The aim of this study was to increase the effectiveness of anesthetic support and
reduce the percentage of complications during orthotopic heart transplantation by
optimizing hemodynamic monitoring in the donor and recipient during surgery.
The study was organized in 2 stages. At the first stage of the study, an evaluation
of the effectiveness of preconditioning of the donor heart was carried out to increase
the resistance of the myocardium to ischemia-reperfusion syndrome and its preparation
for orthotopic heart transplantation. The evaluation of donor preconditioning included
clinical characterization of donor parameters, hemodynamic parameters, biochemical
parameters, and inotropic support.
The second stage of the study included the evaluation of hemodynamic
monitoring during TS in recipients, which was performed at 5 stages of the operation:
sternum cutting (stage 1), before cardiopulmonary bypass (stage 2), after
cardiopulmonary bypass (stage 3), before sternum clamping (stage 4), after sternum
clamping (stage 5). During the analysis of hemodynamic monitoring, the PiCCO
technology was used to measure the following parameters: cardiac index (CI), cardiac
output (CO), global end-diastolic volume (GEDV), global end-diastolic volume index
(GEDVI), extravascular lung water (EVLW), extravascular lung water index
(EVLWI), systemic vascular resistance (SVR), global ejection fraction (GEF). In the
study of recipients, intraoperative studies were used and recorded to measure the acidbase and gas state of the blood at different stages of surgery.
7
In order to solve the questions posed in this work, we examined the quality of
heart preconditioning of 20 donors who underwent donor heart explantation at the first
stage. The determination of brain death of potential donors was carried out in
accordance with the order of the Ministry of Health of Ukraine dated November 09,
2020 No. 2559, registered with the Ministry of Justice of Ukraine on December 18,
2020 under No. 1260/35543, the link is attached for review
[https://zakon.rada.gov.ua/laws/show/z1260-20/sp:dark?dark=0#Text]. The average
age of the surveyed donors was 32.3±11.2 years. Among the patients, there were 17
(85%) men and 3 (15%) women.
At the second stage, 38 patients diagnosed with DCM (dilated cardiomyopathy)
who underwent orthotopic heart transplantation were examined. The average age of the
examined recipients was 38.5±13.5. There were 92.1% of male patients (35 men) and
7.9% of female patients (3 patients).
During the studies conducted at the first stage, it was found that the causes of brain
death in 35% of cases were hemorrhagic stroke, and in 65% of cases it was closed
traumatic brain injury (CTBI), which prevailed almost 2 times over donors with brain
death due to hemorrhagic stroke. The average time from the diagnosis of brain death
to the authorization of anatomical material transplantation was 22.1±4.1 hours.
During the characterization of hemodynamic monitoring in donors, it was recorded that
the heart rate varied within 104±14.2 beats/min, blood pressure was: SBP within
104.3±11.2 mm Hg, DBP 64±10.4 mm Hg, and SBP ranged from 73.2±10.8 mm Hg.
To measure CVP, the internal jugular vein was catheterized. In this case, the values of
CVP were in the range of 6 ± 1,1 mmHg.
At the same time, the analysis of hemodynamic changes conducted at the first
stage of the study showed that almost all donors had tachycardia (p=0.000019), which
was accompanied by a decrease in blood pressure (p=0.0000026).
The correlation between the cardiac index and the time of the decision to undergo
TS and donor heart explantation was highly correlated (p=0.00000107).
8
All donors received inotropic support with drugs such as norepinephrine 0.96±0.41
μg/kg/min (20 donors (100%)), dobutamine 5.37±2.37 μg/kg/min (8 donors (40%)),
dopamine 3.48±1.49 μg/kg/min (5 donors (25%)).
In our study, it was noted that the use of inotropic norepinephrine support
prevailed over the use of dobutamine and dopamine. And the time from the
authorization for transplantation of human anatomical materials had a high significant
correlation with the increase in donor norepinephrine doses (p=0.0000099).
Biochemical analyzes of donors showed that the growth of troponin complexes
was observed with an increase in the time of decision-making for obtaining permission
to use transplantation of human anatomical materials for TS and was higher than the
reference values by an average of 45 times. Lactate levels in 75% of donors were higher
than the reference values of the norm, indicating a possible microcirculation
dysfunction that led to a deterioration in donor preconditioning and increased ischemiareperfusion syndrome for the transplant.
