Analysis of late operations in transplant patients

Perioperative Management of Cardiac Transplant Recipients Undergoing Noncardiac Surgery: Unique Challenges Created by Advancements in Care

Advancements in postcardiac transplant care have resulted in significant reductions in morbidity and increased life expectancy for cardiac transplant recipients. Consequently, many cardiac transplant recipients are living long enough to require subsequent noncardiac surgery. The perioperative care of heart transplant recipients presents a unique challenge as many of the common preoperative risk assessments do not apply to a transplanted heart, immunosuppressive medications have side effects and potential for drug-drug interactions, and the denervated heart results in an altered autonomic physiology and response to medications. Further adding to the challenge is that many of these noncardiac surgeries need to be performed urgently at nontransplant centers that may not be familiar with the care of these patients. This review aims to summarize the current data regarding preoperative assessment, perioperative immunosuppression management, intraoperative and anesthetic considerations, and outcomes of cardiac transplant recipients undergoing noncardiac surgery.

Late noncardiac surgery in heart transplant patients

OBJECTIVE

Because of improved long-term survival of heart transplants (HT), patients often need noncardiac surgery (NCS). Immunosuppression may increase the infection rate. Inadequate management may increase the risk of dysfunction or acute rejection episodes (ARE). Long-term outcomes of NCS and optimal immunosuppressive management in the perioperative period are not well known. The objective of this study was to analyze the incidence, morbidity, and mortality of late NCS after HT.

METHODS

We retrospectively evaluated the incidence and type of late NCS as well as the risk factors for complications and the mortality among 207 HT patients. Immunosuppression and ARE rates were also analyzed.

RESULTS

One hundred and sixteen late NCS (84.5% elective) were performed in 72 HT patients (34.8%). Interventions were: 35 urologic (30.2%), 29 abdominal (25%), 14 vascular (12.1%), 13 ENT (11.2%), 11 skin and soft tissue (9.5%), and 7 orthopedic (6%). Malignancy was the main indication for NCS (33.6%). Only 4 patients (5.6%) died preoperatively. Mortality was higher among emergent vs elective procedures (16.6% vs 1%; P = .012) and among patients with preoperative high vs middle/low risk (26.6% vs 0%). Postsurgical infection was the most frequent complication (6.9%). However, there were no relevant complications in 82.8% of HT patients. Hospitalization time was <15 days in two thirds of patients. Immunosuppression was modified in 33 patients (28.4%), especially when the surgical indication was neoplasia (P < .001). None of the patients with NCS displayed allograft dysfunction or an ARE.

CONCLUSIONS

More than one-third of HT patients needed a late NCS. In our experience, elective surgical procedures with middle/low preoperative cardiovascular risk are safe. In this context, the risk of rejection was low when immunosuppression was carefully monitored to reduce the risk of infection.