Liang, Hong

This review highlights key studies examining perioperative management of cardiothoracic transplantation published in 2023. Articles were manually screened after searching Scopus, PubMed, and Google Scholar databases for manuscripts related to cardiothoracic transplantation, which yielded 343 papers with 15 qualitatively selected as the most salient for readers. Overarching themes include differences in outcomes across the various etiologies of end-stage lung disease, novel developments to expand the donor pool, and multi-organ transplantation.

Lung transplantation (LTx) historically was performed with cardiopulmonary bypass (CPB) or Off-pump. Recent data suggest an increased interest in extracorporeal membrane oxygenation (ECMO) as perioperative circulatory support by many lung transplantation centers worldwide. However, there are no established guidelines for anesthetic management for LTx. We present a patient with a history of systemic sclerosis and interstitial lung disease complicated by acute onset of systemic pulmonary hypertension and right heart failure undergoing LTx. We aim to discuss perioperative circulatory support, including ECMO bridge to LTx, and how best to consider the varied intraoperative strategies of CPB vs ECMO vs off-pump during LTx, intraoperative maintenance, and coagulation management.

In the era of “fast-track’ liver transplantation (LT), neuromuscular blockade (NMB) antagonists such as neostigmine or sugammadex are used to achieve the restoration of neuromuscular function. While sugammadex reverses NMB faster than neostigmine, it has been shown to prolong prothrombin time (PT) and activated thromboplastin time (aPTT). However, this agent’s impact on coagulation during LT is not understood. We compare bleeding risk associated with sugammadex versus neostigmine during liver transplantation. This is a single-center, retrospective review of LT patients who received NMB antagonists intraoperatively between 01/01/2015 to 05/31/2018 at Mayo Clinic in Florida. The primary outcomes were postoperative day (POD) 0-1 bleeding events and POD 0 values of aPTT and INR. Total 241 patients were included, with 135 patients in the neostigmine group (NG) and 106 in the sugammadex group (SG). POD 0-1 postoperative bleeding requiring transfusion occurred in 20% of NG versus 10.4% in SG. POD 0-1 re-operation for bleeding occurred in 1.5% in NG vs. 0% in SG. POD 0 mean INR was 2.0±0.4 in both groups. POD 0 mean aPTT was 45.5±7.9 in NG vs. 49.3±9.0 in SG. Our retrospective study suggests that sugammadex is not associated with an increased risk of bleeding compared to neostigmine use.