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Hwang NC, Sivathasan C. Review of Postoperative Care for Heart Transplant Recipients. J Cardiothorac Vasc Anesth 2023; 37:112-126. [PMID: 36323595 DOI: 10.1053/j.jvca.2022.09.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 09/10/2022] [Accepted: 09/14/2022] [Indexed: 11/11/2022]
Abstract
The early postoperative management strategies after heart transplantation include optimizing the function of the denervated heart, correcting the causes of hemodynamic instability, and initiating and maintaining immunosuppressive therapy, allograft rejection surveillance, and prophylaxis against infections caused by immunosuppression. The course of postoperative support is influenced by the quality of allograft myocardial protection prior to implantation and reperfusion, donor-recipient heart size matching, surgical technique of orthotopic heart transplantation, and patient factors (eg, preoperative condition, immunologic compatibility, postoperative vasomotor tone, severity and reversibility of pulmonary vascular hypertension, pulmonary function, mediastinal blood loss, and end-organ perfusion). This review provides an overview of the early postoperative care of recipients and includes a brief description of the surgical techniques for orthotopic heart transplantation.
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Affiliation(s)
- Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore.
| | - Cumaraswamy Sivathasan
- Mechanical Cardiac Support and Heart Transplant Program, Department of Cardiothoracic Surgery, National Heart Centre, Singapore
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Shi Y, Lerner AH, Rogers R, Vieira K, Merhi B, Mecadon K, Osband AJ, Bayliss G, Gohh R, Morrissey P, Farmakiotis D. Low-Dose Valganciclovir Prophylaxis Is Safe and Cost-Saving in CMV-Seropositive Kidney Transplant Recipients. Prog Transplant 2021; 31:368-376. [PMID: 34839729 DOI: 10.1177/15269248211046037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Observational studies suggest that low-dose valganciclovir prophylaxis (450 mg daily for normal renal function) is as effective as and perhaps safer than standard-dose valganciclovir (900 mg daily) in preventing CMV infection among kidney transplant recipients. However, this practice is not supported by current guidelines due to concerns for breakthrough infection from resistant CMV, mainly in high-risk CMV donor-seropositive/recipient-seronegative kidney transplant recipients. Standard-dose valganciclovir is costly and possibly associated with higher incidence of neutropenia and BKV DNAemia. Our institution adopted low-dose valganciclovir prophylaxis for intermediate-risk (seropositive) kidney transplant recipients in January 2018. Research Question: To analyze the efficacy (CMV DNAemia), safety (BK virus DNAemia, neutropenia, graft loss, and death), and cost savings associated with this change. Design: We retrospectively compared the above outcomes between CMV-seropositive kidney transplant recipients who received low-dose and standard-dose valganciclovir, transplanted within our institution, between 1/19/2014 and 7/15/2019, using propensity score-adjusted competing risk analyses. We also compared cost estimates between the two dosing regimens, for 3 months of prophylaxis, and for different percentage of patient-weeks with normal renal function, using the current average wholesale price of valganciclovir. Results: We studied 179 CMV-seropositive kidney transplant recipients, of whom 55 received low-dose and 124 standard-dose valganciclovir. The majority received nonlymphocyte depleting induction (basiliximab). Low-dose valganciclovir was at least as effective and safe as, and more cost-saving than standard-dose valganciclovir. Conclusion: This single-center study contributes to mounting evidence for future guidelines to be adjusted in favor of low-dose valganciclovir prophylaxis in CMV-seropositive kidney transplant recipients.
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Affiliation(s)
- Yiyun Shi
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alexis Hope Lerner
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ralph Rogers
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Kendra Vieira
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Basma Merhi
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Adena J Osband
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - George Bayliss
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Reginald Gohh
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Paul Morrissey
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
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