CARDIAC ANAESTHESIA
Cardiopulmonary
transplantation: an
anaesthesia review
Vikrant Pathania
Gagan Preet Singh
Khaled Halawa
Abstract
Transplantation is a definitive treatment of choice in suitable patients
with end-stage organ failure. Approximately 5000 heart transplants
and 4000 lung transplants are performed globally every year. Survival
after heart transplant is almost twice in comparison to lung transplant.
Due to deficiency in donor pool, number of patients on waiting list are
increasing every year. Recipient selection should be done carefully as
it massively impacts the outcome. Anaesthesia management for heart
and lung transplant is quite demanding. In this article, we will
review the various challenges encountered by an anaesthetist
during the pre-, intra-, and postoperative period. The postoperative
complications and its management will also be discussed briefly.
Keywords Anaesthesia; complications; donor; heart; lung; rejection;
transplant
Royal College of Anaesthetists CPD Skills Framework: Cardiothoracic
Introduction
Heart failure is a major public health burden with an estimated
global prevalence of over 26 million, leading to major economic
loss. Severe advanced heart failure is estimated to exist in 1e2
million people worldwide who in the absence of advanced
therapies (ventricular assist device or cardiac transplantation)
are at high risk of death (up to 75% in 1 year).1,2
Heart transplantation is currently the gold standard treatment
for refractory heart failure. Despite various advances, the prog-
nosis and quality of life of patients with advanced heart failure
(HF) remains poor. A shortage of donors limits the number of
heart transplants, leading in turn to increased use of mechanical
circulatory support devices.
Vikrant Pathania MBBS MD FNB FCAI EDAIC is a Consultant in
Cardiothoracic Anaesthesia and Intensive Care at the Freeman
Hospital, Newcastle, UK. Conflicts of interest: none declared.
Gagan Preet Singh MBBS DNB FNB is a Clinical Fellow working in the
Cardiothoracic Anaesthesia and Intensive Care Department at the
Freeman Hospital, Newcastle, UK. Conflicts of interest: none
declared.
Khaled Halawa MBBCH MSc-Anaesthesia is a Clinical Fellow working in
the Cardiothoracic Anaesthesia and Intensive Care Department at the
Freeman Hospital, Newcastle, UK. Conflicts of interest: none
declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 25:4
Learning objectives
After reading this article, you should be able to:
C understand the incidence and prevalence of end-stage heart and
lung disease
C understand the current donor situation and recent advances
C understand the indications for and contraindications to heart
and lung transplantation
C understand relevant perioperative anaesthetic concerns
C understand postoperative complications and their management
Currently in the UK, approximately 15% of heart donations
are post-circulatory death (DCD), with the remainder from
donation after brain death (DBD).3 Increased use of DCD dona-
tion is perhaps the most significant change in recent years. The
outcomes from DCD donation are similar to those from DBD
donation, but there is an increased requirement for postoperative
mechanical circulatory support in DCD donation.4
Prioritizing transplant patients
Once accepted for transplantation, patients are placed on a three-
tiered waiting list (Table 1). Super-urgent priority includes pa-
tients receiving temporary mechanical circulatory support (a
short-term left ventricular assist device (LVAD) and extracorpo-
real membrane oxygenation (ECMO)) or those at imminent risk
of dying. Urgent priority includes patients receiving intravenous
(IV) inotropes or those with complications related to a durable
LVAD, such as driveline infection or pump thrombosis. Many
patients classified as non-urgent are supported by a durable
LVAD at home, such as the HeartMate 3 or HeartWare HVAD.
Ischaemic time, organ preservation, and future directions
The donor heart is transported (in an ice box) to the operating
room where the recipient’s heart has been resected. After
completion of cardiac transplantation, the heart-lung machine is
discontinued, and reperfusion is initiated. The time taken from
donor heart arrest to reperfusion in the recipient’s body is called
the ‘ischaemic time’. Ischaemic time is a predictor of survival,
and the goal is to keep ischaemic time <4 hours. A new devel-
opment in organ transportation is securing the donor heart in a
warm, beating state as opposed to the traditional hypothermic,
arrested state. Utilizing the Organ Care System (OCS) Heart
System (TransMedics, Andover, Massachusetts, USA), hearts can
be transported for longer with less concern about ischaemic time
(Figure 1). This technology can increase donor numbers and
maximize donor heart utilization.6
Indications and contraindications
Timely referral of patients to the transplant list is of utmost
importance for their survival. Before referring any patient for
transplantation, indications and contraindications should be
thoroughly addressed (Table 2 and Table 3).
Anaesthesia for heart transplantation
Anaesthesia management for heart transplantation is
demanding and frequently occurs on an emergency basis
229 Ó 2024 Published by Elsevier Ltd.
 CARDIAC ANAESTHESIA

Patients on the heart transplant lists at 31 March 2023 Indications for heart transplantation
(2022) in the UK, by centre5
Absolute indications
Centre Non-urgent Heart urgent Super-urgent 1. Heart failure (HF) causing haemodynamic compromise (refractory
cardiogenic shock, dependence on inotropic support for organ
Adult perfusion, peak VO2 <10 ml/kg/minute)
Birmingham 38 (43) 3 (4) 0 (0) 2. Severe symptoms of cardiac ischaemia not amenable to coronary
Glasgow 15 (14) 4 (2) 0 (0) artery bypass surgery or percutaneous coronary intervention
Great Ormond 1 (1) 1 (0) 0 (0) 3. Refractory ventricular arrhythmias (not responding to any
Street treatment)
Harefield 49 (62) 9 (4) 1 (2) Relative indications
Manchester 29 (30) 2 (2) 0 (1) 1. Peak VO2 11e14 ml/kg/minute and major limitations of daily
Newcastle 62 (72) 12 (10) 0 (0) activity
Papworth 34 (32) 4 (3) 0 (1) 2. Recurrent unstable ischaemia not amenable to any intervention
TOTAL 228 (254) 35 (25) 1 (4) 3. Unstable fluid balance/renal function not due to patient non-
Paediatric compliance with medical treatment
Great Ormond 19 (14) 8 (4) 0 (1) 4. Other; severely impaired left ventricular ejection fraction, func-
Street tional class III or IV HF symptoms
Newcastle 15 (17) 6 (9) 0 (0)
TOTAL 34 (31) 14 (13) 0 (1) Table 2

Table 1
because of unpredictable availability of organs. Recipients may
be stable at home or critically ill in the intensive care unit
(ICU). Patients may have had previous cardiac surgery or be
receiving some form of temporary mechanical circulatory sup-
port, such as ECMO or an LVAD.
Anaesthesia management and monitoring
A senior surgeon and perfusionist should be immediately avail-
able prior to induction of anaesthesia. Induction of anaesthesia
should be carefully coordinated, giving at least 1 hour for
anaesthesia and 1 hour for preimplantation surgery or 2 hours for
re-do surgery. Strict asepsis should be followed, as these patients
are immunosuppressed. The operating theatre team should be
prepared for emergency initiation of cardiopulmonary bypass
(CPB) and immediate blood transfusion.
In addition to standard monitoring, a pulmonary artery cath-
eter (PAC) and transoesophageal echocardiography (TOE) are
appropriate for all heart transplant recipients. External defibril-
lator pads should be applied in all cases. Large-bore IV access
and an arterial catheter should be sited before inducing anaes-
thesia. A central venous catheter (CVC) is often sited post in-
duction but in very-high-risk recipients may be done beforehand.
If possible, the CVC and PAC should be sited in the left internal
jugular vein, as the right vein is reserved for subsequent
myocardial biopsies. The PAC should not be advanced into the
pulmonary artery until after implantation of the graft.

Figure 1

ANAESTHESIA AND INTENSIVE CARE MEDICINE 25:4 230 Ó 2024 Published by Elsevier Ltd.
 CARDIAC ANAESTHESIA
Contraindications for heart transplantation
Absolute
1. Advanced irreversible renal failure without planned concurrent
renal transplantation
2. Advanced irreversible liver disease without planned concurrent
liver transplantation
3. Advanced irreversible lung parenchymal disease
4. Advanced irreversible severe pulmonary hypertension
5. Solid organ or haematological malignancy in the past 5 years
Relative
1. Severe peripheral vascular disease
2. Severe cerebrovascular disease
3. Severe osteoporosis
4. Uncontrolled diabetes mellitus with end organ damage
5. Active infection (excluding left ventricular assist device-related
infection)
6. Individual factors (body mass index >35 kg/minute/m2, lack of
social support, substance abuser, psychological instability)
Table 3
As recipients are fragile and prone to excessive hypotension
induction should be slow with immediate recourse to vaso-
pressor agents. Antimicrobial and immunosuppressive drugs are
given after induction of anaesthesia according to institutional
protocol. IV methylprednisolone is usually given at induction
and again after reperfusion of the graft.
Surgical considerations
After sternotomy, the surgeon exposes the aorta, pulmonary ar-
tery and the superior (SVC) and inferior (IVC) vena cavae. For
patients with LVADs, the pump, inflow and outflow cannula and
driveline must also be mobilized. Before cannulation for CPB, IV
heparin is administered at a standard dose (350e450 U/kg), tar-
geting an activated clotting time >400e500 seconds. Repeat
heparin dosing or antithrombin III concentrate may be required in
patients with heparin resistance (antithrombin III deficiency)
secondary to preoperative heparin therapy. Important consider-
ations prior to separation from CPB include the potential for
pacing, haemodynamic support and blood component therapy.
Vasoactive support
The transplanted heart is denervated, with loss of direct sympa-
thetic and parasympathetic input. Surface a and b receptors are
present, but the graft responds in an attenuated and delayed
manner to circulating catecholamines. Atropine and neostigmine
have no effect on heart rate. Indirect acting sympathomimetic
drugs, such as ephedrine, should be avoided. The choice of
vasoactive drugs is often based on institutional preference. Inhaled
nitric oxide (iNO) at 10e20 ppm can be used as a pulmonary
vasodilator and to attenuate primary graft dysfunction (PGD).
Allograft management
Allow sufficient time for the graft to recover before attempting to
wean from CPB. Typically, 1 hour should be allowed for reper-
fusion and longer when the donor ischaemic time is prolonged.
Studies have found that when the donor ischaemic time is
ANAESTHESIA AND INTENSIVE CARE MEDICINE 25:4
>4 hours, reperfusion for >90 minutes results in better survival.7
After reperfusion and prior to weaning from CPB, TOE is used for
de-airing of the heart and to rule out intra-cardiac thrombus.
Assessment of ventricular function is unreliable until the heart is
unloaded. Once separated from CPB, the PAC should be
advanced into the pulmonary artery to measure cardiac index
and mixed venous oxygen saturation. When the chest is closed,
pacing should be changed to DDD mode.
Optimizing haemodynamic function
The most common cause of failure to separate from CPB is right
ventricular (RV) failure caused by impaired systolic function and
increased pulmonary vascular resistance (PVR). Treatment of RV
failure involves optimizing preload, augmenting RV contractility
and reducing PVR. Simple strategies to reduce PVR include
maintaining normoxia, normocarbia and a normal pH, while
simultaneously avoiding high ventilatory pressures, which in-
crease RV afterload. Mechanical ventilation at a relatively
high ventilatory frequency (>15 bpm) and modest tidal volume
(5e6 ml/kg) helps achieve these objectives. Milrinone and iNO
are also useful agents to reduce PVR.
Hypotension, which can lead to reduced RV perfusion pres-
sure, is managed by infusion of noradrenaline targeting a mean
arterial pressure (MAP) of 60e65 mmHg. Other causes of hy-
potension include impaired left ventricular (LV) systolic function
and vasoplegia. Vasoplegia can occur in about one-third of pa-
tients after heart transplantation. Risk factors include preopera-
tive use of angiotensin-converting enzyme inhibitors, the
presence of an LVAD and prolonged CPB. Treatment includes
vasopressors and IV methylene blue.8
Blood component therapy
To minimize the problem of allosensitization all blood products
should be leucodepleted and cytomegalovirus (CMV) negative.
Blood products are guided by the patient’s preoperative coagu-
lation status, bleeding before CPB and blood testing (haemoglo-
bin, platelet count, fibrinogen concentration, prothrombin time
(PT), activated partial thromboplastin time (aPTT) and throm-
boelastography (TEG).
Mechanical circulatory support
Patients who fail to wean from CPB or who do so with marginal
haemodynamics (MAP <65 mmHg, CI < 2 litres/minute/m and
central venous pressure (CVP) >15 mmHg) despite modest
to high dose inotropic support (adrenaline or noradrenaline
>0.1e0.2 mg/kg/minute) should be placed on mechanical cir-
culatory support. Options include venoarterial (VA) ECMO and a
temporary RV assist device. Evidence suggests that early insti-
tution of VA ECMO is the best option.9
Complications
Early complications
1. Primary graft failure is defined as primary failure of the
graft, affecting the left and/or right ventricle causing hae-
modynamic compromise. Treatment includes haemody-
namic support with vasopressors and use of mechanical
circulatory devices in severe cases.
231 Ó 2024 Published by Elsevier Ltd.
 CARDIAC ANAESTHESIA
2. RV dysfunction is the most common early postoperative
complication. Recipients with high pulmonary vascular
resistance, present with increased risk of RV failure. Intra-
operatively it is vital to exclude mechanical causes, such as
torsion of the pulmonary artery anastomosis, to note extra-
corporeal circulation output, and to consider the possibility
of pulmonary vasoconstriction following protamine and gas
embolism. Treatment aims to optimize RV preload and
normovolaemia, reduce PVR with vasodilators (nitroprus-
side, nitric oxide, prostacyclin, and sildenafil) while
increasing myocardial contractility. Mechanical ventilation
should be adjusted to avoid hypoxia and elevated ventilatory
pressures. If there is no adequate response, the use of cir-
culatory assistance devices should be considered.
3. Infections are with primary graft failure among the principal
causes of mortality in the first 3 years after transplantation.
They account for 12% of deaths in the first 30 days and 29%
between 1 month and 1 year (excluding CMV infections).10
Most are opportunistic and secondary to immunosuppression.
Late complications
1. Cardiac allograft vasculopathy is among the primary causes
of death after the first year of heart transplant. This is an
important factor affecting long-term survival, along with
neoplasms, with an incidence of 8% in the first year, 30% in
5 years, and 50% in 10 years.10 Its clinical manifestations are
similar to those of coronary artery disease, such as ar-
rhythmias, myocardial infarction, HF, and sudden death. It
has limited clinical treatment, with retransplant as the only
definitive therapeutic option.
2. Neoplasms Transplant recipients have a two- to fourfold
increased risk of developing neoplasia secondary to immu-
nosuppression. This includes malignancies related to viral
infections, such as non-Hodgkin’s lymphoma and Hodgkin’s
lymphoma, Kaposi sarcoma, anogenital cancers and hepatic
cancers. Mammalian target of rapamycin (mTOR) inhibitors
have antitumor action and are used in these conditions.
Rejection
According to the latest International Society for Heart and Lung
Transplantation (ISHLT) register, the incidence of graft rejection
has fallen progressively over recent years. In 2010, it reached its
nadir at approximately 25%, thanks to the development of
immunosuppression drugs and strategies.10 Classically there are
three types: hyperacute, cellular, and humoral. The performance
of ABO-compatible transplantation and pretransplant panel-
reactive antibody (PRA) testing has reduced the incidence of
rejection. Equally endomyocardial biopsy maintains its gold
standard in accurate and early rejection diagnosis.
Immunosuppression
According to ISHLT,10 the triple regimen of corticosteroid
(methylprednisolone, prednisolone), calcineurin inhibitor
(cyclosporine, tacrolimus) and an antiproliferative agent (cyclo-
sporine and tacrolimus) is used routinely in most major centres.
Likewise, mTOR) inhibitors (sirolimus, everolimus) are used to
reduce the incidence and progression of neoplasia and cardiac
allograft vasculopathy. Additionally, induction therapy deploys
ANAESTHESIA AND INTENSIVE CARE MEDICINE 25:4
agents such antilymphocyte antibodies (thymoglobulin) and
interleukin-2 antagonists (basiliximab) for intensive immuno-
suppression in situations of acute rejection.
Anaesthesia for lung transplantation
Introduction
Lung transplantation has gained increased success over the past
20 years owing to improved surgical techniques, refinements in
donor and recipient selection, and overall improved post-
operative care of the recipients. The number of lung transplants
performed worldwide has increased dramatically since 1985,
however further achievement is limited by organ availability.
Since May 2005, lung transplant waiting list prioritisation has
been based on a Lung Allocation Score (LAS) developed to
address high waiting list mortality. To increase organ availability
and improve outcomes, a portable lung perfusion system, Organ
Care System (OCS) Lung, has also been developed.
Recipient selection
Lung transplantation is an operation of last resort. There are
insufficient donors and patients are unlikely to be considered
unless other measures have failed, and their short-term prog-
nosis is otherwise poor. The presence of uncontrolled systemic
disease precludes consideration and good renal and hepatic
function is essential, particularly in view of immunosuppressant
toxicity. This is particularly important in a1-antitrypsin defi-
ciency and cystic fibrosis, both of which may affect the liver
directly. An aspergilloma is a contraindication to any form of
lung transplantation as its attempted removal inevitably leads to
seeding of the pleural cavity and mediastinum. Previous
thoracic surgery may make it difficult to operate and the possi-
bility of a future lung transplant should therefore be borne in
mind when considering the best treatment for conditions such as
pneumothorax.11
Indications for lung transplantation
These include chronic obstructive pulmonary disease (COPD),
emphysema, pulmonary fibrosis, cystic fibrosis, pulmonary hy-
pertension, a-1-antitrypsin deficiency, bronchiectasis, congenital
heart diseases and pulmonary manifestations of systemic dis-
eases such as sarcoidosis and systemic lupus erythematosus
(SLE).
Lung transplantation should be considered in patients with
advanced lung disease whose clinical status has progressively
declined despite maximal medical or surgical therapy. Candi-
dates are usually symptomatic during activities of daily living
and have a limited expected survival over the next two years.
Other considerations include appropriate age (previously 65-
year-old, but now trending older), acceptable nutritional status;
usually 80e120% of ideal body weight and BMI 30e35, satis-
factory psychosocial profile and support system.12
Contraindications
 Non-curable systemic infection (chronic active hepatitis B,
hepatitis C, and HIV)
 Malignancy in the last 2 years (except cutaneous squa-
mous cell carcinoma or basal cell carcinoma)
 Significant dysfunction of other vital organs (may consider
concurrent transplant of a second organ)
232 Ó 2024 Published by Elsevier Ltd.
 CARDIAC ANAESTHESIA
 Significant coronary artery disease or heart failure, include
congenital cardiomyopathy (may consider combined heart-
lung transplant)
 Active tobacco smoking
 Significant psychosocial issues: absence of a reliable social
support system, ongoing history of substance abuse, his-
tory of non-compliance, or inability to comply with com-
plex medical regimen and follow-up care13
 Advanced age (>65 years old, but a relative CI)14
 Significant chest wall/spinal deformity (relative CI).
Anaesthetic management
Preoperative assessment should address potential transplant
rejection or infection, immunosuppressive effects on other or-
gans and the effect of organ dysfunction on the transplanted
lung. Likewise, disease in the native lung, indications for the
surgical procedure and its effect on the lung merit consideration.
It is also necessary to evaluate supplemental oxygen re-
quirements, pulmonary function tests, arterial blood gases, chest
X-ray, CT, ECG, echocardiogram, complete blood count, glucose,
electrolytes, renal and liver function tests, coagulation tests and
to exclude infections.
Perioperative management
If possible, continue immunosuppressants until the day of sur-
gery with judicious use of anxiolytics lest they lead to hyper-
carbia. Administer immunosuppressants IV if oral agents are
precluded and prophylactic antibiotics. Avoid femoral lines and
nasal intubation as they increase risk infection.15
Invasive monitoring
Despite over 260 lung transplant centres conducting over 4000
lung transplants annually, there are no formalized clinical
guidelines for advanced intraoperative monitoring. Nevertheless,
invasive arterial pressure (IAP) monitoring, PAC, CVP and TOE
are widely advocated in lung transplantation.15
Airway equipment
Left-sided double-lumen tube (DLT): general guideline (for
men: 39 or 37 Fr and for women: 35 or 37 Fr), fibreoptic
equipment with DLT exchange catheter, GlideScope, continuous
positive airways pressure set-up (for during one lung ventila-
tion), prepare for potentially a full stomach and a difficult
airway. Other systemic manifestations of the underlying lung
disease (such as rheumatoid arthritis and cervical spinal disease,
scleroderma and CREST syndrome, SLE and renal disease, and
steroid side effects) can be challenging.
The decision on whether to perform the transplantation on
ECMO, CPB, or off pump depends on the patient’s RV function,
severity of pulmonary hypertension (will worsen with pulmo-
nary artery cross-clamp), haemodynamic stability and oxygen
saturation during dissection on one lung ventilation, and any
intra-cardiac repair.16
The advantages of on CPB
 Haemodynamic stability, especially if there is significant
RV dysfunction.
 Transfusion via the reservoir is easy in the setting of
haemorrhage. Saturation is easily maintained.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 25:4
 The first graft organ can be rested while on CPB. It is still
ventilated with low pressure and low FiO2, but without
receiving excessive flow and risking become hyperaemic
and oedematous.
 Permits to repair of any intra-cardiac shunt or tricuspid
regurgitation on CPB.
The advantages of off CPB
 Avoids exposure to the CPB circuit, post-CPB coagulopathy
and bleeding.
 Avoids instrumentation of aorta and vascular complication
 Can provide gas exchange and hemodynamic stability with
less heparin exposure.
The majority of bilateral lung transplant at UCSF are now
done with central VA ECMO.
Remember that ventilation is still necessary while on ECMO.
Venous drainage may be poor and fluid replacement may be
necessary.
PA anastomosis: it is during this period that the surgeon will
request methylprednisolone (10 mg/kg), timed to finish prior to
the release of PA and reperfusion of the graft organ. Graft
reperfusion is a critical period. PGD can occur quickly with onset
of severe pulmonary oedema that despite suctioning may
necessitate initiation of ECMO (if done off ECMO). Also, lung
reperfusion can release metabolites causing acidosis and hypo-
tension. It is therefore best to avoid excessive fluid/albumin after
donor lung implantation lest oedema arise. The donor lung has
no functional lymphatics. Nevertheless, fluid may be necessary if
there is significant base deficit.
Haemodynamic management
The recipient’s haemodynamics require inotropic support and
management of SVR and PVR.
Endothelial derived relaxing factor (EDRF), now identified as
nitric oxide (NO), plays a key role management of PVR and areas
of ventilation-perfusion (V/Q) mismatch in patients with
ischaemia-reperfusion injury.6 Monitor central venous pressure,
pulmonary artery pressure, and urine output. Maintain a careful
fluid balance and consider that altered lymphatic drainage in the
transplanted lung may cause interstitial fluid accumulation. Treat
these patients with diuretics and limited crystalloid infusion.
ECMO as a bridge to lung transplantation has increased 27%,
while mechanical ventilation (MV) has decreased 38% over the
past decade. Survival with ECMO has significantly improved and
is now equivalent to survival in recipients bridged on MV. These
results suggest gains in use, outcomes, and safety of ECMO in
this patient cohort.17
Pain management strategies in lung transplantation
Management of acute postoperative pain in the lung transplant
recipient can be challenging, yet a balanced approach that is
mindful of cardiopulmonary function while minimizing side ef-
fects can optimize outcomes. Not only is acute postoperative
pain a challenge, but chronic pain is as well. A recent survey
of lung transplant recipients reported chronic pain in 51% a year
post-surgery.
Given these circumstances, techniques involving use of
regional anaesthetics are often employed. The most frequently
233 Ó 2024 Published by Elsevier Ltd.
 CARDIAC ANAESTHESIA
studied, thoracic epidural analgesia (TEA), is noted to be the
‘gold standard’. Overall, data regarding the impact of analgesic
approach on lung transplantation outcomes are limited, howev-
er, TEA has been shown to decrease postoperative mechanical
ventilation time.18 Other pain management strategies reported
include use of paravertebral catheters, serratus anterior plane
blocks, and erector spinae blocks. Larger studies are necessary to
define optimal pain management in this patient population and
require direct comparisons of specific regional anaesthetic
techniques.
Postoperative care
The principles of ICU care after lung transplantation involve lung
protective ventilation, early tracheal extubation, fluid restriction,
routine immunosuppressive and antimicrobial therapy. Also
necessary is adequate analgesia provision and prophylaxis
against venous thromboembolism (VTE).
In the absence of significant cardiorespiratory dysfunction,
patients should be weaned and extubated within 24 hours. Low-
dose noradrenaline (<0.05 micrograms/kg/minute) is helpful to
support MAP and to avoid excessive fluid administration. Seek
and treat infection or rejection. Continue immunosuppressive
therapy; immunosuppression typically involves a calcineurin in-
hibitor (tacrolimus or cyclosporine), an antiproliferative agent
(azathioprine or mycophenolate) and corticosteroids. Patients
require ongoing antimicrobial therapy, either as prophylaxis or
directed against pre-existing infection in the donated lungs. Early
extubation and ambulation decrease ICU and hospital stay. Reg-
ular chest X-rays can be helpful in detecting signs of infection or
primary graft dysfunction.
Management of complications
Complications during ICU stay primarily relate to cardiorespira-
tory failure and development of multiple-organ dysfunction.
Recovery from multiple-organ dysfunction is often greatly pro-
longed because of pre-existing deconditioning and malnutrition.
The most common significant postoperative complication is
PGD, affecting approximately 30% of patients. PGD is defined by
impaired oxygenation and diffuse alveolar opacities on the chest
radiograph and can occur at any time from allograft reperfusion
up to 3 days after surgery. PGD is associated with increased early
and late morbidity and mortality. PGD is more common in pa-
tients with severe pulmonary hypertension. Modifiable risk-
factors include the use of extracorporeal life support (ECLS),
high intraoperative fluid and blood product administration, and
high FiO2 during reperfusion. Treatment is supportive, and in-
cludes lung protective ventilation, iNO, fluid restriction and VV
ECMO. In one study, 6% of patients undergoing lung trans-
plantation required VV ECMO for PGD, with a 5-year survival of
49%, which is worse but not substantially so than survival for all
comers.19
Other causes of early respiratory compromise include mucus
plugging and atelectasis, a large haemothorax or pneumothorax
(blocked or kinked drains), acute rejection, pneumonia, bron-
chial anastomotic leak, pulmonary embolism and dynamic hy-
perinflation. Pulmonary embolism is an especially feared
complication, as, in the absence of a bronchial circulation, there
is a high risk of pulmonary infarction. Consequently, routine VTE
prophylaxis is essential once surgical bleeding has settled.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 25:4
Cardiovascular failure is most commonly attributable to RV
dysfunction, and is exacerbated by hypoxia, acidosis, fluid
overload and cardiac tamponade. Early, bedside TOE is essential
to confirm the diagnosis and exclude other causes of hypoten-
sion. Treatment is as described above. Severe RV dysfunction
that does not respond to more simple manoeuvres should be
managed with VA ECMO.
Acute kidney injury occurs in about half of patients after lung
transplantation with approximately one in eight patients
requiring renal replacement therapy. It may be appropriate to
withhold routine calcineurin inhibitor therapy in patients with
evolving acute kidney injury. To minimize the adverse conse-
quences of fluid overload and acidosis, early institution of renal
replacement therapy is appropriate.20 A
REFERENCES
1 Costanzo MR, Mills RM, Wynne J. Characteristics of “Stage D”
heart failure: insights from the Acute Decompensated Heart Failure
National Registry Longitudinal Module (ADHERE LM). Am Heart J
2008; 155: 339e47. https://doi.org/10.1016/j.ahj.2007.10.020
2 Abouezzeddine OF, Redfield MM. Who has advanced heart fail-
ure?: definition and epidemiology. Congest Heart Fail Greenwich
Conn 2011; 17: 160e8. https://doi.org/10.1111/j.1751-7133.2011.
00246.x
3 Clarkson A, Forsythe J, Gardiner D. National Health Service organ
donation and transplantation activity report 2019/20.
4 Chew HC, Iyer A, Connellan M, et al. Outcomes of donation after
circulatory death heart transplantation in Australia. J Am Coll
Cardiol 2019; 73: 1447e59.
5 Organ and tissue donation activity report 2022-2023 for UK
transplant registry. Also available at: https://nhsbtdbe.blob.core.
windows.net/umbraco-assets-corp/30188/activity-report-2022-
2023-final.pdf
6 Messer S, Ardehali A, Tsui S. Normothermic donor heart perfu-
sion: current clinical experience and the future. Transpl Int 2015;
28: 634e42. https://doi.org/10.1111/tri.12361
7 Jernryd V, Metzsch C, Andersson B, et al. The influence of
ischemia and reperfusion time on outcome in heart trans-
plantation. Clin Transplant 2020; 34: e13840.
8 Chan JL, Kobashigawa JA, Aintablian TL, et al. Characterizing
predictors and severity of vasoplegia syndrome after heart
transplantation. Ann Thorac Surg 2018; 105: 770e7.
9 Takeda K, Li B, Garan AR, et al. Improved outcomes from extra-
corporeal membrane oxygenation versus ventricular assist device
temporary support of primary graft dysfunction in heart transplant.
J Heart Lung Transplant 2017; 36: 650e6.
10 Lund LH, Edwards LB, Kucheryavaya AY, et al. International So-
ciety for Heart and Lung Transplantation. The Registry of the In-
ternational Society for Heart and Lung Transplantation: thirtieth
official adult heart transplant reporte2013; focus theme: age.
J Heart Lung Transplant 2013; 32: 951e64.
11 de Perrot M, Granton JT, McRae K, et al. Impact of extracorporeal
life support on outcome in patients with idiopathic pulmonary
arterial hypertension awaiting lung transplantation. J Heart Lung
Transplant 2011; 30: 997e1002. https://doi.org/10.1016/j.healun.
2011.03.002
12 Weill D, Benden C, Corris PA, et al. A consensus document for the
selection of lung transplant candidates: 2014–an update from the
234 Ó 2024 Published by Elsevier Ltd.
 CARDIAC ANAESTHESIA
Pulmonary Transplantation Council of the International Society for
Heart and Lung Transplantation. J Heart Lung Transplant 2015;
34: 1e15. https://doi.org/10.1016/j.healun.2014.06.014
13 Hook JL, Lederer DJ. Selecting lung transplant candidates: where
do current guidelines fall short? Expert Rev Respir Med 2012; 6:
51e61. https://doi.org/10.1586/ers.11.83
14 Elnahas S, Kang P, Roy SB, et al. Outcomes of lung transplant
recipients 70 and over. J Heart Lung Transplant 2019; 38: S335.
https://doi.org/10.1016/j.healun.2019.01.847
15 Martin AK, Yalamuri SM, Wilkey BJ, et al. The impact of anesthetic
management on perioperative outcomes in lung transplantation.
J Cardiothorac Vasc Anesth 2020; 34: 1669e80. https://doi.org/
10.1053/j.jvca.2019.08.037
16 Ardehali A, Laks H, Levine M, et al. A prospective trial of inhaled
nitric oxide in clinical lung transplantation. Transplantation 2001;
72: 112e5. https://doi.org/10.1097/00007890-200107150-00022
ANAESTHESIA AND INTENSIVE CARE MEDICINE 25:4
17 Hakim AH, Ahmad U, McCurry KR, et al. Contemporary outcomes
of extracorporeal membrane oxygenation used as bridge to lung
transplantation. Ann Thorac Surg 2018; 106: 192e8. https://doi.
org/10.1016/j.athoracsur.2018.02.036
18 McLean SR, Homeyer von P, Cheng A, et al. Assessing the
benefits of preoperative thoracic epidural placement for lung
transplantation. J Cardiothorac Vasc Anesth 2018; 32: 2654e61.
https://doi.org/10.1053/j.jvca.2018.04.002
19 Snell GI, Yusen RD, Weill D, et al. Report of the ISHLT working
group on primary lung graft dysfunction: Part I. Definition and
gradingda 2016 consensus group statement of the International
Society for Heart and Lung Transplantation. J Heart Lung Trans-
plant 2017; 36: 1097e103.
20 Atchade E, Barour S, Tran-Dinh A, et al. Acute kidney injury after
lung transplantation: perioperative risk factors and outcome.
Transplant Proc 2020; 52: 967e76.
235 Ó 2024 Published by Elsevier Ltd.