Anesthesiology & Intensive Care Committee in Heart Transplantation (AICCinHTX)
1. General clinical aspects
The complexity of perioperative patient care in heart transplantation and heart failure surgery remains a challenge for the cardiac anesthesiologist and critical care physician. Successful clinical management in this area of acute medicine is not only life-saving for the patient but also rewarding for the caregivers. Next to up-to-date clinical care including the most modern diagnostic and therapeutic modalities, we see teaching of students, interns and residents as a focus of our group.
2. Perioperative indicators of outcome in heart transplantation with special regards to kidney function
Perioperative modification of therapy will have an impact on mortality and morbidity after heart transplantation. Primary field of research is the identification of perioperative risk indicators and the interaction between pre- and postoperative risk factors. Second step is modification of perioperative therapy and outcome analysis. Renal function is a sensitive risk indicator and susceptible to the modification of therapy.
3. Bridging to transplantation
Elevated pulmonary pressure in chronic heart failure patients is associated with increased mortality and morbidity peri-operatively after heart transplantation. Therefore, repeated evaluation of pulmonary pressure and transpulmonary gradient in the preoperative setting is crucial in these patients for selecting the optimal treatment for the individual patient. If pulmonary pressure is not reversible after vasodilator testing, heart transplantation is not an option for the patient. We have been the first in demonstrating that implantation of a LVAD is reducing pulmonary pressure by unloading the left ventricle and thus bridging the patient to candidacy for heart transplantation.
This study group is mainly interested in testing and selecting patients for heart transplantation, decreasing the risk of perioperative right heart failure and thus optimizing outcome.
4. Imaging the graft: perioperative TEE
Echocardiography has a critical role in the diagnosis and therapy of heart failure. It has a major part in the perioperative management of patients receiving a heart transplant or VAD implantation to assess organ or implant function. Precise intraoperative diagnostics to achieve better VAD implantation, assessment of right ventricular function and the development of improved parameters for the assessment of VAD devices with new technologies as 3D echocardiography should further improve outcome for these patients. The management of complications, postoperative assessment after transplant and VAD implant and the transfer of knowledge in Echo courses are also important tasks.
5. PGD, risk and outcome
Primary graft dysfunction (PGD) during and immediately after heart transplantation is the main life-threatening complication in cardiac transplantation and is associated with high morbidity and mortality. The risk of severe PGD unfortunately has not decreased over the past years. The continuous liberalization of criteria of donor acceptance due to scarcity of donor organs may have contributed to this situation. However, with regards to clinical and economic aspects, it is of utmost importance to detect PGD and to work out medical strategies to avoid early graft dysfunction. This study group has devoted its primary focus to the establishment of hemodynamic and clinical criteria of early PGD to identify patients who should be considered for perioperative assisted mechanical support. Improved patient selection and perioperative treatment of transplant candidates as well as accurate clinical follow-up with multidisciplinary input will optimize long-term results in this difficult setting.
6. Infection in immunosuppressed htx-patients
Nosocomial infections in pharmacologically immunosuppressed patients remain the major cause of morbidity and mortality after heart transplantation. Although intensivists investigated new strategies and changed practice in antibiotic therapy and prophylaxis in htx-patients, the incidence of perioperative infections increased over the last decade. This is probably at least partially due to the acceptance of more severe compromised recipients with resultant complicated surgical course (ECMO and revisions). This management group is interested in clinical strategies for the early use of a combination of potent broad spectrum antibiotics together with antimycotic therapy in htx-patients to reduce the incidence of sepsis induced ICU-mortality.