, milrinone, inotropes, mechanical support if refractory
  7. Temporary pacing: Common (90-100 bpm); 5-10% need permanent pacemaker
  8. Immunosuppression: Triple therapy (calcineurin inhibitor, antiproliferative, steroid); induction with basiliximab or ATG
  9. Complications: Rejection (biopsy surveillance), infection (CMV, bacterial), CAV (late mortality), renal dysfunction
  10. Outcomes: 1-year survival 85-90%, 5-year survival 70-75%

Assessment Content

SAQ 1: Heart Transplant Anaesthesia (20 marks)

Question: A 52-year-old man with dilated cardiomyopathy (EF 15%) is undergoing orthotopic heart transplantation. His preoperative right heart catheterization shows PVR 3.5 Wood units (reversible to 2.0 with inhaled NO).

a) Describe the key considerations for induction of anaesthesia in this patient. (6 marks) b) Outline the weaning strategy from cardiopulmonary bypass after donor heart implantation. (8 marks) c) The patient has persistent hypotension (MAP 55 mmHg) with elevated CVP (18 mmHg) and TEE shows severe RV dilation with reduced function after weaning from bypass. What is your management? (6 marks)

Model Answer:

a) Induction considerations (6 marks):

  • Hemodynamic stability critical: Avoid myocardial depression, maintain coronary perfusion (1 mark)
  • Agent selection: Etomidate 0.2-0.3 mg/kg (hemodynamically neutral) or ketamine (sympathomimetic) (1.5 marks)
  • Avoid propofol: Vasodilation and myocardial depression contraindicated in severe HF (1 mark)
  • High-dose opioid: Fentanyl 10-20 μg/kg or remifentanil to blunt sympathetic response (1 mark)
  • Inotrope readiness: Continue preoperative inotropes, have adrenaline/milrinone drawn up (1 mark)
  • ICD: Deactivate before surgery (shock risk) (0.5 marks)

b) Weaning strategy (8 marks):

Preparation:

  • Rewarming: Complete to 36-37°C (1 mark)
  • Temporary pacing: Epicardial wires, set rate 90-100 bpm (denervated heart needs higher rate) (1 mark)
  • Inotropes prepared: Isoprenaline, adrenaline, milrinone (1 mark)

Pharmacological support:

  • Isoprenaline: 0.01-0.05 μg/kg/min (primary chronotrope, β-agonist) (1 mark)
  • Milrinone: Load 50 μg/kg slowly, then 0.375-0.75 μg/kg/min (inodilator, pulmonary vasodilation) (1 mark)
  • Adrenaline: 0.01-0.1 μg/kg/min if additional inotropy needed (0.5 marks)

Weaning sequence:

  • TEE assessment: Baseline function after reperfusion (0.5 marks)
  • Gradual flow reduction: Observe hemodynamics (0.5 marks)
  • Volume loading: Fill heart as coming off bypass (0.5 marks)
  • Trial off: If stable, remove venous cannula, then aortic cannula (0.5 marks)
  • Protamine: Full heparin reversal (0.5 marks)

c) Post-bypass RV failure management (6 marks):

  • Optimize preload: Ensure adequate but not excessive (CVP 12-15 ideal, not >18) (1 mark)
  • RV inotropy: Continue/increase milrinone (inodilator with pulmonary vasodilation) (1 mark)
  • Pulmonary vasodilation: Inhaled NO 20-40 ppm (selective pulmonary vasodilation) (1.5 marks)
  • Systemic vasopressors: Noradrenaline to maintain MAP >65-70 mmHg (RV coronary perfusion) (1 mark)
  • Afterload reduction: Avoid high afterload (vasodilate if SVR high) (0.5 marks)
  • Mechanical support: If refractory, consider ECMO or RVAD (0.5 marks)
  • IABP: May augment coronary perfusion (0.5 marks)

SAQ 2: Denervated Heart (20 marks)

Question: a) Describe the physiological characteristics of the denervated transplanted heart. (8 marks) b) How do these characteristics affect the pharmacological management of heart rate and blood pressure in the post-transplant period? (6 marks) c) What are the clinical implications of cardiac denervation for patient monitoring and symptom recognition? (6 marks)

Model Answer:

a) Physiological characteristics (8 marks):

  • Autonomic denervation: Vagal and sympathetic nerves transected during surgery (1 mark)
  • Resting heart rate: 90-110 bpm (higher than normal due to absence of vagal tone) (1.5 marks)
  • No rate variation: HR does not increase with exercise (no sympathetic neural response) or decrease with sleep (no vagal tone) (1.5 marks)
  • Delayed response: Relies on circulating catecholamines (slow) rather than neural control (fast) (1 mark)
  • Cardiac reserve: Blunted maximal heart rate (reduced exercise reserve) (1 mark)
  • Venous return dependent: Cardiac output increases primarily via stroke volume with exercise (1 mark)
  • Position changes: Minimal HR change with postural changes (no vagal reflex) (0.5 marks)
  • Denervated supersensitivity: Exaggerated response to catecholamines and digoxin (0.5 marks)

b) Pharmacological management (6 marks):

  • Direct-acting agents required: Isoprenaline, adrenaline, dobutamine, dopamine (β-agonists act directly on receptors) (2 marks)
  • Indirect agents ineffective: Atropine (no vagal tone to block), glycopyrrolate, edrophonium have no chronotropic effect (1.5 marks)
  • Pacing: Temporary epicardial pacing often required (90-100 bpm initially) (1 mark)
  • Denervated supersensitivity: Exaggerated response to catecholamines - use lower doses, titrate carefully (1 mark)
  • No digoxin vagal effect: Inotropic effect preserved, no rate-slowing effect (0.5 marks)

c) Clinical implications (6 marks):

  • Silent ischemia: No angina due to denervation (CAV can progress undetected) (1.5 marks)
  • Arrhythmia presentation: May not feel palpitations the same way; syncope may be first sign (1 mark)
  • Rejection detection: Cannot rely on resting tachycardia (no vagal response to inflammation) (1.5 marks)
  • Biopsy surveillance: Essential (endomyocardial biopsies) as clinical signs unreliable (1 mark)
  • Exercise tolerance: Reduced maximal capacity, HR response blunted, fatigue may be only symptom (1 mark)

Viva Scenario: Bicaval vs Biatrial Technique

Examiner: "Discuss the advantages of bicaval versus biatrial anastomotic technique in heart transplantation."

Candidate: "The bicaval technique involves separate anastomoses of the superior vena cava, inferior vena cava, left atrium, aorta, and pulmonary artery, whereas the biatrial technique uses a single large right atrial anastomosis incorporating both cavae. The bicaval technique has become preferred because it preserves more normal right atrial anatomy and physiology. This leads to less tricuspid regurgitation since the sinoatrial node region and right atrial geometry are better preserved. It also reduces atrial arrhythmias like atrial flutter and fibrillation."

Examiner: "Are there any situations where biatrial might still be used?"

Candidate: "Biatrial technique might be used in very urgent situations where cross-clamp time needs to be minimized, as it's technically faster to perform a single large right atrial suture line than separate caval anastomoses. It might also be used in small pediatric transplants where the anatomy is very different, or in some reoperative cases where extensive adhesions make the bicaval approach more difficult. However, most centers now use bicaval as their standard technique."

Examiner: "How does this affect the anaesthetic management?"

Candidate: "From an anaesthetic perspective, both techniques require similar management. However, the bicaval technique may have a slightly higher incidence of early bradycardia or heart block requiring pacing since the sinoatrial node region is more extensively dissected. The improved hemodynamics with less tricuspid regurgitation may make weaning from bypass slightly easier with the bicaval technique, and the reduced arrhythmia burden postoperatively may mean less need for antiarrhythmic drugs."

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