Since the first human heart transplantation. (Ozinsky, 1967) its success as a treatment has been established for selected patients with end-stage cardiomyopathy ...
Br.J. Anaesth. (1986), 58, 1357-1364
ANAESTHESIA FOR HEART TRANSPLANTATION A Retrospective Study and Review K. DEMAS, J. WYNER, F. G. MIHM AND S. SAMUELS Since the first human heart transplantation (Ozinsky, 1967) its success as a treatment has been established for selected patients with end-stage cardiomyopathy. The experience at Stanford has encouraged the establishment of a number of cardiac transplantation centres in the United States and United Kingdom (Oyer et al., 1981; Pennock et al., 1982) particularly since possible alternative therapy for such patients—including the use of a total artificial heart (DeVries et al., 1984) or the insertion of a left-ventricular assist device (Rose et al., 1983)—is still in the experimental phase. Although several anaesthetic techniques and agents have been used, the literature regarding the anaesthetic management of heart transplantation, for both the initial and any subsequent operation, is sparse (Keats et al., 1969; Paiement et al., 1970; Fernando, Keenan and Boyan, 1978). We review our clinical experience concerning the anaesthetic techniques and agents used at Stanford over the first 15 yr. PATIENTS AND METHODS
Between January 1968 and May 1982, heart transplantation was undertaken on 261 patients at Stanford University. The charts of all recipients were reviewed and data were extracted concerning demographic characteristics, physical status, results of preoperative cardiac catheterization studies, anaesthetic agents, and the incidences of those complications which may have been related to anaesthetic management. These complications included intraoperative ventricular arrhythmias, systemic arterial hypotension, prolonged postoperative requirement for mechanical ventilation, KATHRYN DEMAS, M.D.; JANET WYNER, M.B., CH.B; FREDERICK G. MTHM, M.D.; STANLEY SAMUELS, M.B., CH.B.; Department
of Anesthesia S278, Stanford University School of Medicine, Stanford, CA 94305, U.S.A. Correspondence to J. W.
SUMMARY The anaesthetic records of 261 heart transplant recipients were reviewed. Data collected included demographic characteristics, physical status, results of preoperative cardiac catheterization studies, anaesthetics agents and incidences of complications which may have been related to anaesthetic management. Forty-five patients received a volatile agent (methoxyflurane 31, enflurane 10, ha/othane 4) and 216 patients were anaesthetized with a high-dose narcotic technique (morphine 122, fentanyl 71, hydromorphone 14, meperidine 9). Hypotension and arrhythmias were correlated with use of volatile and narcotic anaesthetics, respectively. No mortality was associated with anaesthetic management.
renal failure and the development of either global neurological dysfunction or focal neurological deficits. Hypotension during anaesthesia was defined as a systolic arterial pressure of less than 90 mm Hg, a diastolic arterial pressure of less than 50 mm Hg, or a mean arterial pressure of less than 60 mm Hg determined on more than two readings, 5 min apart. Postoperative mechanical ventilation was considered prolonged when this was required for more than 24 h after transplantation. Ventricular arrhythmias were denned as significant only if these required specific therapeutic intervention (cardioversion, drugs). Renal failure was defined as significant only if haemodialysis was required. Chi square analysis was used to relate the incidences of these complications to the anaesthetic technique used and was considered statistically significant if the P value was < 0.05. The incidence and causes of death within 1 week after transplantation were also reviewed. Similar data were collected pertaining to all subsequent anaesthetics administered to cardiac transplant
BRITISH JOURNAL OF ANAESTHESIA
1358 recipients. A total of 397 anaesthesia records were reviewed which included cardiac transplantation (237), repeat transplantation (24) and anaesthesia for a subsequent surgical procedure (136).
TABLE II. Results of preoperative cardiac catheterization studies in cardiac transplant recipients. RAP = right atrial pressure; PAP = pulmonary arterial pressure ; PCWP = pulmonary capillary wedge pressure; LV = left ventricular {end-diastolic) pressure; PA = pulmonary artery
RESULTS
Demographic data
Recipients ranged in age from 12 to 58 yr. The primary diagnoses of recipients were: ischaemic cardiomyopathy, 45 %; idiopathic cardiomyopathy, 46%; valvular heart disease, 4.7%; congenital heart disease, 1.7%; post-traumatic aneurysm, and primary cardiac tumour, 0.4%. Twenty-four patients underwent a second transplantation, the reasons for which included atherosclerosis or rejection of the donor heart. Preoperative physical status
All patients were classified as New York Heart Association Class IV or V. Physical signs of congestive heart failure were present in the majority of cardiac transplant recipients on the day of surgery (table I). Twelve percent required pharmacological inotropic support before surgery and a further 2 % required mechanical circulatory support with intra-aortic balloon counterpulsation (table I). Renal dysfunction, as reflected by increases in BUN and creatinine concentrations, and liver dysfunction, as defined by a non-iatrogenic increase in prothrombin time, were present before operation in 41% and 52% of patients, respectively. Preoperative ventricular arrhythmias were reported in 12% of patients, TABLE I. Evidence of ventricular failure in cardiac transplantation recipients on day of operation Evidence Symptoms Orthopnoea Dyspnoea Peripheral oedema Physical signs Rales S3 gallop Jugular venous distension Hypotension Oliguria Chest radiograph Pleural effusion Pulmonary oedema Circulatory support Inotropic drags Intra-aortic balloon
Incidence 42% 42% 27% 44% 67% 47%
28% 3% 8% 7% 12% 2%
RAP mean (mm Hg) PAP systolic (mm Hg) PAP diastolic (mm Hg) PCWP mean (mm Hg) LV end-diastolic (mm Hg) Cardiac output (litre min~>) Cardiac index (litre min"1 m1 BSA) PA O, saturation (%)
Mean
SD
12 50 27 27 27 3.3 1.8
17 10 9 2 2.5 1.3
48
16
8
and were most common in patients suffering from idiopathic cardiomyopathy. Preoperative cardiac catheterization data
Most often, the cardiac catheterization data demonstrated marked left ventricular dysfunction as indicated by increases in left ventricular end-diastolic pressures and pulmonary capillary wedge pressures, and low cardiac indices (table II). Since the selection criteria eliminated those patients with severe pulmonary hypertension (pulmonary vascular resistance greater than 6 Wood-units), the close relationship between the pulmonary diastolic and capillary wedge pressures and the absence of marked increases in right-sided pressures were expected findings. Anaesthetic agents
After aseptic placement of intravascular catheters and attachment to appropriate monitors, anaesthesia was induced with either an inhalation or an i.v. technique. During the early period of cardiac transplantation at Stanford, the preferred anaesthetic agent was methoxyflurane in oxygen. However, with the subsequent documentation of this agent's nephrotoxicity, its use was abandoned (Mazze, Shue and Jackson, 1971). After the introduction of the high-dose narcotic technique for cardiac anaesthesia (Lowenstein, Hallowell and Levine, 1969; Stanley and Webster, 1978), this method soon became popular for the anaesthetic management of cardiac transplantation. Of the patients studied, 45 received a volatile agent as the primary anaesthetic drug and 216 were anaesthetized with a high-dose narcoticoxygen technique (table III). There has also been a trend towards the use of fentanyl or hydromor-
CARDIAC TRANSPLANTATION
1359
TABLE III. Anaesthetic agents Patients
Agent Volatile Methoxyflurane Enflurane Halothane
TABLE V. Surgical procedures performed after cardiac transplantation. * Usually abcess drainage. ^Vascular access, vocal cord nodules, condylomata, skin grafts, etc.
Complications
Emergency exploration for mediastinal bleeding Complications caused by infection* Laparototny Craniotomy Mediastinotomy/thoractomy Extremity abscess drainage Bronchoscopy Vitrectomy Scleral buckle Complications caused by steroid treatment Total hip arthroplasty or pinning Laparotomy for perforated viscus Cataract excision Vascular surgery Aortic Peripheral Amputations Cardioversion Elective cholecystectomy Miscellaneousf
The major complications encountered are tabulated in table IV. The incidence of hypotension was significantly lower when narcotic agents were used, while serious ventricular arrhythmias occurred more often with this technique. Seven patients who had not required haemodialysis before surgery required dialysis after transplantation. All of these patients had some preoperative renal dysfunction. The incidences of both prolonged mechanical ventilation and new onset renal failure were low (< 3%) and not significantly different between the patients receiving different anaesthetic techniques. Gross neurological deficits after transplantation were uncommon, occurring in only six patients. Of the six patients, two were in preoperative cardiogenic shock when a donor became available, two suffered early postoperative cardiac arrest (within 72 h), and three suffered from postoperative septicaemia with renal and hepatic dysfunction. Five other patients had focal neurological
deficits. None of these neurological complications could be ascribed to the anaesthetic agent(s) or technique. Five deaths occurred within 7 days of transplantation, of which three occurred during surgery. One patient could not be weaned from cardiopulmonary bypass because of right heart failure associated with pulmonary embolization and pulmonary hypertension, and in the other two death was caused by uncontrollable haemorrhage. Two more deaths occurred within 72 h of surgery: one was associated with right heart failure secondary to pulmonary hypertension (as the donor heart was too small to work against the high pulmonary vascular resistance) while, in the other, hyperacute rejection of the donor heart occurred. Mortality rate and anaesthetic technique were not correlated.
Narcotic Morphine 1.5-2 mg kg"1 Fentanyl 25-75 ng kg-' Hydromorphone 0.2-0.5 mg kg"1 Pethidine 10 mg kg"1 Benzodiazepine Diazepam 0.2-0.3 mg kg"1
31 10 4 122 71 14 9 85
phone rather than morphine or pethidine over the past 5 years. Diazepam 0.2-0.3 mg kg"1 was used to supplement narcotic anaesthesia in 85 patients.
TABLE IV. Incidence of complications in anaesthesia for cardiac transplantation. *P values obtainedfrom Chi square analysis comparing the incidences of each complication between volatile and narcotic groups Anaesthetic Complication Hypotension Mechanical ventilation > 24 h Ventricular arrhythmia Renal failure
Volatile (n •= 45)
Narcotic (n = 186)
P*
51% 2% 9% 2%
21% 3% 21% 3%
