O. Simsch, T. Gromann, C. Knosalla, M. Hübler, R. Hetzer, H. Lehmkuhl
Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Germany
[Applied Cardiopulmonary Pathophysiology 15: 230-240, 2011]
Today heart transplantation (HTx) is accepted worldwide as a treatment option for terminal cardiac failure. In approximately 90% of HTx patients the indication is ischemic or dilative cardiomyopathy. Seventy-five percent of the organ recipients are more than 40 years old and most of them are men (1). At the Deutsches Herzzentrum Berlin a total of 1637 HTx were carried out between April 1986 and July 2010. The age of the organ recipients ranged between 3 months and 71 years, with an average age of 50 years. Male organ recipients (n=1320) were about four times more frequent than female recipients (n=317).
Postoperative observation and treatment of patients on the intensive care unit (ICU) after HTx are essentially similar to those required after other heart operations. Nevertheless, HTx patients require special care, because not only must the immediate results of the operation be treated, but also immunological processes influence the clinical course and the necessary treatment. In the early phase after HTx the stabilization of organ functions and the introduction of immunosuppressive therapy are in the foreground.
The cardiovascular circulation requires intensive and continuous monitoring. Measures for hemodynamic optimization by means of volume substitution, inotropes and vasoactive substances must take into account specific features of the transplanted organ. Compensatory mechanisms to stabilize the hemodynamics can be applied only restrictedly on account of the ischemia, the reperfusion damage and the autonomic denervation with the subsequent chronotropic and inotropic failure. Stimulation by a pacemaker and catecholamine treatment are important.
The heart-transplanted patient is endangered in particular by right ventricular dysfunction, which can become life-threatening. The aims of postoperative therapy are therefore individually tailored preload conditions and ensuring contractility and an adequate reduction in the pulmonary vascular resistance. Mechanical ventilation serves to maintain adequate gas exchange and enables the right ventricular afterload to be specifically influenced.
Further important components of the intensive therapy after HTx are immediate immunosuppressive therapy and rejection monitoring. The intensive medical care after transplantation is always an interdisciplinary task.
In the following, treatment standards are given for the perioperative intensive medical management of HTx patients at the Deutsches Herzzentrum Berlin.
Key words: heart transplantation, intensive care
Hans Lehmkuhl, MD, PhD
Deutsches Herzzentrum Berlin
Augustenburger Platz 1