Anesthetic considerations for the postcardiac transplant patient

The first human heart transplant was performed in 1967. The low survival rates of the early transplant patients revealed that the surgical procedure was only a small part of successfully managing these patients. Patient outcome depended upon the interrelationship of surgery, immunology, pharmacology, epidemiology and oncology. A comprehensive understanding of the transplanted heart is essential to effectively plan the anesthetic management of posttransplant patients requiring any type of surgery. The transplant recipient has a healthy heart which utilizes different mechanisms to meet the body's requirements. The autonomic regulatory mechanisms are not available to prevent wide swings in the patient's hemodynamic state, and the stress response is slower than normally expected. Since cardiac parameters are significantly altered, patients may demonstrate decreases in systemic blood pressure and cardiac filling pressures. Compensatory maneuvers are delayed and reductions in cardiac output lead to lessened cerebral perfusion. Anesthetists must allow time for the denervated heart to compensate for these changes. Pharmacologic intervention should consist of drugs with direct action on the myocardium and vasculature. Posttransplant patients are immunosuppressed and maintenance of a delicate balance is essential for survival. Protocols for immunosuppressive therapy must be individualized to achieve optimal effects. Cyclosporine plays a major role in immune system depression. Anesthetic management must compensate for alterations in hepatic and renal function, vascular integrity and cardiac function. Strict adherence to aseptic technique helps reduce infections related to anesthesia management.