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Heart transplantation: intraoperative management, postoperative therapy and complications
A Haverich1, L Dammenhayn, J Albes
1Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, FRG.
Insights
Heart transplantation (HTX) survival rates exceed 80% with modern immunosuppression and prophylactic strategies. Early detection and treatment of complications like organ rejection and infections are crucial for patient outcomes.
Area of Science:
- Cardiology
- Transplantation Surgery
- Immunology
Background:
- Orthotopic heart transplantation (HTX) is the standard procedure, offering good outcomes.
- Heterotopic HTX survival rates remain significantly lower.
- Postoperative management focuses on preventing rejection and infections.
Purpose of the Study:
- To review current practices in heart transplantation.
- To highlight common complications and their management.
- To discuss factors influencing patient survival rates.
Main Methods:
- Standard orthotopic heart transplantation technique.
- Triple drug immunosuppression (cyclosporine, prednisolone, azathioprine).
- Prophylactic measures including reversed isolation, antibiotics, antivirals, and antifungals.
Main Results:
- Rejection incidence decreases over the first year post-transplant.
- Acute rejection treated with methylprednisolone or anti-T-cell antibodies.
- Infections often follow immunosuppression or rejection treatment.
Conclusions:
- Close patient monitoring and prompt complication management are key.
- Current one-year survival rates after HTX are 80% or higher.
- Optimized immunosuppression and prophylaxis improve heart transplant outcomes.
Abstract:
Currently, heart transplantation (HTX) is performed as an orthotopic cardiac replacement according to the technique of Lower and Shumway in over 95% of the cases with good results. Survival after heterotopic HTX, by contrast, remain poor (one year survival: 50%). Postoperative therapy compiles primarily prophylactic measures to prevent complications, especially organ rejection and infections. Immunosuppressive prophylaxis generally includes a triple drug therapy consisting of cyclosporin, prednisolone, and azathioprine for maintenance therapy. Initially there is often an additional application of poly- or monoclonal antibodies. The prime measure to prevent infection during the initial hospital stay will be reversed isolation of the recipient. Initial antibiotic prophylaxis resembles that of conservative cardiac surgery, but in addition antiviral and antifungal prophylaxis is applied. The most common postoperative complication following HTX is cardiac rejection, which is detected by routine endomyocardial biopsies. At our institution the incidence of rejection decreases from 3.07 episodes per patient in the first 3 months to 1.97 episodes during the last 6 months of the first year after HTX. In general, acute rejection is treated by methylprednisolone (3 x 500 mg/day) or anti-T-cell-antibodies. Infections often occur following intervals of increased immunosuppression, usually early postoperatively and following therapy of acute rejections. Often, invasive diagnostic measures have to be taken rapidly in order to allow for specific therapy (antibiotics, antimycotic treatment, virostatic agents). Close follow-up of the heart transplant recipient and rapid therapy of possible postoperative complications enable the current one-year survival rates of 80% or more.