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Fiala A, Breitkopf R, Sinner B, Mathis S, Martini J. [Anesthesia for organ transplant patients]. DIE ANAESTHESIOLOGIE 2023; 72:773-783. [PMID: 37874343 PMCID: PMC10615924 DOI: 10.1007/s00101-023-01332-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 10/25/2023]
Abstract
Organ transplant patients who must undergo nontransplant surgical interventions can be challenging for the anesthesiologists in charge. On the one hand, it is important to carefully monitor the graft function in the perioperative period with respect to the occurrence of a possible rejection reaction. On the other hand, the ongoing immunosuppression may have to be adapted to the perioperative requirements in terms of the active substance and the route of administration, the resulting increased risk of infection and possible side effects (e.g., myelosuppression, nephrotoxicity and impairment of wound healing) must be included in the perioperative treatment concept. Furthermore, possible persistent comorbidities of the underlying disease and physiological peculiarities as a result of the organ transplantation must be taken into account. Support can be obtained from the expertise of the respective transplantation center.
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Affiliation(s)
- Anna Fiala
- Universitätsklinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - Robert Breitkopf
- Universitätsklinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
| | - Barbara Sinner
- Universitätsklinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - Simon Mathis
- Universitätsklinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - Judith Martini
- Universitätsklinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
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Haberbusch M, De Luca D, Moscato F. Changes in Resting and Exercise Hemodynamics Early After Heart Transplantation: A Simulation Perspective. Front Physiol 2020; 11:579449. [PMID: 33240102 PMCID: PMC7677526 DOI: 10.3389/fphys.2020.579449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/30/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: During heart transplantation (HTx), cardiac denervation is inevitable, thus typically resulting in chronic resting tachycardia and chronotropic incompetence with possible consequences in patient quality of life and clinical outcomes. To this date, knowledge of hemodynamic changes early after HTx is still incomplete. This study aims at providing a model-based description of the complex hemodynamic changes at rest and during exercise in HTx recipients (HTxRs). Materials and Methods: A numerical model of early HTxRs is developed that integrates intrinsic and autonomic heart rate (HR) control into a lumped-parameter cardiovascular system model. Intrinsic HR control is realized by a single-cell sinoatrial (SA) node model. Autonomic HR control is governed by aortic baroreflex and pulmonary stretch reflex and modulates SA node activity through neurotransmitter release. The model is tuned based on published clinical data of 15 studies. Simulations of rest and exercise are performed to study hemodynamic changes associated with HTxRs. Results: Simulations of HTxRs at rest predict a substantially increased HR [93.8 vs. 69.5 beats/min (bpm)] due to vagal denervation while maintaining normal cardiac output (CO) (5.2 vs. 5.6 L/min) through a reduction in stroke volume (SV) (55.4 vs. 82 mL). Simulations of exercise predict markedly reduced peak CO (13 vs. 19.8 L/min) primarily resulting from diminished peak HRs (133.9 vs. 169 bpm) and reduced ventricular contractility. Yet, the model results show that HTxRs can maintain normal CO for low- to medium-intensity exercise by increased SV augmentation through the Frank-Starling mechanism. Conclusion: Relevant hemodynamic changes occur after HTx. Simulations suggest that (1) increased resting HRs solely result from the absence of vagal tone; (2) chronotropic incompetence is the main limiting factor of exercise capacity whereby peripheral factors play a secondary role; and (3) despite the diminished exercise capacity, HTxRs can compensate chronotropic incompetence by a preload-mediated increase in SV augmentation and thus maintain normal CO in low- to medium-intensity exercise.
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Affiliation(s)
- Max Haberbusch
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
| | - Daniela De Luca
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- BioRobotics Institute, Scuola Superiore Sant’Anna, Pisa, Italy
- Department of Information Engineering, University of Pisa, Pisa, Italy
| | - Francesco Moscato
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
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3
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DeFilippis EM, Rubin G, Farr MA, Biviano A, Wan EY, Takeda K, Garan H, Topkara VK, Yarmohammadi H. Cardiac Implantable Electronic Devices Following Heart Transplantation. JACC Clin Electrophysiol 2020; 6:1028-1042. [PMID: 32819520 DOI: 10.1016/j.jacep.2020.06.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/12/2020] [Accepted: 06/27/2020] [Indexed: 11/29/2022]
Abstract
Permanent pacemaker (PPM) implantation is required in a subset of patients (∼10%) for sinus node dysfunction or atrioventricular block both early and late after heart transplantation. The incidence of PPM implantation has decreased to <5% with the advent of bicaval anastamosis transplantation surgery. Pacing dependence upon follow-up has been variably reported. An even smaller percentage of transplantation recipients (1.5% to 3.4%) undergo implantable cardioverter-defibrillator (ICD) placement. Rigorous data are lacking for the use of ICDs in the transplantation population and is largely derived from cohort studies and case series. Sudden cardiac death occurs in approximately 10% of transplantation recipients, but multiple nonarrhythmic factors are believed to be responsible, including acute rejection, late graft failure with electromechanical dissociation, and ischemia due to cardiac allograft vasculopathy. This review provides a comprehensive analysis of the existing data regarding the role for PPMs and ICDs in this population, including leadless PPMs and subcutaneous ICDs, special considerations, and future directions.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Geoffrey Rubin
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Maryjane A Farr
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Angelo Biviano
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Elaine Y Wan
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Hasan Garan
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Hirad Yarmohammadi
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.
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Nygaard S, Christensen AH, Rolid K, Nytrøen K, Gullestad L, Fiane A, Thaulow E, Døhlen G, Godang K, Saul JP, Wyller VBB. Autonomic cardiovascular control changes in recent heart transplant recipients lead to physiological limitations in response to orthostatic challenge and isometric exercise. Eur J Appl Physiol 2019; 119:2225-2236. [PMID: 31407088 PMCID: PMC6763412 DOI: 10.1007/s00421-019-04207-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 08/06/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE Heart transplantation causes denervation of the donor heart, but the consequences for cardiovascular homeostasis remain to be fully understood. The present study investigated cardiovascular autonomic control at supine rest, during orthostatic challenge and during isometric exercise in heart transplant recipients (HTxR). METHODS A total of 50 HTxRs were investigated 7-12 weeks after transplant surgery and compared with 50 healthy control subjects. Continuous, noninvasive recordings of cardiovascular variables were carried out at supine rest, during 15 min of 60° head-up tilt and during 1 min of 30% of maximal voluntary handgrip. Plasma and urine catecholamines were assayed, and symptoms were charted. RESULTS At supine rest, heart rate, blood pressures and total peripheral resistance were higher, and stroke volume and end diastolic volume were lower in the HTxR group. During tilt, heart rate, blood pressures and total peripheral resistance increased less, and stroke volume and end diastolic volume decreased less. During handgrip, heart rate and cardiac output increased less, and stroke volume and end diastolic volume decreased less. Orthostatic symptoms were similar across the groups, but the HTxRs complained more of pale and cold hands. CONCLUSION HTxRs are characterized by elevated blood pressures and total peripheral resistance at supine rest as well as attenuated blood pressures and total peripheral resistance responses during orthostatic challenge, possibly caused by low-pressure cardiopulmonary baroreceptor denervation. In addition, HTxRs show attenuated cardiac output response during isometric exercise due to efferent sympathetic denervation. These physiological limitations might have negative functional consequences.
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Affiliation(s)
- Sissel Nygaard
- Department of Pediatric Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anders Haugom Christensen
- Department of Pediatric Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Katrine Rolid
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kari Nytrøen
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Lars Gullestad
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,KG Jebsen Center for Cardiac Research, University of Oslo, Oslo, Norway.,Center for Heart Failure Research, Oslo University Hospital, Oslo, Norway
| | - Arnt Fiane
- Department of Cardiothoracic Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Erik Thaulow
- Department of Pediatric Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Gaute Døhlen
- Department of Pediatric Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kristin Godang
- Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital, Oslo, Norway
| | - J Philip Saul
- Department of Pediatrics, West Virginia University, Morgantown, USA
| | - Vegard Bruun Bratholm Wyller
- Faculty of Medicine, University of Oslo, Oslo, Norway. .,Department of Paediatrics, Akershus University Hospital, 1478, Lørenskog, Norway.
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Herborn J, Parulkar S. Anesthetic Considerations in Transplant Recipients for Nontransplant Surgery. Anesthesiol Clin 2017; 35:539-553. [PMID: 28784225 DOI: 10.1016/j.anclin.2017.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
As solid organ transplantation increases and patient survival improves, it will become more common for these patients to present for nontransplant surgery. Recipients may present with medical problems unique to the transplant, and important considerations are necessary to keep the transplanted organ functioning. A comprehensive preoperative examination with specific focus on graft functioning is required, and the anesthesiologist needs pay close attention to considerations of immunosuppressive regimens, blood product administration, and the risk benefits of invasive monitoring in these immunosuppressed patients. This article reviews the posttransplant physiology and anesthetic considerations for patients after solid organ transplantation.
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Affiliation(s)
- Joshua Herborn
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Suraj Parulkar
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, 251 East Huron Street, F5-704, Chicago, IL 60611, USA
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Awad M, Czer LSC, Hou M, Golshani SS, Goltche M, De Robertis M, Kittleson M, Patel J, Azarbal B, Kransdorf E, Esmailian F, Trento A, Kobashigawa JA. Early Denervation and Later Reinnervation of the Heart Following Cardiac Transplantation: A Review. J Am Heart Assoc 2016; 5:JAHA.116.004070. [PMID: 27802930 PMCID: PMC5210323 DOI: 10.1161/jaha.116.004070] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Morcos Awad
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Lawrence S C Czer
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Margaret Hou
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Sarah S Golshani
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael Goltche
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Michelle Kittleson
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jignesh Patel
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Babak Azarbal
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Evan Kransdorf
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Fardad Esmailian
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Alfredo Trento
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jon A Kobashigawa
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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Antithymocyte globulin induction therapy adjusted for immunologic risk after heart transplantation. Transplant Proc 2014; 45:2393-8. [PMID: 23953554 DOI: 10.1016/j.transproceed.2013.02.114] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 02/05/2013] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The efficacy of antithymocyte globulin (ATG) induction in the therapy of immunologically low- and high-risk patients after heart transplantation is not known. METHODS All patients who received ATG induction from January 2000 through January 2010 were divided into two groups based on the risk of rejection. A higher-risk group (age younger than 60 years, multiparous females, African Americans, panel-reactive antibody >10%, or positive cross-match) received ATG (1.5 mg/kg) for 7 days (ATG7), and the remaining lower-risk group received ATG for 5 days (ATG5), all followed by calcineurin inhibitor, mycophenolate, and prednisone. Endomyocardial biopsies were performed based a standard protocol for up to 3 years after heart transplantation, and for suspected rejection. RESULTS Of 253 heart transplant recipients, 87 received ATG5 and 166 ATG7. Absolute lymphocyte count <200 per microliter was achieved within 10 days in 88% of ATG5 and 86% of ATG7. Baseline creatinine was 1.3 ± 0.8 pre-transplantation, 1.8 ± 0.9 post-transplantation, and 1.0 ± 0.4 mg/dL at discharge (mean ± standard deviation [SD]; P < .001, compared with pre-transplantation). Of 3667 biopsies, 33 (0.90%) had ≥3A/2R cellular rejection (CR). Of 3599 biopsies, 16 (0.44%) had definite antibody-mediated rejection (AMR). At 5 years, freedom from ≥3A/2R CR (94% ± 2.8% vs 83% ± 7.7%; P = .31) and freedom from AMR (95% ± 2.4% vs 90% ± 6.4%; P = .98) were similar between ATG5 and ATG7, respectively. Survival for ATG5 and ATG7 was comparable at one year (94% ± 2.5% vs 93% ± 2.0%), and at 8 years (61% ± 6.9% and 61% ± 4.7%; P = .88). At 5 years, ATG5 and ATG7 were similar in freedom from cytomegalovirus (CMV) infection (92.3% vs 94.3%; P = not significant [NS]), freedom from pneumonia (83.8% vs 82.1%; P = NS), and in rate of malignancy (excluding skin cancer; 8.0% vs 6.0%; P = NS). CONCLUSIONS ATG induction therapy (prospectively dose-adjusted for immunologic risk) in low- and high-risk patients results in excellent and equivalent short- and long-term survival rates, with a low incidence of CR and AMR. The use of ATG does not increase rates of CMV infection with appropriate prophylaxis. ATG may benefit renal function by delaying calcineurin inhibitor exposure, and may have a role in the prevention of AMR.
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On A, Karapolat H, Zoghi M, Nalbantgil S, Yagdi T, Ozbaran M. Analysis of heart rate variability with electromyography in heart transplant recipients. Arch Phys Med Rehabil 2009; 90:1635-8. [PMID: 19735794 DOI: 10.1016/j.apmr.2009.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Revised: 03/12/2009] [Accepted: 03/13/2009] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate vagal parasympathetic functions by electromyographic R-R interval variation analyses in heart transplant recipients. DESIGN Cross-sectional and longitudinal study. SETTING Department of physical medicine and rehabilitation, university hospital. PARTICIPANTS Early (n=8; <3 mo) and late (n=17; >1 y) heart transplant recipients and healthy volunteers (n=20) were included. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The R-R interval variations at rest and in response to deep breathing, Valsalva, and tilt/standup maneuvers were analyzed in all patient and control groups. Further, 8 early heart transplant recipients were followed up at the sixth and twelfth months after transplantation. RESULTS Compared with controls, both early and late transplant recipients had significantly lower R-R interval variation ratios (P<.05). There were no statistically significant differences between the early and late groups (P>.05). R-R interval variation ratios showed no significant changes from baseline (P>.025) in the early heart transplant recipients. CONCLUSIONS The findings of the study suggest that parasympathetic activities are suppressed in the early stage after heart transplantation and do not significantly recover with time. The electromyographic analysis of R-R interval variation is a simple test that may offer an attractive alternative for routine evaluation of autonomic dysfunction in heart transplant recipients.
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Affiliation(s)
- Arzu On
- Department of Physical Medicine, University of Ege, Izmir, Turkey
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Anderson E, McDonald DD, Mikky I, Brewer T, Koscizewski C, Lacoursiere S, Andrews L, Delaney C. Health care implications and space allocation of research published in nursing journals. Nurs Outlook 2003; 51:70-83. [PMID: 12712142 DOI: 10.1016/s0029-6554(02)05451-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To examine how research is disseminated through nursing journals and to examine characteristics of published research. DESIGN A cross-sectional descriptive survey was conducted with manuscripts from 78 nursing journals that publish research. METHOD The final issue for 1999 was examined. Pairs of independent raters content-analyzed all research manuscripts. DISCUSSION Research studies comprised 241 (42.9%) of the manuscripts and 51.4% of the journal space. Many empirical studies omitted validity and reliability. Few manuscripts reported the date for completion of data collection, and fewer than one third contained the length of time from acceptance to publication. CONCLUSIONS Enhanced instrumentation reporting, shorter time from data collection to publication, and an increase in journal space devoted to research might enable nurses to make more cutting-edge clinical decisions.
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