Heart Transplant with Dr. Warren Zuckerman & Dr. Gav Apfel--Part 1
Jul 24, 2023
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Dr. Warren Zuckerman, a pediatric cardiologist, and Dr. Gav Apfel, a CICU hospitalist, discuss pediatric heart transplants, including indications for transplant, preoperative management, surgical techniques, and post-transplant considerations. They also highlight the importance of a proactive approach in managing heart transplant patients in the operating room.
The decision-making process for listing patients for heart transplant involves considering factors such as patient condition, hemodynamics, and organ size matching.
Proactive support of the right ventricle with medications and therapies is essential to prevent right ventricular dysfunction in heart transplant recipients and requires careful management.
Deep dives
Pre and post-op heart transplant management
This podcast episode discusses pre and post-op management of heart transplants. It covers topics such as patient evaluation for transplant, decision-making processes for listing patients, and management strategies for optimizing patients prior to surgery. The episode emphasizes the importance of considering factors such as patient condition, hemodynamics, and organ size matching in the decision-making process. It also highlights the need for multidisciplinary teams consisting of cardiologists, surgeons, anesthesiologists, and intensivists to provide comprehensive care for heart transplant patients.
Right ventricular dysfunction and its management
The episode focuses on the high risk of right ventricular dysfunction in heart transplant recipients. It explains that this arises from the transplantation of a healthy donor heart into a recipient with abnormal pulmonary vasculature due to cardiomyopathy or congenital heart disease. The speakers stress the importance of proactively supporting the right ventricle during and after surgery using medications like dopamine or milrinone, as well as nitric oxide therapy. They also discuss the risk factors for right ventricular dysfunction, including elevated pulmonary vascular resistance and abnormal pulmonary hemodynamics.
Surgical considerations and complications
The podcast provides insights into the surgical aspects of heart transplants. It explains that orthotopic heart transplants are the standard procedure, with the donor heart being placed in the same location as the recipient's original heart. It highlights the differences between biatrial and bicaval anastomosis, clarifying that the choice depends on surgical preference and patient factors. The episode also mentions the relevance of post-operative complications such as bleeding and the need for proactive management of these issues in the operating room and intensive care unit.
Post-operative monitoring and potential challenges
The final main idea focuses on the importance of post-operative monitoring for heart transplant recipients. The episode emphasizes the need to assess ventricular function, both left and right, as well as to monitor chest tube output and manage bleeding effectively. It highlights the significance of knowing the size match between the donor heart and recipient, the ischemic time, and the pulmonary vascular resistance in predicting post-operative outcomes. The speakers also discuss potential arrhythmias and the involvement of electrophysiology colleagues in managing acute arrhythmia issues. The episode concludes by emphasizing the need for a multidisciplinary approach and careful monitoring of these patients in the early post-operative period.
Dr. Warren Zuckerman is an associate professor of pediatrics as well as the associate director of the pediatric cardiology division at the Columbia University College of Physicians and Surgeons in New York. He completed both his pediatric residency and his cardiology fellowship at Columbia University College of Physicians and Surgeons. He is now a practicing pediatric cardiologist at Morgan Stanley Children’s Hospital. His research interests include pediatric cardiomyopathies, donor- and recipient-related issues surrounding pediatric heart transplantation, and drug therapies for prevention and treatment of graft rejection following heart transplantation.
Gav Apfel is a CICU hospitalist at Columbia University College of Physicians and Surgeons. He completed his residency training at Columbia University College of Physicians and Surgeons and will be joining the Columbia University’s critical care fellowship program in July 2023. He is interested in pursuing a career in cardiac intensive care.
Learning Objectives:
By the end of this podcast, listeners should be able to:
Describe the common indications for pediatric heart transplant.
Recall the goals of preoperative management of heart failure patients and medical optimization for heart transplant.
Recall the general surgical strategies for cardiac implantation.
Recognize the key information provided in surgical and anesthesia handover that will affect postoperative management.
Recognize the common and important postoperative complications and develop an approach to their management.
Develop a mental framework of the expected postoperative CICU course with a focus on common or important barriers to ICU discharge.
Recall important long-term complications of heart transplant with an emphasis on those that might result in critical illness.
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Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.comfor detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.
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