Residency · Residency · Cardiothoracic Surgery
Heart Transplant: Recipient Operation and Early Postoperative Care
Introduction
The recipient operation in cardiac transplantation requires precise surgical technique, expert anesthetic management, and meticulous early postoperative care. With refinements in surgical approach, immunosuppression, and critical care management, early survival following heart transplantation now exceeds 90% at experienced centers.
Preoperative Preparation
Recipient Assessment at Time of Offer
At the time of a donor offer, the team must confirm absence of active infection, new neurological events, or significant clinical deterioration. The current hemodynamic support status (inotropes, ECMO, LVAD, IABP) is reviewed, ABO compatibility and crossmatch results (virtual or prospective) are verified, and total anticipated ischemic time is estimated in coordination with the procurement team.
Anesthetic Considerations
Anesthetic preparation includes large-bore peripheral and central venous access with pulmonary artery catheter placement, arterial line monitoring (radial and/or femoral), and transesophageal echocardiography for intraoperative monitoring. Blood products must be readily available, with anticipation of significant transfusion in redo sternotomy patients. The team should be prepared for potential pulmonary hypertension management with inhaled nitric oxide, milrinone, and epinephrine.
Redo Sternotomy Considerations
Many recipients have prior sternotomy from LVAD implantation or prior cardiac surgery. A preoperative CT scan is obtained to assess sternal adhesions and proximity of cardiac structures to the sternum. Peripheral cannulation for cardiopulmonary bypass may be established before sternotomy, and an oscillating saw technique with careful dissection is used to avoid catastrophic injury.
Surgical Technique
Bicaval Technique (Standard)
The bicaval technique is preferred over the biatrial technique due to lower incidence of tricuspid regurgitation, fewer atrial arrhythmias, and improved atrial function. The recipient cardiectomy excises the heart, leaving a posterior left atrial cuff containing the pulmonary vein ostia, SVC and IVC stumps, and the aorta and pulmonary artery. If an LVAD is present, the device is explanted, the apical core site is oversewn, and the outflow graft is removed.
Anastomotic Sequence
The anastomoses are performed in a specific sequence. The left atrial anastomosis is completed first using continuous 3-0 or 4-0 polypropylene suture, beginning at the left inferior pulmonary vein and running circumferentially to ensure wide, unobstructed pulmonary vein ostia. The IVC anastomosis follows as an end-to-end repair with continuous polypropylene suture. The SVC anastomosis is then performed end-to-end, with any size discrepancy managed by oblique transection of the donor SVC. The pulmonary artery anastomosis uses end-to-end continuous suture, trimmed to appropriate length to avoid kinking. The aortic anastomosis is performed last with end-to-end continuous suture to allow de-airing.
De-airing and Reperfusion
Meticulous de-airing is performed through the aortic root vent and LA appendage before unclamping. After cross-clamp removal and reperfusion, the heart typically resumes sinus rhythm or requires cardioversion. Temporary epicardial pacing wires are placed on the right atrium and right ventricle. Biventricular function is assessed by TEE after separation from bypass.
Biatrial Technique (Historical)
The biatrial technique involves direct anastomosis of left and right atrial cuffs. While simpler, it is associated with larger dilated atria, more arrhythmias, and greater AV valve regurgitation. It is rarely used in current practice except in select circumstances.
Bicaval vs. Biatrial Technique Comparison
| Feature | Bicaval (Standard) | Biatrial (Historical) |
|---|---|---|
| Anastomoses | LA cuff, SVC, IVC, PA, aorta | LA cuff, RA cuff, PA, aorta |
| Atrial geometry | Preserved normal anatomy | Enlarged, abnormal atrial geometry |
| Tricuspid regurgitation | Lower incidence | Higher incidence |
| Atrial arrhythmias | Lower incidence | Higher incidence |
| Sinus node function | Better preserved | More sinus node dysfunction |
| Hemodynamic performance | Superior atrial function | Inferior atrial contribution |
| Technical complexity | Slightly more complex (3 separate anastomoses vs. 2 atrial) | Simpler |
| Current use | Standard of care | Rarely used |
Separation from Cardiopulmonary Bypass
Adequate rewarming (core temperature above 36 degrees C) is confirmed before separation. Inotropic support is initiated with isoproterenol for chronotropic support, milrinone, or low-dose epinephrine. Temporary pacing at a rate of 90-110 bpm is used if chronotropic incompetence is present, which is common due to denervation. Inhaled nitric oxide is administered for elevated pulmonary vascular resistance. TEE assessment confirms biventricular function, valvular competence, and anastomotic integrity, and bypass is weaned gradually with hemodynamic optimization.
Early Postoperative Care
Hemodynamic Management
The target cardiac index is above 2.2 L/min/m2 with targeted use of inotropes. Isoproterenol is commonly used for the first 3-5 days for chronotropic and inotropic support. Monitoring for right ventricular dysfunction includes tracking elevated CVP, decreased flows, and hepatic congestion. Pulmonary artery catheter data guides volume management and afterload reduction, with a target mean arterial pressure of 65-80 mmHg.
Immunosuppression Initiation
Induction therapy with anti-thymocyte globulin (ATG) or basiliximab is started intraoperatively or immediately postoperatively. Methylprednisolone at 500-1000 mg IV is administered intraoperatively, followed by a rapid taper. A calcineurin inhibitor (tacrolimus) is initiated within 24-72 hours when renal function is stable, and mycophenolate mofetil is started within the first 24 hours. Early immunosuppression protocols are institution-specific.
Primary Graft Dysfunction
Primary graft dysfunction is defined as severe cardiac dysfunction within the first 24 hours not attributable to rejection, tamponade, or surgical complication. It occurs in 5-10% of transplants and is a significant cause of early mortality. Management involves maximizing inotropic support and considering mechanical circulatory support with ECMO or percutaneous VAD. Risk factors include prolonged ischemic time, donor-recipient size mismatch, donor inotrope use, and recipient pulmonary hypertension.
Monitoring and Surveillance
Continuous telemetry is maintained with awareness that the transplanted heart is denervated, resulting in absence of vagal tone and a resting heart rate of 90-110 bpm. Serial echocardiography monitors biventricular function and pericardial effusion. Daily laboratory monitoring includes renal function, hepatic function, lactate, and complete blood count. Chest tube output is monitored for hemorrhage.
Key Clinical Pearls
The bicaval technique is the modern standard and results in superior atrial geometry, fewer arrhythmias, and less tricuspid regurgitation compared to the biatrial approach. The transplanted heart is denervated and does not respond to atropine, vagal maneuvers, or carotid sinus massage -- isoproterenol or pacing should be used for bradycardia. Primary graft dysfunction is the leading cause of early post-transplant mortality, and early ECMO support improves salvage rates. Redo sternotomy in LVAD patients requires meticulous planning with preoperative CT and peripheral bypass standby. Right ventricular failure is the most common hemodynamic problem after transplant, often exacerbated by recipient pulmonary hypertension.
References
- Lund LH, Khush KK, Cherikh WS, et al. The registry of the International Society for Heart and Lung Transplantation: thirty-fourth adult heart transplantation report. J Heart Lung Transplant. 2017;36(10):1037-1046.
- Sievert H, Weymann A, Schmack B, et al. Bicaval versus biatrial orthotopic heart transplantation: a systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2020;160(3):757-767.
- Kobashigawa J, Zuckermann A, Macdonald P, et al. Report from a consensus conference on primary graft dysfunction after cardiac transplantation. J Heart Lung Transplant. 2014;33(4):327-340.
- Costanzo MR, Dipchand A, Starling R, et al. The International Society of Heart and Lung Transplantation guidelines for the care of heart transplant recipients. J Heart Lung Transplant. 2010;29(8):914-956.