Perioperative Challenges for Heart Transplantation

Free online EACTAIC webinar

Click here to access the on-demand (available for EACTAIC members)

Take Home message – dr. Nandor Marczin

This webinar was organised by the EACTAIC Education Committee to cover the clinical and scientific aspects of current perioperative challenges of Heart Transplantation.
We have selected 4 hot topics to highlight these challenges and to provide and update on progress. Members of the faculty were selected based on their active roles in the EACTAIC Transplant and VAD subcommittee and their local,national and international reputation for senior clinical leadership in these areas.

The first talk by Vera von Dossow focused on the need and options for biventricular support for patients with end stage heart disease and the role of total artificial hearts from one of the most experience centres in Germany. Her video concisely highlighted the most important aspects of TAH therapy and signalled the   requirement for multidisciplinary nature of care. Vera focused on devices, the importance of careful anaesthesia management and provided international data on the current status of this exciting therapy at the interphase of mechanical support and transplant.
Nandor Marczin was tasked to review donation aspects and summarise the current status of DBD and DCD heart transplantation. His theme was built around the recognition of current complexity of cardiac transplantation as a “Perfect Storm” by the complexity of the recipients less than ideal donors and sophisticated technologies of organ assessment, evaluation and reconditioning. This era is definitely dominated by advances in machine perfusion pushing the boundaries of perfusion science, and clinical management of ischemia reperfusion injury.
This theme was further developed by Eric de Waal covering the topic of Primary Graft Dysfunction. He has reviewed the basic mechanisms of this noinspecific injury in the context of the recent consensus definition by ISHLT and advocated the role of perioperative cytokine response and the role of multiple hits in this devastating condition.
This nicely set the theme for the next presentation by Antonio Rubino on the critical aspects of intensive care management. He conveyed the importance of the initial postoperative management and the need of very careful, broad and detailed monitoring of heart and distant organ function and early therapies to reduce postoperative complications that impacts on allograft survival and patient outcomes. Business is not as usual and the role of early multidisciplinary  management is paramount including early implementation of mechanical support in case of severe graft dysfunction. Antonio also concluded that DCD heart transplantation approaches clinical outcomes similar to DBD based on the leading Papworth experience.
In recognition that Heart Transplantation represents unique challenges for general anaesthesia, the last topic was devoted to this important field. Andrea Szekely has focused on the most important physiological changes to be considered when patients with previous transplants present for emergency or elective non cardiac surgery. She has reviewed the most frequent surgeries and provided important insights for anaesthetic considerations including haemodynamic management, immunosuppression and managing susceptibility to infections.  She also discussed the signs of rejection, and she added that the elective noncardiac surgery planned should be postponed in case of signs of rejection.

The overall take home message is that despite these complexities, our specialty has introduced leading technologies, involved in various new aspects that traditionally were outside of our realm including contributions to machine perfusions, risk assessment and risk reduction. The demonstration that DCD and nonischemic preservation can achieve 100 percent survival sets a new standard to aspire to and mobilise all our knowledge, experience and devotion to manage these high-risk patients and operations. This era of transplantation also calls for more sophisticated research to better understand ischaemia-reperfusion and PGD and to translate basic science advances to clinical practice.

The Perioperative Challenges for Heart Transplantation, Rome, Italy, 31/05/2021-31/05/2021 has been accredited by the European Accreditation Council for Continuing Medical Education (EACCME®) with 2 European CME credits (ECMEC®s). Each medical specialist should claim only those hours of credit that he/she actually spent in the educational activity.

What’s in it for me?

After participating in this webinar, you will better understand:

  • The role of total artificial heart transplantation in the management of end stage heart-failure;
  • Pro’s and cons of DBD versus DCD heart donation;
  • The underlying mechanisms and outcomes of primary graft dysfunction;
  • The intensive care management after heart transplantation;
  • Non-cardiac surgery in heart transplanted patients.

Target audience

Cardiac surgeons, cardiovascular anaesthetists, perfusionists, intensivists, general anaesthetists, anaesthesia certified nurses, nurses, interns, and medical students.

Scientific director: Mohamed R. El Tahan, EACTA Education chair

Scientific Moderators: Eric de Waal (The Netherlands), Nandor Marczin (UK)

  1. 17:00-17:25 The role of Total Artificial Heart Transplantation in the management of end-stage heart failure - Vera von Dossow, Germany
  2. 17:25-17:50 The current status of DCD and DBD heart transplantation - Nandor Marczin, UK
  3. 17:50-18:15 Primary Graft dysfunction after heart transplantation - Eric de Waal, The Netherlands
  4. 18:15-18:40 Intensive care management of heart transplantation - Antonio Rubino, UK
  5. 18:40-19:05 Non-cardiac surgery in Heart Transplanted patients - Andrea Szekely, Hungary
  6. 19:05-19:25 Q&A from the audience
  7. 19:25-19:30 Wrapping up and Adjourn - Nandor Marczin, UK

 

 

It is difficult to attribute the immediate RVf to one case only, it is usually multifactorial. 

Most common causes are either related to recipient such as increased PVR with  consequent increase in afterload and early graft dysfunction or donor related such as  prolonged ischaemic time and reperfusion. Vasoplegia often seen in the immediate post operative period  is also a contributing factor that leads to hypoperfusion of the right ventricle

Speakers:

The first 24-48  hours are always critical to monitor and detect any early primary graft dysfunction or guide the inotropic weaning. In our practice we integrate clinical parameters with intra-operative and post operative US images. I believe it would be difficult to justify a cost-benefit analysis of using continuous TEE when you can perform and repeat TTE (TOE if necessary) studies integrating the findings with the clinical picture.

Speakers:

Yes, the concept of thoracoabdominal NRP for DCD hearts has been developed by the Papworth team based on old time experiemce putting even DBD donors on cardiopulmonary bypass by a number of UK transplant centres. The NRP program has achieved excellent results but some ethical concerns remain around the issue of the permanency criteria of death and it is a more complex organisation than direct procurement to machine perfusion. For these reasons, our commissionairs the NHS BT has made a consensus that DCD heart retrieval will employ direct procurement in the near future. Abdominal NRP is still current practice in the UK. 

Speakers:

Thank you. I agree withg you both in terms of potential in improving activity and the need of very close communications. Most centres consider 30-60 min of funcional warm ischemia time a limit but a lot depends on experience of the team, logistics and com plexity of the recipients. After the mandatory standoff it takes around 30 minutes to place the heart on the OCS and tthere will be a surgical implantation time of 45-80 min to reperfusion. OCS preservation in my view is safe up to 4-6 hours but my concern is the accumulatiion of cytokines and injurious mediators and metaboolic changes over time in the recirculating system.

Speakers:

As already mentioned during the session, this is an interdisciplinary decision, however, all logistic efforts should be mobilized to go for transplantation in these high risk patients.

Speakers:

This is a  difficult and ethical question, especially the discussion for pediatric patients. It is necessary that in transplant conferences the decision is made by the interdisciplinary team.

Speakers:

That is a tough question. The clinical suspicion should always be there for rejection, and multidisciplinary decisions should be promptly made not only on histological evidence but a broader clinical picture. An expert cardiologist added that biopsy is a poor gold standard. It is possible to 'miss' rejection, either because the right bit of the myocardium isn't biopsied or because the steroid has been started before the biopsy and the inflammatory infiltrate has already resolved. But it's difficult to justify aggressively treating rejection without a histological diagnosis. It's a bit like cancer - you wouldn't use chemotherapy or radiotherapy unless you were certain about the histological diagnosis. In future, we will use circulating biomarkers of rejection - Troponin, cell-free allospecific DNA, etc.

Speakers:

Dr De Waal: We in our hospital most often use norepinehrine with NO and dobutamine for weaning from bypass. If the RV function is worse and/or the Pulmonary artery pressures are high, we may chop over to milrinone with NO and Norepinephrine, and eventually epinephrine small boluses of 5 - 10 microgram and eventually starting a continuous infusion of epinephrine as well. However, some centers imay believe in another practice in inotropic support, with probably norepinephrin, dobutamine and epinephrine and NO.

Dr. Szekely: we use the milrinone-dobutamine or milrinone -low dose epinephrine infusion with Nitric oxide supplementation. Norepinephrine and vasopressine will be added in vasoplegic patients (if SVR <600).

Speakers:

Yes, we use the left side and we punctate with ultrasound technique. I strongly advise to check the  patency of the neck and subclavian veins before the operation in any doubtful case (like superficial skin veins, complicated posttransplant care, need for hemodyalysis, etc).

Speakers:

The webinar is supported by an unrestricted educational grant by TransMedics.

The TransMedics Organ Care System (OCS) is a fully portable, multi-organ, normothermic preservation and assessment technology that mirrors human physiology. This revolutionary technology allows physicians and institutions to maximize the potential of donor hearts, lungs, and livers while monitoring each organ throughout the entire process, ensuring transplant teams can preserve organs in an optimal condition.

Event Details
  • Start Date
    May 31, 2021 5:00 pm
  • End Date
    May 31, 2021 7:30 pm
  • Status
    Expired
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