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Perioperative Aspekte der Herztransplantation

  • Leitthema
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Zusammenfassung

Seit über 20 Jahren wird die orthotope Herztransplantation zur Therapie von Patienten mit terminaler Herzerkrankung eingesetzt. Die perioperative Betreuung dieser Patienten ist eine Herausforderung für den Anästhesisten. Zunächst muss es gelingen, einen Patienten mit terminaler Herzinsuffizienz, Herzrhythmusstörungen und oftmals multiplen Voroperationen sicher an die Herz-Lungen-Maschine anzuschließen. Danach ist selbst bei einer unproblematischen Durchführung der eigentlichen Transplantation und kurzer Ischämiezeit der Abgang von der Herz-Lungen-Maschine häufig erschwert. Der rechte Ventrikel des Spenderorgans ist in vielen Fällen nicht an den pulmonalen Gefäßwiderstand des Empfängers angepasst. Bei vorbestehender pulmonaler Hypertonie des Empfängers entwickelt sich oft eine akute Rechtsherzinsuffizienz. Zur Therapie des akuten Rechtsherzversagens gehören die Senkung des pulmonalen Gefäßwiderstands und die Verbesserung der rechtsventrikulären Pumpfunktion. Der Einsatz der transösophagealen Echokardiographie (TEE) ermöglicht die frühzeitige Diagnose und Therapiekontrolle des akuten Rechtsherzversagens. Darüber hinaus können wichtige Differenzialdiagnosen, wie beispielsweise ein Abknicken der pulmonalen Anastomose oder eine Klappeninsuffizienz im Spenderorgan (z. B. Trikuspidalinsuffizienz), erkannt werden. Neben der Betreung von Patienten, die sich einer Herztransplantation unterziehen, gehört auch die perioperative Versorgung von Patienten nach Herztransplantation zu den Aufgaben des Anästhesisten. Die Kenntnis der physiologischen und pharmakologischen Besonderheiten dieser Patientengruppe ist hierbei von entscheidender Bedeutung.

Abstract

Over the past 30 years, heart transplantation has evolved into a definitive therapy for patients with end-stage cardiomyopathy. However, perioperative management of patients undergoing heart transplantation remains a challenge for anesthesiologists. The presence of biventricular failure, arrhythmias and associated multisystem organ dysfunction may contribute to significant intraoperative hemodynamic instability prior to the initiation of cardiopulmonary bypass (CPB). Even after an uneventful transplantation, weaning from CPB may be difficult. Acute right ventricular failure can develop in the recipient secondary to pre-existing pulmonary hypertension. Treatment options frequently focus on therapeutic interventions directed towards decreasing pulmonary vascular resistance and improving right ventricular contractility. Intraoperative use of transesophageal echocardiography (TEE) enables the anesthesiologist to diagnose acute right ventricular failure early on and guide therapy. Concurrent pathology including kinking of the pulmonary artery anastomosis or valvular insufficiency in the transplanted heart can also be recognized and addressed. The number of patients undergoing cardiac transplantation is continually increasing. In addition, the use of more effective immunosuppressive agents has curtailed transplant rejection and permitted longer survival. Consequently, heart transplant recipients are more frequently presenting for non-cardiac surgical procedures. Thus, an understanding of physiological and pharmacological implications associated with heart transplantation is crucial for managing these patients in the perioperative period.

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Danksagung

Wir danken der kardioanästhesiologischen Abteilung des Brigham and Women's Hospitals, Harvard Medical School in Boston für die Bereitstellung des umfangreichen Bildarchivs, insbesondere Joe Scott und James Bell sowie Klaus-Jürgen Eltzschig für die Erstellung der Zeichnungen zur bikavalen Technik der orthotopen Herztransplantationen.

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Authors and Affiliations

  1. Klinik für Anaesthesiologie und Intensivmedizin, Eberhard-Karls-Universität Tübingen

    H. K. Eltzschig

  2. Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston

    H. K. Eltzschig & T. W. Felbinger

  3. Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Johann Wolfgang Goethe-Universität, Frankfurt

    B. Zwissler

  4. Klinik für Anästhesiologie, Klinikum Grosshadern-Innenstadt der LMU, München

    T. W. Felbinger

  5. Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115

    H. K. Eltzschig

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  1. H. K. Eltzschig
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  2. B. Zwissler
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  3. T. W. Felbinger
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Eltzschig, H.K., Zwissler, B. & Felbinger, T.W. Perioperative Aspekte der Herztransplantation. Anaesthesist 52, 678–689 (2003). https://doi.org/10.1007/s00101-003-0556-1

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