Anesthetic management of heterotopic heart transplantation on beating heart

Abstract

A 58-year-old man (weight 55 kg, body surface area 1.58 m 2 ) had end-stage dilated cardiomyopathy. A left ventricular ejection fraction of 20% was measured by two-dimensional echocardiography. Cardiac catheterization documented severe pulmonary hypertension with pulmonary arterial pressures of 86/40 mmHg (mean, 48 mmHg), pulmonary capillary wedge pressure of 29 mmHg, and pulmonary vasculary resistance of 7.3 Wood units, which decreased to a level of 4.0 Wood units with multiple drug manipulations (isoproterenol, prostoglandin E 1 , nitroprusside, and oxygen inhalation). Cardiac output and cardiac index were 2.4 l·min Ϫ1 and 1.51 l·mm Ϫ1 ·m Ϫ2 , respectively. Coronary angiography was normal, but left ventriculography confirmed moderate mitral regurgitation and dilated cardiomyopathy. The patient was placed on our waiting list and the decision was made to repeat right heart catheterization at the time of transplantation for the definitive operative procedure. Since the patient had NYHA class IV congestive heart failure, he was hospitalized for high-dose inotropic support with (dopamine 10 µg·kg Ϫ1 ·min Ϫ1 , dobutamine 10 µg·kg Ϫ1 ·min Ϫ1 , and isoprenaline 0.5 µg·kg Ϫ1 ·min Ϫ1 ), During his hospitalization, a young female donor (52 kg body weight and 1.50 m 2 body surface area) was referred to us. The patient received premedication with midazolam 5 mg intramuscularly 30 min preoperatively. In the operating room, the patient was monitored with a five-lead ECG, and ST segment analysis, SpO 2 , ETCO 2 , invasive radial artery blood pressure, and rectal and esophageal temperature were measured. In the operating room, a pulmonary artery catheter was placed. The pulmonary artery pressure and calculated pulmonary vascular resistance were 80/38 (mean, 46 mmHg) and 6.4 Wood units, respectively. Anesthesia was induced with 5 mg midazolam, 1 mg fentanyl, and 0.1 mg·kg Ϫ1 vecuronium to facilitate tracheal intubation. Anesthesia was maintained with a