Heart transplantation: operative techniques and postoperative management.

Heart transplantation has become an established therapeutic option for some patients with end stage heart failure. The technique of heart transplantation involves excision of the diseased heart leaving behind cuffs of the right and left atria, pulmonary artery and aorta, which are subsequently attached to their counterparts in the procured donor heart. In most cases donor and recipient operations are carried out in two different hospitals which can be hundreds of miles apart. Careful coordination and timing of the donor and recipient operations is fundamental to keep the ischemic time (ie, the time taken to remove the donor heart, transport to the transplant center and implant in the recipient) to a minimum. Ischemic time longer than 4 hours carries a significantly higher operative mortality. Preservation of the donor heart during the period of ischemia is achieved using a potassium based cardioplegic solution which arrests the heart in diastole, and is supplemented with topical cooling to keep the myocardial temperature at 4 degrees C. Due to cardiac denervation and impaired ability to respond to high filling pressures, maintaining a fast heart rate is essential to maximize cardiac output during the early postoperative period. High pulmonary vascular resistance can occur postoperatively and can result in failure of the donor heart. This may require the use of vasodilators and mechanical right heart assistance. In addition to the use of immunosuppressive agents to prevent rejection of the donor heart, careful attention should be given to renal function and to prophylaxis against infection. The overall 30-day survival (ie, operative survival) currently exceeds 95%.