Extramediastinal surgical problems in heart transplant recipients

Upper Extremity Infections in the Transplant Population

PURPOSE

As the duration of lifetime survival after organ transplantation continues to increase, the consequences of long-term immunosuppression, such as opportunistic and rare infections, are a high-risk reality. This study examined upper extremity infections in the transplant population to determine the current clinical risk profile, management, and outcomes.

METHODS

An institutional database of 16,640 patients who underwent transplantation was queried for upper extremity infections from 2005 to 2017, defined as the presence of infection from the shoulder to the fingertips. The resulting data were analyzed using multivariable linear and logistic regression modeling.

RESULTS

A total of 230 eligible patients experienced upper extremity infections at a mean age of 54.1 ± 15.3 years, occurring, on average, 7.9 ± 8.6 years after transplantation. The most commonly transplanted organ was the kidney (51.3%), followed by the liver (20%). The most common location of infection was the forearm (31.7%), digits (27.4%), and upper arm (17%). The most common types of infection were cellulitis (69.1%), abscess (33.5%), joint sepsis (6.5%), infectious tenosynovitis (3.9%), and osteomyelitis (1.3%). Patients taking an antifungal medication, those who had a joint infection, or those who had undergone lung transplantation had an approximately 2.5-day longer stay in the hospital. For every 1-year increase in age at the time of transplantation, the time from transplantation to infection decreased by 0.21 years. Those who had undergone bone marrow transplantation or those who were taking tacrolimus were expected to have approximately 8- and 6-year decreases, respectively, in the time from transplantation to infection.

CONCLUSIONS

Upper extremity infections should be individually evaluated and treated because of the heterogeneity of transplant type, immunosuppression medications, the age of the patient, and infection characteristics.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Perioperative care of heart transplant recipients undergoing non-cardiac surgery

The life expectancy of patients with end-stage heart disease undergoing Orthotopic Heart Transplantation (OHT) has increased significantly in the recent decades since its original introduction into the medical practice in 1967. Substantial advances in post-operative intensive care, surgical prophylaxis, and anti-rejection drugs have clearly impacted survivability after OHT, therefore the volume of patients presenting for non-cardiac surgical procedures is expected to continue to escalate in the upcoming years. There are a number of caveats associated with this upsurge of post-OHT patients requiring non-cardiac surgery, including presenting to healthcare facilities without the resources and technology necessary to manage potential perioperative complications or that may not be familiar with the care of these patients, facilities in which a cardiac anesthesiologist is not available, patients presenting for emergency procedures and so forth. The perioperative care of patients after OHT introduces several challenges to the anesthesiologist including preoperative risk assessments different to the general population and intraoperative management of a denervated organ with altered response to medications and drug-drug interactions. The present review aims to synopsize current data of patients presenting for non-cardiac surgery after OHT, surgical aspects of the transplant that may impact perioperative care, physiology of the transplanted heart as well as anesthetic considerations.

Acute Care Surgery in Heart Transplant Recipients

Orthotopic heart transplantation (OHT) is the optimal treatment for end-stage heart failure. We reviewed our institutional experience between 2008 and 2012 with acute care surgery (ACS) consultations and procedures within 1 year of OHT in recipients bridged to transplantation with medical therapy (MT, n = 169), including intravenous inotropes, and ventricular assist devices (VADs, n = 74). In total, 28 consultations were required in 21 patients (9%) and 16 procedures were performed in 11 patients (5%). The interval from transplantation to consultation was shorter for the MT group (50 vs 82 days; P = 0.015), whereas the interval from consultation to operation was longer (5 vs 1 day; P = 0.03). Patients undergoing MT were more likely to require consultation for abdominal problems (88 vs 27%; P = 0.004). All but one of the seven ischemic/inflammatory abdominal problems occurred in the MT group. Complications occurred after five ACS procedures (31%) in two patients undergoing MT and three patients undergoing VAD. Mortality was 24 per cent with five deaths occurring within 30 days of ACS consultation and/or operation. In summary, this is one of the largest series of ACS problems in patients undergoing OHT bridged to transplant with MT or VAD. With similar incidence in MT and VAD groups, ACS consultations and operations are infrequent with high mortality and morbidity.

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

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.

Late noncardiac surgery in heart transplant patients

OBJECTIVE

Because of improved long-term survival of heart transplants (HT), patients often need noncardiac surgery (NCS). Immunosuppression may increase the infection rate. Inadequate management may increase the risk of dysfunction or acute rejection episodes (ARE). Long-term outcomes of NCS and optimal immunosuppressive management in the perioperative period are not well known. The objective of this study was to analyze the incidence, morbidity, and mortality of late NCS after HT.

METHODS

We retrospectively evaluated the incidence and type of late NCS as well as the risk factors for complications and the mortality among 207 HT patients. Immunosuppression and ARE rates were also analyzed.

RESULTS

One hundred and sixteen late NCS (84.5% elective) were performed in 72 HT patients (34.8%). Interventions were: 35 urologic (30.2%), 29 abdominal (25%), 14 vascular (12.1%), 13 ENT (11.2%), 11 skin and soft tissue (9.5%), and 7 orthopedic (6%). Malignancy was the main indication for NCS (33.6%). Only 4 patients (5.6%) died preoperatively. Mortality was higher among emergent vs elective procedures (16.6% vs 1%; P = .012) and among patients with preoperative high vs middle/low risk (26.6% vs 0%). Postsurgical infection was the most frequent complication (6.9%). However, there were no relevant complications in 82.8% of HT patients. Hospitalization time was <15 days in two thirds of patients. Immunosuppression was modified in 33 patients (28.4%), especially when the surgical indication was neoplasia (P < .001). None of the patients with NCS displayed allograft dysfunction or an ARE.

CONCLUSIONS

More than one-third of HT patients needed a late NCS. In our experience, elective surgical procedures with middle/low preoperative cardiovascular risk are safe. In this context, the risk of rejection was low when immunosuppression was carefully monitored to reduce the risk of infection.

Drug immunosuppression therapy for adult heart transplantation. Part 2: clinical applications and results

This review describes the clinical application of classical immunosuppressive drugs as well as that of more recent drugs. All current immunosuppressive drugs target T-cell activation, and cytokine production and clonal expansion, or both. Immunosuppressive protocols can be broadly divided into induction therapy, maintenance immunosuppression, and treatment of acute rejection episodes.

[Cholelithiasis in heart transplant patients]

The incidence of cholelithiasis is increased in heart transplant recipients.

STUDY AIM

The aim of this retrospective study was to report a series of 27 heart transplant recipients operated for cholelithiasis and to assess the indications and safety of cholecystectomy in this population.

PATIENTS AND METHODS

Over a 9-year period, from January 1991 to December 1999, 27 heart transplant recipients (21 men and 6 women; mean age: 54.6 years, mainly transplanted for ischemic or dilated cardiomyopathy) underwent cholecystectomy. All patients received immunosuppressive therapy with a combination of corticosteroids and cyclosporin and 10 also received azathioprine. Five patients admitted urgently with calculous acute cholecystitis and one patient with previous gastrectomy underwent laparotomy, while the other 21 patients were operated by laparoscopy.

RESULTS

There were no postoperative deaths. In patients operated by laparoscopy, there was no conversion to laparotomy and oral immunosuppressive drugs were continued without interruption. There was one postoperative hemoperitoneum related to liver biopsy performed concomitantly. In patients operated by laparotomy, intravenous cyclosporin was necessary until return to bowel function and the only complication was a wound abscess. Mean length of hospital stay was 3.1 days after laparoscopy and 8.8 days after laparotomy.

CONCLUSION

Systematic ultrasound screening of cholelithiasis after heart transplantation is necessary because cholelithiasis carries a risk of septic complications in these patients. Laparoscopic cholecystectomy, associated with a low morbidity, is justified even in asymptomatic cases. In patients with acute cholecystitis, "open" cholecystectomy must be preferred in order to minimize the risk of biliary complications which would be very serious in these immunosuppressed patients.