Heart Transplantation: Intraoperative Management, Postoperative Therapy and Complications

Summary Currently, heart transplantation (HTX) is performed as an orthotopic cardiac replacement according to the technique of LOWER and SHUMWAy in over 95% of the cases with good results. Survival after heterotopic HTX, by contrast, remain poor (one year survival: 50%). Postoperative therapy compiles primarily prophylactic measures to prevent complications, especially organ rejection and infections. Immunosuppressive Prophylaxis generally includes a triple drug therapy consisting of cyclosporin, prednisolone, and azathioprine for maintenance therapy. Initially there is often an additional application of poly- or monoclonal antibodies. The prime measure to prevent infection during the initial hospital stay will be reversed isolation of the recipient. Initial antibiotic Prophylaxis resembles that of conservative cardiac surgery, but in addition antiviral and antifungal Prophylaxis is applied. The most common postoperative complication following HTX is cardiac rejection, which is detected by routine endomy-ocardial biopsies. At our Institution the incidence of rejection decreases from 3.07 episodos per patient in the first 3 months to 1.97 opisodes during the last 6 months of the first year after HTX. In general, acute rejection is treated by methylprednisolon (3 × 500 mg/day) or anti-T-cell-antibodies. Infections often occur following intervals of increased immunosuppression, usually early postoperatively and following therapy of acute rejections. Often, invasive diagnostic measures have to be taken rapidly in order to allow for speciflc therapy (antibiotics, anti-mycotic treatment, virostatic agents). Close follow-up of the heart transplant recipient and rapid therapy of possible postoperative complications enable the cur-rent one-year survival rates of 80% or more.