Perioperative Management of Cardiac Transplant Recipients Undergoing Noncardiac Surgery: Unique Challenges Created by Advancements in Care

Abstract

Advancements in postcardiac transplant care have resulted in significant reductions in morbidity and increased life expectancy for cardiac transplant recipients. Consequently, many cardiac transplant recipients are living long enough to require subsequent noncardiac surgery. The perioperative care of heart transplant recipients presents a unique challenge as many of the common preoperative risk assessments do not apply to a transplanted heart, immunosuppressive medications have side effects and potential for drug-drug interactions, and the denervated heart results in an altered autonomic physiology and response to medications. Further adding to the challenge is that many of these noncardiac surgeries need to be performed urgently at nontransplant centers that may not be familiar with the care of these patients. This review aims to summarize the current data regarding preoperative assessment, perioperative immunosuppression management, intraoperative and anesthetic considerations, and outcomes of cardiac transplant recipients undergoing noncardiac surgery.

Heart-Kidney Transplantation in a Transgender Woman

“…Breast cancer Oral Estradiol Daily Parenteral Estradiol valerate or cypionate SQ every 2 weeks IM every week Transdermal Estradiol Twice weekly Antiandrogens GnRH agonist (leuprolide) Monthly Dehydration, hyponatremia Histrelin implant Every 12 months Bone loss (if not combined with estradiol) Spironolactone Daily Hyperkalemia Testosterone regimens for transgender men Testosterone Oral (not available in the U.S.) Testosterone undecanoate Daily Erythrocytosis Hypertension Obstructive sleep apnea Osteoporosis Hyperlipidemia ?Liver dysfunction Intranasal Testosterone nasal gel 3 times daily Parenteral Testosterone enanthate or cypionate SQ or IM every 2 weeks Transdermal Testosterone gel (1%) Daily Testosterone patch Daily Implant Testosterone pellets Every 3 to 6 months Data derived from Tangpricha et al, 2 Connelly et al, 3 and Jurgens et al. 9 SQ = subcutaneous; IM = intramuscular. …”

“… Data derived from Tangpricha et al, 2 Connelly et al, 3 and Jurgens et al. 9 SQ = subcutaneous; IM = intramuscular. …”

“…In general, elective surgical procedures are deferred until after the first 6 to 12 months after transplantation until immunosuppression is at a lower and stable dose and when there is a lower risk of graft dysfunction. 9 The benefits of deferring these surgeries should be weighed against the risks of psychological distress that may be experienced by the patient. Additionally, access to essential services like gender-affirming surgery can be stymied by a lack of insurance or growing waiting lists in the aftermath of the COVID-19 pandemic.…”

Facing the Ever-Changing Challenges of Caring for Cardiothoracic and Transplant Surgery Patients

“…Thus, the article by Dr Jurgens and his group-"Perioperative Management of Cardiac Transplant Recipients Undergoing Noncardiac Surgery: Unique Challenges Created by Advancements in Care"-is timely, and reviews the latest on preoperative assessment, perioperative management of immunosuppression, intraoperative anesthetic considerations, and potential postoperative complications of cardiac transplant patients undergoing noncardiac surgery. 11 In the field of liver transplantation, the number of living organ donations worldwide has increased significantly, with right hepatic lobe donation being the most common approach. Although liver donation is associated with an estimated 2.3% morbidity, recipients are also at risk.…”

“…Thus, the article by Dr Jurgens and his group—“Perioperative Management of Cardiac Transplant Recipients Undergoing Noncardiac Surgery: Unique Challenges Created by Advancements in Care”—is timely, and reviews the latest on preoperative assessment, perioperative management of immunosuppression, intraoperative anesthetic considerations, and potential postoperative complications of cardiac transplant patients undergoing noncardiac surgery. 11…”