GENERAL SURGERY IN HEART TRASNPLANT RECIPIENTS

X. Neelessen, J-O Defraigne,J-C Demoulin, R Limet Departement of Cardiovascular Surgery and Cardiology. CHU Liège. University of Liège. Sart-Tilman, B 35 4000 Liège

Heart transplantation has become an alternative in the treatment of end-stage cardiac failure, with achievment of long-term survival. As a consequence heart transplant recipient are now more frequerntly prone to require non-cardiac surgery during their follow-up.
Operations may be required for two main reasons. Of course, transplant patient may develop unrelated diseases requiring surgery as any usual patient. But, in addition, they are at special risk of requiring surgery for several reasons. Some of these risks may be related to the cardiac transplantation or to the underlying processes which has imposed cardiac transplantation. Vascular surgery is a typical example. Patients may present thromboembolism from the dilated native atria, requiring vascular surgery for limb ischemia. When cardiac transplantation has been performed for ischemic heart disease, the progression of the atheromatous disease may necessitate vascular surgery for treating limb ischemia. Aortic dissection may also occur partly as a consequence of new high shear stresses on a previously diseaad aorta. Some patients may have pre-transplant small aneurysms which present a rapid increase in size after transplantation. A high incidence of cholelithiasis has also been noted. Abdominal hematomas may promptly develop in anticoagulated patients suffering from trauma.
In addition, some complications of long term immunosuppressive therapy may require surgical procedure, as in any kind of transplantation. For example, corticosteroids exposes to onset of osteroporosis with spontaneous fracture, to aseptic necrosis of bone, to lenticular cataracts or glaucomas and to the development of gastrointestinal complications. Some of the latter may require urgent surgery (perforation, or bleeding ulceration, especially in patients taking antiplatelets drugs). In addition, infectious complication are more frequent in immunosuppressed patients and may favor for example diverticulitis and abdominal complications. Incidence of cancer is also more frequent
Preoperative assessement, except in case of acute complications, should check for acute and/or chronic rejection in order to ereduce if possible immunosuppressive regimen before undertaking surgery. Antibio-prophylaxy is adapted to the procedure and is guided by the same principles than in normal surgical population. Anesthesia may require some specific precautions. Several points has to be taken into consideration: 1) increased susceptibility to infection, 2) higher incidence of atrial and ventricular arythmias promoted by lack of vagal suppressant tone and increased sesnsitivity to catecholamines 3) potential side-effects and drugs interactions due to immunosuppressive therapy. Anesthetic management should also consider the physiology of the denervated heart. Denervated heart are "preload-dependent" and respond primarily by increasing stroke volume. This point may be particularly important in case of aortic surgery at the time of unclamping for exemple or in procedures at risk for bleeding. Indwelling catethers should also be kept at a minimum. Early posotperative mobilization is essential to avoid venous and pulmonarry embolism which are more frequent in ciclosporin-treated patients. Based on this various strategies, surgery may be performed with low morbidity and mortality rates.
In our series, a total of 197 patients underwent heart transplantation over a 15 years period. Among these, more than 150 operations were required in the follow-up vraying from resection of skin tumors to cure of abdominal aortic aneurysms. The most frequent indications were: vascular surgery (23 cases), gastro-intestinal procedures (22 cases), orthopedic surgery (10 cases). Results will be presented.