Heart and Lung Transplants: The First 48 Hours in ICU

Sunday · 24 min · Episode 5 · 35.4 MB

0:00-24:35

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The operation is over. The new heart and lungs are in, and the patient has just arrived on the unit. This is where you actually earn your keep.

In this episode Mike and Calum work through the first forty-eight hours after a heart or lung transplant — and almost everything comes back to one structure: the right ventricle. This is the postoperative ICU half; the theatre half is the previous episode.

Please note: the drugs and doses discussed are Wythenshawe-specific local protocol, and are given as a worked example of how one centre does it. Take the principles, and check your own guidelines for the numbers.

We start with why the RV dominates everything — because when these patients fail, it happens almost without you noticing, and by the time you've understood the trajectory you're reopening the chest. That drives how you ventilate them: keep intrathoracic pressures low, but hold normocarbia, because letting the CO₂ drift causes pulmonary vasoconstriction and starts the spiral. We call it the Goldilocks zone.

Then the mechanical support decisions. Why a lung transplant with wet lungs or a long ischaemic time comes out on veno-arterial rather than veno-venous ECMO — a practical answer, not a physiological one — and the real cost of a long VA run, including patients returning for serial tracheal dilatations years later. We cover a piece of institutional learning worth hearing: heart transplants were once cannulated on the strength of a damped radial trace, when a femoral line would have shown straightforward vasoplegia that fluid and time would fix. Hence two arterial lines, always, and the radiofemoral difference.

We also make the case for leaving the chest open when things haven't been straightforward, the deliberately soft threshold for filtration, and the counterintuitive reason you might run low-dose adrenaline on VA-ECMO — to keep the heart ejecting, so the bypassed pulmonary circulation doesn't go stagnant and clot.

Finally: why a transplanted heart is paced at 110 (a fixed stroke volume makes cardiac output almost entirely rate-dependent), milrinone as a first choice with the honest admission that inotropes are an art rather than a science, immunosuppression and whether the patient is actually absorbing it, the BiVAD and VV-ECMO bridges and why we want those patients awake and off cardioactive drugs — and how to manage acute RV dysfunction before the spiral rather than during it.

Chapters

(00:00) Cold open — the hard bit isn't the operation
(01:00) Why everything comes back to the right ventricle
(02:30) Ventilating for the RV: the Goldilocks zone
(05:00) Why lung transplants come out on VA rather than VV ECMO
(07:00) The bronchial anastomosis cost of a long ECMO run
(08:20) Heart transplants and the damped radial trace
(10:30) Two arterial lines and the radiofemoral difference
(12:00) Open or closed chest — being realistic with the surgeons
(14:00) Renal replacement: much softer criteria than you'd expect
(15:40) Adrenaline on VA-ECMO — keeping the heart ejecting
(17:30) Pacing at 110 and the fixed stroke volume
(19:30) Milrinone, and why inotropes are an art
(21:00) Immunosuppression — and whether they're absorbing it
(22:30) The BiVAD bridge: awake, rehabbed, off cardioactive drugs
(24:00) VV-ECMO as a bridge to lung transplant
(25:30) Acute RV dysfunction — deciding before the spiral
(26:40) Wrap-up

Key takeaways

Everything after a heart or lung transplant comes back to the right ventricle — and RV failure arrives fast enough that you have to be ahead of it
Ventilate for the RV: low intrathoracic pressures but normocarbia, normoxia and a normal pH
Lung transplants come out on VA-ECMO because the cannulas are already there — but a long run risks the bronchial anastomosis
Two arterial lines, always: the radiofemoral difference distinguishes vasoplegia from low output and can spare someone an unnecessary cannulation
If it's been anything other than straightforward, leave the chest open
Filter early — much softer criteria than a general ICU — because overload and acidosis tip the RV over
Low-dose adrenaline on VA-ECMO keeps the heart ejecting so the pulmonary circulation doesn't go stagnant
Pace a transplanted heart at 110: stroke volume is fixed, so output is all rate
Make the VA-ECMO decision before the patient spirals, not during

References / further reading

Velleca A et al. ISHLT Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2023
Snell GI et al. ISHLT Working Group report on primary graft dysfunction: definition and grading. J Heart Lung Transplant 2017
Hoetzenecker K et al. Extracorporeal support in lung transplantation: intraoperative and postoperative strategies. J Thorac Cardiovasc Surg 2020
Royal College of Anaesthetists. 7th National Audit Project (NAP7): perioperative cardiac arrest. 2023
Reade MC. Temporary epicardial pacing after cardiac surgery: a practical review. Anaesthesia 2007 (parts 1 and 2)
Mathew R et al. DOREMI: milrinone vs dobutamine in cardiogenic shock. NEJM 2021
NHS England. Adult Extracorporeal Membrane Oxygenation Service Specification

This podcast is for medical education for healthcare professionals. It is not clinical advice. All drugs and doses discussed reflect local Wythenshawe protocol at the time of recording — always follow your own centre's guidelines and current local policy.