Disclosures I have received salary support from the Gordon and Betty - - PDF document

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Anesthetic Considerations in Patients who Have Undergone Heart

• r Lung Transplantation*

Kevin Thornton, MD Associate Clinical Professor Cardiac Anesthesia and Critical Care Medicine UCSF

Disclosures

• I have received salary support from the

Gordon and Betty Moore Foundation

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Objectives

• Describe physiologic changes associated with

the transplanted lung

• Describe effective treatment for bradycardia

in the heart transplant patient

• Outline three principles of hemodynamic

management in patients with an LVAD

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Lung Transplantation Lung Transplant ‐ Basics

Indications

– Cystic Fibrosis – COPD – IPF – PH – alpha ‐1 AT – RA – Congenital disease – ILD

Patients # Waiting (as of 9/11/15) 1,534 Transplanted in 2014 1,925* Source: UNOS website

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Lung Transplant – SLT vs. DLT

• Better outcomes with

DLT

• SLT most commonly

performed in COPD

– Improves QOL – Varies by center

• DLT

– PFTs normalize over time

• SLT

– Native lung function remains poor – ~60‐70% of blood flow goes to transplanted lung – Differences in compliance determine distribution of ventilation

Feltracco, P. et al. J Clin Anesthesia 2011

The Transplanted Lung

• Lymphatic disruption

– More prone to developing pulmonary edema

• Impaired mucociliary function

– Poor secretion clearance

• Abnormal alveolar macrophage function
• Denervation distal to airway anastomosis

– Tracheal vs. bronchial anastomoses

• Hypoxic pulmonary vasoconstriction remains

intact

Keegan, M. et al. Anes Clin North America 2004

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Lung Transplant – Preoperative Considerations

• Rejection increases

morbidity

– Sxs: cough, dyspnea, purulent secretions – Chronically, it leads to bronchiolitis

• Important to rule out active

infection

• Pulmonary HTN and RV

dysfunction should have resolved

• GERD is common

– Increased risk of aspiration (with greater consequences)

Immunosuppression

• Steroids

– HTN, glucose intolerance/DM – Osteoporisis

• Calcineurin‐inhibitors (tacrolimus)

– Renal insufficiency

• ‘Stress‐dose’ steroids?

– Controversial – probably only beneficial with major surgery or in patients with evidence of adrenal insufficiency (hypotension, shock)

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Airway Management

• Increased risk of GERD

and aspiration

– May want to avoid the use

• f LMAs
• Important to avoid

trauma at anastomoses

• Avoid nasotracheal

intubation

– Increases risk of infection

• Many patients will have

had prior trach

– Some may develop stenosis at anastomoses

• Avoid barotrauma

– Lung protective ventilation is probably a good idea

• Vt ~6cc/kg IBW, Maintain

Pplat < 30cm H2O

• PEEP 5‐8cm H2O is safe and

recommended

• In SLT patients,

differential lung ventilation can be a challenge

– Dependent on disease of native lung and compliance relative to allograft

Other Considerations

• Engage the lung transplant team prior to

elective surgery

– Establish plan for treatment of infection or rejection ahead of surgery

• General anesthesia is safe

– Regional, neuraxial also acceptable

• Recommend cautious use of IV fluids
• Recommend aggressive pulmonary toilet post‐
• p

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Heart Transplant Heart Failure

• Common

– 1‐2% of people in developed countries – Up to 10% of patients

• ver 70
• Multisystem disease
• Mainstays of treatment

– Drugs – Resynchronization therapy and ICDs – Transplantation

McMurray, JJ. NEJM 2010

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Heart Transplant Statistics

• Indications:

– Cardiomyopathy

• Ischemic
• Idiopathic
• Myocarditis
• Etc.

– Congenital disease – PH

Patients # Waiting (as of 9/11/15) 4,200 Transplanted in 2014 1,377 Source: UNOS website

The Transplanted Heart

• Denervated

– Intrinsic HR ~90‐100 (no vagal innervation)

• No response to vagal maneuvers

– No response to ‘stimulation’

• Laryngoscopy, light anesthesia

– Dependent on circulating catecholamines

• May be orthostatic
• No reflex tachycardic response to hypovolemia

– No sensation of cardiac ischemia

• No chest pain
• Dual p‐waves
• First degree A‐V block is common

Keegan, M. et al. Anes Clin North America 2004

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Anesthetic Implications

• Indirect catecholamines may be ineffective

– Direct‐acting agents are preferred

• Epi, norepi, dobutamine…
• Vagotonics are ineffective

– Atropine, glycopyrrolate will not increase HR

• Atrial arrhythmias are associated with rejection

and warrant evaluation before elective surgery

• Atherosclerosis is accelerated in the donor heart

Implantable LVADs

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A new alternative?

NEJM 2001

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NEJM 2009 Slaughter, et al. NEJM 2009

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Outcomes

Slaughter, et al. NEJM 2009

Putting it Together

Fang, JC. NEJM 2009

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Heartware HVAD But who is getting LVADs?

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Increasing LVAD Use

Stewart GC, Stevenson LW. Circulation 2011.

No longer a salvage therapy

INTERMACS Level “Shorthand” NYHA Classification 1 ‘crash and burn’ IV 2 ‘sliding fast’ on inotropes IV 3 Stable on continuous inotropes IV 4 Resting sxs on oral rx at home Amb IV 5 Housebound, sxs with minimum ADL Amb IV 6 ‘walking wounded’ – meaningful activity limited IIIB 7 Advanced Class III III Adapted from: Stewart GC, Stevenson LW. Circulation 2011.

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LVAD Considerations

• Continuous flow = no

(or little) pulsatility

• Elevated SVR can

reduce flow

• Hypovolemia is poorly

tolerated

• RV failure is common

immediately post‐ implantation

– And worsens outcomes