A patient who has undergone heart transplantation requires non-cardiac surgery. What problems may this present for the anaesthetist?

Heart transplantation is well established and it is increasingly common for patients to present for non-cardiac surgery. The difficulties that such patients present are in fact quite modest, but it is important for anaesthetists to appreciate the physiological implications.

Introduction

Long-term survival after cardiac transplantation is continuing to improve and it is increasingly frequent for patients to present for non-cardiac surgery. Anaesthetic problems are related to the natural history of the transplanted heart, to its altered physiology and to the effects of the necessary immunosuppressive drug regimens.

Natural history of the transplanted heart

• Heart transplantation is a treatment for end-stage cardiac disease

1. — In some patients, for example those with hyperlipidaemias, the underlying diathesis persists and may continue to affect coronary artery patency.

2. — Graft atherosclerosis may also be accelerated by the chronic rejection process and so patients must be assumed to have coronary artery disease.

3. — Transplanted hearts are denervated and so patients do not usually suffer from warning signs of angina pectoris (some believe that residual reinnervation can eventually occur).