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

9/21/2015 Anesthetic Considerations in Patients who Have Undergone Heart or 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 1

9/21/2015 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 2

9/21/2015 Lung Transplantation Lung Transplant ‐ Basics Indications – Cystic Fibrosis – COPD Patients # – IPF Waiting (as of 9/11/15) 1,534 – PH Transplanted in 2014 1,925* – alpha ‐ 1 AT – RA – Congenital disease – ILD Source: UNOS website 3

9/21/2015 Lung Transplant – SLT vs. DLT • Better outcomes with • SLT DLT – Native lung function remains poor • SLT most commonly – ~60 ‐ 70% of blood flow performed in COPD goes to transplanted – Improves QOL lung – Varies by center – Differences in • DLT compliance determine distribution of – PFTs normalize over time 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 4

9/21/2015 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) 5

9/21/2015 Airway Management • Increased risk of GERD • Avoid barotrauma and aspiration – Lung protective ventilation is probably a good idea – May want to avoid the use of LMAs • V t ~6cc/kg IBW, Maintain P plat < 30cm H 2 O • Important to avoid • PEEP 5 ‐ 8cm H 2 O is safe and trauma at anastomoses recommended • Avoid nasotracheal • In SLT patients, intubation differential lung ventilation can be a – Increases risk of infection challenge • Many patients will have – Dependent on disease of had prior trach native lung and compliance – Some may develop relative to allograft stenosis at anastomoses 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 ‐ op 6

9/21/2015 Heart Transplant Heart Failure • Common – 1 ‐ 2% of people in developed countries – Up to 10% of patients over 70 • Multisystem disease • Mainstays of treatment – Drugs – Resynchronization therapy and ICDs – Transplantation McMurray, JJ. NEJM 2010 7

9/21/2015 Heart Transplant Statistics • Indications: – Cardiomyopathy • Ischemic • Idiopathic Patients # • Myocarditis Waiting (as of 9/11/15) 4,200 • Etc. Transplanted in 2014 1,377 – Congenital disease – PH 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 8

9/21/2015 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 9

9/21/2015 A new alternative? NEJM 2001 10

9/21/2015 NEJM 2009 Slaughter, et al. NEJM 2009 11

9/21/2015 Outcomes Slaughter, et al. NEJM 2009 Putting it Together Fang, JC. NEJM 2009 12

9/21/2015 Heartware HVAD But who is getting LVADs? 13

9/21/2015 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 IV inotropes 3 Stable on continuous IV inotropes 4 Resting sxs on oral rx at Amb IV home 5 Housebound, sxs with Amb IV minimum ADL 6 ‘walking wounded’ – IIIB meaningful activity limited 7 Advanced Class III III Adapted from: Stewart GC, Stevenson LW. Circulation 2011. 14

9/21/2015 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 15