The postoperative period
The postoperative period
The hemodynamic performance of a recipient is supported by a combination of vasopressors and cardiotonics. The level of ionized calcium in the blood is monitored, as the denervated heart is very sensitive to the level of calcium. Also, the acid-base status of the patient is carefully corrected.
Immunosuppressive therapy starts shortly after the operation. In various clinics around the world different modes of immunosuppression, including pre-transplantation induction therapy or post operative maintenance therapy are used.
After stabilization, the patient is awakened, disconnected from the ventilator, and the doses of cardiotonics are reduced. The duration of hospitalization after transplantation varies, depending on the center, and the initial postoperative condition of the patient.
To assess the function of transplant in the postoperative period endomyocardial biopsy is performed. During the first month these analysis can be carried out once a week or two, and then the frequency of biopsies is reduced. During the first month the selection of immunosuppressive therapy is conducted. Regular monitoring of patients in the transplant center is gradually lessened. In some centers, annual coronary angiography is performed.
The early postoperative complications include the bleeding. The treatment for this is reexploration.
Acute graft rejection can manifest immediately after the restoration of the blood flow, as well as during the first week after the surgery despite the immunosuppressive therapy.
The main problem in modern transplantation is infectious complications. In order to prevent infections especial organizational and pharmacological measures are taken. In the early postoperative period bacterial infections can often develop. The frequency of fungal infections increases in the presence of diabetes or excessive immunosuppression. Prophylactic measures against pneumocystis pneumonia and monoclonal antibodies are taken.
The main method of the diagnosis of rejection is endomyocardial biopsy. Depending on the severity of the process the immunosuppressive regime may be increased, higher doses of steroid hormones may be applied, and the use of polyclonal or monoclonal antibodies may be added.
The main cause of death and allograft dysfunction in the long term is the pathology of the coronary arteries. Progressive concentric hyperplasia of smooth muscles and intimal occur in the arteries of the heart. The reason for this process is unknown. It is believed that a significant role in this process is played by cytomegalovirus infection and graft rejection. Studies illustrate that the risk of coronary artery disease increases when expressed initial ischemic and reperfusion injury of the donor organ and repeated episodes of rejection risk take place. The treatment of this condition is heart re-transplantation. In some cases, the stenting of an affected artery is appropriate.
The outcome and prognosisAccording to US estimates, the survival rate after a heart transplant is estimated at 81.8%, for a 5-year survival rate, it equals to 69.8%. Many patients live after the transplant for more than 10 years. The functional state of the recipients, as a rule, is good.