Acta Scientific Pharmaceutical Sciences (ISSN: 2581-5423) Volume 3 Issue 12 December 2019 Review Article An Overview of Anesthesia Practices for Heart Transplant in India Sandeep Kumar Kar* and Pallav Mishra Assistant Professor, Cardiac Anesthesiology, IPGMER, Kolkata, India *Corresponding Author: Sandeep Kumar Kar, Assistant Professor, Cardiac Anesthesiology, IPGMER, Kolkata, India. Received: November 20, 2019 DOI: 10.31080/ASPS.2019.03.0449 Abstract is growing. Immunosuppressive agents have dramatically improved success of heart transplantation. Non-ischemic cardiomyopathy Heart transplant has seen a significant progress the number of patients with heart failure qualifying for cardiac transplantation has surpassed ischemic cardiomyopathy as need for transplantation. The use of bridge therapy with mechanical circulatory support has improved both short-term and long-term survival of heart transplant recipients has gradually improved over time Keywords: Heart Transplant; Non-Ischemic Cardiomyopathy; Mechanical Circulatory Assist Introduction st Organ Transplantation in India under aegis of National Organi- Dr. Christiaan 1 successful adult heart transplant on Mr. Louis Neethling Washkansky 3 December 1967 at Groote Schuur zation Tissue Transplantation Organization (NOTTO) setup under Barnard hospital Cape town, South Africa Directorate General of Health Services established to oversee all Caves and Transvenous endomyocardial biopsy for diagnosis donation and transplantation activities. In this regard, the entire Colleagues of immune rejection of heart transplant in 1970. country is having the following setup at National, Regional and Jean Francois Immunosuppressive effects of cyclosporin A as State Level. Borel preventive strategy to cardiac rejection in 1976. Bruce Reitz National and Norman 1st successful combined heart lung transplant [4]. (NOTTO) Level Shumway Regional KEM Guwahati Table 2 PGIMER IPGME and RGGGH Level Hospital Medical Chandigarh R Kolkata Chennai (ROTTO) Mumbai College ents. Ischemic cardiomyopathy remains the most prevalent diag- State nosis in patients older than 59 years. This trend continues even Level though older patients now represent an increasing proportion of (SOTTO) the transplant population. Table 1 Primary underlying diagnosis for Frequency The transplant registry for cardiac transplant is in the process of adult heart Transplant % making data from various hospitals show greater number of heart Non-Ischemic cardiomyopathy 49.2 transplant conducted in southern states of country showing Tamil Ischemic cardiomyopathy 34.6 Nadu with highest number of cardiac transplants undertaken. Congenital heart disease 3.2 History of heart transplant [1-4] Retransplantation 3 The International Society for Heart and Lung Transplantation Hypertrophic cardiomyopathy 3 Valvular cardiomyopathy 2.7 recipients. The most common primary diagnosis has shifted over (ISHLT) identifies 8 primary diagnoses for adult heart transplant Other 1.1 time from ischemic cardiomyopathy (ICM) to non-ICM (NICM), Table 3 with NICM now representing 49.2% of all heart transplant recipi- Citation: Sandeep Kumar Kar and Pallav Mishra. “An Overview of Anesthesia Practices for Heart Transplant in India”. Acta Scientific Pharmaceutical Sciences 3.12 (2019): . An Overview of Anesthesia Practices for Heart Transplant in India 53 Anaesthesia for heart transplant [5] • Severe functional limitation secondary to underlying cardiac Heart transplant be considered for adults with the following condition with Peak oxygen consumption Peak VO2 below criteria; age, Six-minute walk test below 300 meters. • Cardiogenic shock with low probability of recovery as as- 12-14ml/kg/min or serial decline over time in context to - • Ischemic heart disease with Canadian Cardiac Society Class tion. Inability to wean temporary mechanical circulatory sociated with volume overload/inability to wean ventila support such as IABP, VAD and ECMO supported patients. surgical and interventional therapy. III/IV refractory angina pectoris despite optimal medical, Inability to wean continuous inotropic support. • Recurrent life-threatening ventricular arrhythmia despite • NYHA Grade III-IV despite maximal medical and surgical optimal medical, surgical and electrophysiological therapy. - • Localized cardiac tumor with low likelihood of metastasis. myopathy, complex congenital heart disease not amenable therapy in conditions like hypertrophic/restrictive cardio to surgical or procedural intervention. Absolute Contraindication Relative Contraindication Systemic illness with a life expectancy <2yrs Relative Contraindications; despite heart transplant include the follow- ing; 1. Age >72 years 1. Active or recent solid organ or blood 2. Any active infection (with exception of device-related infection in ventricular as- malignancy within 5 years. sist device recipients) 2. - 3. Active peptic ulcer disease. tion. AIDS with frequent opportunistic infec 4. Diabetes with end-organ damage 3. Systemic lupus erythematosus, sarcoid, 5. Severe peripheral vascular or cerebrovascular disease or amyloidosis that has multisystem involvement and is still active. 6. 4. Irreversible renal or hepatic dysfunc- 7. Morbid obesity (BMI >35 kg/m2) or cachexia (BMI<18 kg/m2) tion in patients considered for only heart transplantation. Serum creatinine>2.5 mg/dL or creatinine clearance less than 25ml/min. warfarin. 5. - 8. Bilirubin >2.5 mg/dL, serum transaminases >3 times normal, or INR >1.5 off 9. Severe pulmonary dysfunction with FEV1 below 40%. Significant obstructive pulmonary dis 6. easeFixed (FEV1<1l/min) pulmonary hypertension with 10. Active mental illness or psychosocial instability 11. Drug, tobacco, or alcohol Pulmonary artery systolic pressure >60 abuse within 6 months. mm Hg. Mean transpulmonary gradi- ent >15 mm Hg. Pulmonary vascular 11. resistance >6 wood units. 12. RecentIrreversible pulmonary neurologic infarction or neuromuscular within 6 to 8 disorder.weeks. Table 4 Diseases specific candidate selection [5] Severe cardiac dysfunction with LVEF below 30% with pseudo Patient selection needs to be meticulously undertaken by iden- tifying acute heart failure cases and managing critical issues prior PCWP>16normal/restrictive or RAP>12 mitral mmHg inflow pattern. work involving management of hemodynamics and intensifying to undertaking transplant procedure. This requires dedicated team medical management. Identifying acute heart failure. impaired functional capacity with inability to exercise, six-minute BNP/NT Pro BNP rise in absence of noncardiac causes severely Diagnostic criteria walk below 300 meter and Peak Vo2 less than 12-14ml/kg/min. NYHA class III-IV. History of more than one heart failure hospitalization in past six months. Heart failure decompensation characterized by volume over- load/reduced cardiac output. Citation: Sandeep Kumar Kar and Pallav Mishra. “An Overview of Anesthesia Practices for Heart Transplant in India”. Acta Scientific Pharmaceutical Sciences 3.12 (2019): . An Overview of Anesthesia Practices for Heart Transplant in India 54 Clinical events suggesting acute Heart failure Surgery involves a median sternotomy and pericardiotomy, sys- • Heart failure more than two hospitalization in emergency temic heparinization is accomplished and the superior vena cava department in past 12 months. is ligated. The aortic root is then cannulated for the administration • Progressive decline in renal function. of cardioplegia. After ligation of the great veins, the heart is exsan- guinated and decompressed. Following the infusion of cardioplegia • Cardiac cachexia. and cardiac arrest, the aorta is cross-clamped. Topical hypother- • Intolerance to ACE inhibitors due to hypotension or wors- mia by way of iced slush is sometimes applied to the heart. Donor ening renal failure. cardiectomy is then performed leaving remnants of the posterior • Intolerance to beta blocker due to hypotension. atrial walls, pulmonary veins and venae cava intact. Conventionally • or worsening heart failure. accepted donor heart ischemic time ranges from 3 to 6 hours. Cold • ischemic time be minimized leading to innovations like the Trans Medics Portable Warm Blood Perfusion System (Organ Care Sys- • Frequent Systolic blood pressure below 90mmHg. tem, Trans Medics Corporation, Andover, MA) which is currently • Inability to walk one block on level ground because of dys- Persistent dyspnea with dressing/bathing requiring rest. under investigation in the United States. This system is designed pnea or fatigue. to keep the donor heart warm and beating, maintaining pulsatile • Escalation of diuretic to maintain euvolemic perfusion. Donor blood is used and the system provides blood oxy- • - • ing system. This has the advantage of enabling resuscitation of the (furosemide more than 160mg/day or Metolazone use). genation and flow from an internal gas supply and pulsatile pump donor organ, potentially improving its function and increasing the • Frequent ICD shock. amount of time that an organ can be maintained outside the body Frequent hyponatremia below 133meq/ml. Anesthetic management of donor heart [9-12] in a condition suitable for transplantation by reducing time depen- Perioperative management of the heart transplant involves dent ischemic injury. This system has been approved for use in the recipient-donor cross matching for ABO compatibility and donor’s European Union since mid-2006. cardiac history with the degree of hemodynamic compromise Elec- Anaesthetic concerns for cardiac transplant recipient [13-15]