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724 ACtIff. CARE. HANDBOOK FOR PHYSICAL THFRAIlISTS
With myocardial depression, the transplanted heart may be affected
temporarily by bradycardia, decreased diastOlic compliance, diminished systOlic function, and impaired contractility.s.u Other potential complications after heart transplant include mediastinal bleeding, cyclosporine-induced hypertension, post-transplant diabetes, thrombosis or leakage of anastOmosis, right heart failure, biventricular heart failure, pulmonary hypertension, pericardial effusion, and renal dysfunction.5.IO.14.22 Bivenrricular failure is a potential complication that is seen in the first 24-48 hours after transplantation.
Most patients have some degree of pulmonary hypertension becallse of
native left ventricular failure. Right heart failure is the most common
calise of cardiac dysfunction postoperatively." It may be caused by a
pre-existing elevated I'VR, donor size mismatch in which the donor
heart is too small for the recipient, long ischemic time of more than 4
hours, and acute rejection.22 Clinical evidence of right ventricular heart
failure includes hypotension, low cardiac output, an elevated central
venous pressure, and low urinary output. tJ Right atrial pressures, pulmonary artery pressure, PVR, cardiac output, and signs of right-sided heart failure are monitOred c1osely.s Medications, such as isoproterenol
hydrochloride or miirinone, are used to reduce pulmonary pressures
and make it easier for the right heart to pumpIl
Many cardiac transplant recipients have pre-existing renal insufficiency due to their low cardiac output, congestive heart failure, and long-term diuretic use.s.n After transplantation, cardiopulmonary
bypass and the use of cyclosporine, which is a nephrotoxic agent, can
cause renal failure in rhe transplant recipienr.s Dopamine is administered ro improve renal blood flow, and diuretics are used to maintain adequate urine output.s In addition, intravenous cyclosporine may be
held postoperatively, and, instead, less-nephrotoxic agents may be
administered.22
Heart transplant recipients have an increased risk of excessive
postoperative bleeding and cardiac tamponade.1J Owing ro chronic
congestive heart failure, patients usually have passive liver congestion,
which increases the risk of bleeding." Many patients also receive
anticoagulation therapy preoperatively to prevent thrombus formation. However, inadequate heparin reversal may occur and, depending on the severity of anticoagulation, treatment includes transfusion of
platelets or ftesh-frozen plasma."
Objective characteristics of acute rejection specific to cardiac
transplant recipients include new cardiac arrhythmias, hypotension,
pericardia I friction rub, ventricular S3 gallop, decreased cardiac Out-