The anaesthesiologist's role in heart transplant: An Armed Forces Medical Services perspective

Heart transplantation remains the definitive therapy for refractory endstage heart failure. While surgical and immunosuppressive advances have been pivotal, the anaesthesiologist's role is underrepresented-particularly within Armed Forces Medical Services (AFMS), with logistical and geographic constraints. This study examines perioperative anaesthetic strategies in AFMS heart transplants and their impact on patient and graft outcomes.

This retrospective case series included 33 consecutive heart transplants performed across AFMS centres between 2018 and 2024. Data were analysed for preoperative optimisation, intraoperative management, and postoperative outcomes. Donor optimisation was done often in resource-limited peripheral hospitals with transport by air. Intraoperative strategies included opioid-based induction, pulmonary artery catheterisation, transesophageal echocardiography, and goaldirected perfusion. Supportive measures such as intra-aortic balloon pump (IABP), and extracorporeal membrane oxygenation (ECMO) were applied as indicated.

Dilated cardiomyopathy was the predominant indication. Three recipients received preoperative ambulatory milrinone. Intraoperatively, isoprenaline was required in 27% (n=9), temporary pacing in 18% (n=6), IABP in 12% (n=4), and ECMO in 9% (n=3). Early extubation was achieved in 67% (n=22), with mean ventilation duration of 1.43 ± 0.79 days. Postoperative complications included infection (36%, n=12), arrhythmias (27%, n=9), acute kidney injury requiring CRRT (18%, n=6), and early graft dysfunction (12%, n=4). One-year mortality was 24% (n=8), which included acute graft dysfunction (n=5).

This AFMS cohort underscores the vital role of anaesthesiologists in heart transplantation, spanning donor optimisation, intraoperative management, and postoperative care. Structured, resource-conscious protocols facilitated acceptable outcomes despite systemic constraints, highlighting the importance of anaesthesiologist-led perioperative strategies in military transplant programs.