The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients

Abstract

ChairCostanzo MR: Midwest Heart Foundation, Lombard Illinois, USATask Force 1Dipchand A: Hospital for Sick Children, Toronto Ontario, Canada; Starling R: Cleveland Clinic Foundation, Cleveland, Ohio, USA; Anderson A: University of Chicago, Chicago, Illinois, USA; Chan M: University of Alberta, Edmonton, Alberta, Canada; Desai S: Inova Fairfax Hospital, Fairfax, Virginia, USA; Fedson S: University of Chicago, Chicago, Illinois, USA; Fisher P: Ochsner Clinic, New Orleans, Louisiana, USA; Gonzales-Stawinski G: Cleveland Clinic Foundation, Cleveland, Ohio, USA; Martinelli L: Ospedale Niguarda, Milano, Italy; McGiffin D: University of Alabama, Birmingham, Alabama, USA; Parisi F: Ospedale Pediatrico Bambino Gesù, Rome, Italy; Smith J: Freeman Hospital, Newcastle upon Tyne, UKTask Force 2Taylor D: Cleveland Clinic Foundation, Cleveland, Ohio, USA; Meiser B: University of Munich/Grosshaden, Munich, Germany; Baran D: Newark Beth Israel Medical Center, Newark, New Jersey, USA; Carboni M: Duke University Medical Center, Durham, North Carolina, USA; Dengler T: University of Hidelberg, Heidelberg, Germany; Feldman D: Minneapolis Heart Institute, Minneapolis, Minnesota, USA; Frigerio M: Ospedale Niguarda, Milano, Italy; Kfoury A: Intermountain Medical Center, Murray, Utah, USA; Kim D: University of Alberta, Edmonton, Alberta, Canada; Kobashigawa J: Cedar-Sinai Heart Institute, Los Angeles, California, USA; Shullo M: University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Stehlik J: University of Utah, Salt Lake City, Utah, USA; Teuteberg J: University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Uber P: University of Maryland, Baltimore, Maryland, USA; Zuckermann A: University of Vienna, Vienna, Austria.Task Force 3Hunt S: Stanford University, Palo Alto, California, USA; Burch M: Great Ormond Street Hospital, London, UK; Bhat G: Advocate Christ Medical Center, Oak Lawn, Illinois, USA; Canter C: St. Louis Children Hospital, St. Louis, Missouri, USA; Chinnock R: Loma Linda University Children's Hospital, Loma Linda, California, USA; Crespo-Leiro M: Hospital Universitario A Coruña, La Coruña, Spain; Delgado R: Texas Heart Institute, Houston, Texas, USA; Dobbels F: Katholieke Universiteit Leuven, Leuven, Belgium; Grady K: Northwestern University, Chicago, Illlinois, USA; Kao W: University of Wisconsin, Madison Wisconsin, USA; Lamour J: Montefiore Medical Center, New York, New York, USA; Parry G: Freeman Hospital, Newcastle upon Tyne, UK; Patel J: Cedar-Sinai Heart Institute, Los Angeles, California, USA; Pini D: Istituto Clinico Humanitas, Rozzano, Italy; Pinney S: Mount Sinai Medical Center, New York, New York, USA; Towbin J: Cincinnati Children's Hospital, Cincinnati, Ohio, USA; Wolfel G: University of Colorado, Denver, Colorado, USAIndependent ReviewersDelgado D: University of Toronto, Toronto, Ontario, Canada; Eisen H: Drexler University College of Medicine, Philadelphia, Pennsylvania, USA; Goldberg L: University of Pennsylvania, Philadelphia, Pennsylvania, USA; Hosenpud J: Mayo Clinic, Jacksonville, Florida, USA; Johnson M: University of Wisconsin, Madison, Wisconsin, USA; Keogh A: St Vincent Hospital, Sidney, New South Wales, Australia; Lewis C: Papworth Hospital Cambridge, UK; O'Connell J: St. Joseph Hospital, Atlanta, Georgia, USA; Rogers J: Duke University Medical Center, Durham, North Carolina, USA; Ross H: University of Toronto, Toronto, Ontario, Canada; Russell S: Johns Hopkins Hospital, Baltimore, Maryland, USA; Vanhaecke J: University Hospital Gasthuisberg, Leuven, Belgium. Costanzo MR: Midwest Heart Foundation, Lombard Illinois, USA Dipchand A: Hospital for Sick Children, Toronto Ontario, Canada; Starling R: Cleveland Clinic Foundation, Cleveland, Ohio, USA; Anderson A: University of Chicago, Chicago, Illinois, USA; Chan M: University of Alberta, Edmonton, Alberta, Canada; Desai S: Inova Fairfax Hospital, Fairfax, Virginia, USA; Fedson S: University of Chicago, Chicago, Illinois, USA; Fisher P: Ochsner Clinic, New Orleans, Louisiana, USA; Gonzales-Stawinski G: Cleveland Clinic Foundation, Cleveland, Ohio, USA; Martinelli L: Ospedale Niguarda, Milano, Italy; McGiffin D: University of Alabama, Birmingham, Alabama, USA; Parisi F: Ospedale Pediatrico Bambino Gesù, Rome, Italy; Smith J: Freeman Hospital, Newcastle upon Tyne, UK Taylor D: Cleveland Clinic Foundation, Cleveland, Ohio, USA; Meiser B: University of Munich/Grosshaden, Munich, Germany; Baran D: Newark Beth Israel Medical Center, Newark, New Jersey, USA; Carboni M: Duke University Medical Center, Durham, North Carolina, USA; Dengler T: University of Hidelberg, Heidelberg, Germany; Feldman D: Minneapolis Heart Institute, Minneapolis, Minnesota, USA; Frigerio M: Ospedale Niguarda, Milano, Italy; Kfoury A: Intermountain Medical Center, Murray, Utah, USA; Kim D: University of Alberta, Edmonton, Alberta, Canada; Kobashigawa J: Cedar-Sinai Heart Institute, Los Angeles, California, USA; Shullo M: University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Stehlik J: University of Utah, Salt Lake City, Utah, USA; Teuteberg J: University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Uber P: University of Maryland, Baltimore, Maryland, USA; Zuckermann A: University of Vienna, Vienna, Austria. Hunt S: Stanford University, Palo Alto, California, USA; Burch M: Great Ormond Street Hospital, London, UK; Bhat G: Advocate Christ Medical Center, Oak Lawn, Illinois, USA; Canter C: St. Louis Children Hospital, St. Louis, Missouri, USA; Chinnock R: Loma Linda University Children's Hospital, Loma Linda, California, USA; Crespo-Leiro M: Hospital Universitario A Coruña, La Coruña, Spain; Delgado R: Texas Heart Institute, Houston, Texas, USA; Dobbels F: Katholieke Universiteit Leuven, Leuven, Belgium; Grady K: Northwestern University, Chicago, Illlinois, USA; Kao W: University of Wisconsin, Madison Wisconsin, USA; Lamour J: Montefiore Medical Center, New York, New York, USA; Parry G: Freeman Hospital, Newcastle upon Tyne, UK; Patel J: Cedar-Sinai Heart Institute, Los Angeles, California, USA; Pini D: Istituto Clinico Humanitas, Rozzano, Italy; Pinney S: Mount Sinai Medical Center, New York, New York, USA; Towbin J: Cincinnati Children's Hospital, Cincinnati, Ohio, USA; Wolfel G: University of Colorado, Denver, Colorado, USA Delgado D: University of Toronto, Toronto, Ontario, Canada; Eisen H: Drexler University College of Medicine, Philadelphia, Pennsylvania, USA; Goldberg L: University of Pennsylvania, Philadelphia, Pennsylvania, USA; Hosenpud J: Mayo Clinic, Jacksonville, Florida, USA; Johnson M: University of Wisconsin, Madison, Wisconsin, USA; Keogh A: St Vincent Hospital, Sidney, New South Wales, Australia; Lewis C: Papworth Hospital Cambridge, UK; O'Connell J: St. Joseph Hospital, Atlanta, Georgia, USA; Rogers J: Duke University Medical Center, Durham, North Carolina, USA; Ross H: University of Toronto, Toronto, Ontario, Canada; Russell S: Johns Hopkins Hospital, Baltimore, Maryland, USA; Vanhaecke J: University Hospital Gasthuisberg, Leuven, Belgium. Since the dawn of heart transplantation in the 1960s, the medical care of heart transplant recipients has been guided by the experience of individual clinicians and has varied from center to center. Despite many advances in surgical techniques, diagnostic approaches, and immunosuppressive strategies, survival after heart transplantation is limited by the development of cardiac allograft vasculopathy and by the adverse effects of immunosuppression. The International Society for Heart and Lung Transplantation (ISHLT) has made an unprecedented commitment to convene experts in all areas of heart transplantation to develop practice guidelines for the care of heart transplant recipients. After a vast effort involving 40 writers from 9 countries worldwide, the ISHLT Guidelines for the Care of Heart Transplant Recipients have now been completed and the Executive Summary of these guidelines is the subject of this article.The document results from the work of 3 Task Force groups:•Task Force 1 addresses the peri-operative care of heart transplant recipients, including the surgical issues affecting early post-operative care; monitoring and treatment of early hemodynamic, metabolic, and infectious issues; evaluation and treatment of allosensitization; evaluation and treatment of early coagulopathies; the organization of a multidisciplinary care team; management of ABO “incompatible” pediatric heart transplantation; and the use of extracorporeal membrane oxygenation (ECMO) for the hemodynamic support of pediatric recipients.•Task Force 2 discusses the mechanisms, diagnosis, and treatment of heart transplant rejection; the mechanisms of action, dosing, and drug level monitoring of immunosuppressive drugs as well as their adverse effects and interactions with concomitantly used medications; and reviews the major clinical trials and the immunosuppressive strategies to be used in special clinical situations.•Task Force 3 covers the myriad of clinical issues occurring long-term after heart transplantation, including cardiac allograft vasculopathy, the chronic adverse effects of immunosuppression (neurotoxicity, renal insufficiency, hypertension, bone disease, diabetes and malignancy), as well as reproductive health, exercise, psychologic problems, return to work, and operation of motor vehicles after heart transplantation.It is important to note that each task force was co-chaired by a pediatric heart transplant physician who had the specific mandate to highlight issues unique to the pediatric heart transplant population and to ensure their adequate representation.As the reader will undoubtedly observe, most of the recommendations only achieve a Level of Evidence C, indicating that these recommendations are based on expert consensus and not on randomized controlled clinical trials. A concerted effort was also made to highlight the numerous gaps in evidence pertaining to many aspects of the care of heart transplant recipients. This lack of “evidence-based” recommendations is mostly due to the limited number of heart transplant recipients worldwide. However, it is the hope of all contributing writers and reviewers that the increased awareness of the “gaps in evidence” provided by these guidelines will spur further research in many important areas of heart transplantation.Task Force 1: Peri-operative Care of the Heart Transplant RecipientChair: Maria Rosa Costanzo, MD; Co-Chairs: Anne Dipchand, MD; Randall Starling, MDContributing Writers: Allen Anderson, MD; Michael Chan, MD; Shashank Desai, MD; Savitri Fedson, MD; Patrick Fisher, MD; Gonzalo Gonzales-Stawinski, MD; Luigi Martinelli, MD; David McGiffin, MD; Jon Smith, MDTopic 1: Surgical Issues Impacting Care in the Immediate Post-operative PeriodRecommendations on Donor Heart Selection:1Young J.B. Hauptman P.J. Naftel D.C. et al.Determinants of early graft failure following cardiac transplantation, a 10-year, multi-institutional, multivariable analysis.J Heart Lung Transplant. 2001; 20: 212Abstract Full Text Full Text PDF PubMed Google Scholar, 2Lietz K. John R. Mancini D.M. Edwards N.M. Outcomes in cardiac transplant recipients using allografts from older donors versus mortality on the transplant waiting list; implications for donor selection criteria.J Am Coll Cardiol. 2004; 43: 1553-1561Abstract Full Text Full Text PDF PubMed Scopus (48) Google ScholarClass IIa1Taking into consideration only the variable of “donor age,” the hearts of donors younger than 45 years will invariably have sufficient reserves to withstand the rigors of heart transplant (HT) even in settings of prolonged ischemic time, recipient comorbidities, and multiple previous recipient operations with hemodynamically destabilizing bleeding. Hearts from donors between the ages of 45 and 55 years should probably be used when the projected ischemic time is ≤ 4 hours and the potential recipient does not have comorbidities or surgical issues where anything less than robust donor heart performance could prove fatal. The use of donor hearts > 55 years should only be used if the survival benefit of HT for a recipient unequivocally exceeds the decrement in early HT survival due to transplantation of a heart with limited myocardial reserves.Level of Evidence: B.Recommendation on the Transplantation of Hearts from Donors with Infection3Kubak B.M. Gregson A.L. Pegues D.A. et al.Use of hearts transplanted from donors with severe sepsis and infectious deaths.J Heart Lung Transplant. 2009; 28: 260-265Abstract Full Text Full Text PDF PubMed Scopus (8) Google ScholarClass IIa1Hearts from donors with severe infection can be used provided that (1) the donor infection is community acquired and donor death occurs rapidly (within 96 hours); (2) repeat blood cultures before organ procurement are negative; (3) pathogen-specific anti-microbial therapy is administered to the donor; (4) donor myocardial function is normal; and (5) there is no evidence of endocarditis by direct inspection of the donor heart. If such hearts are used for transplantation, the recipient should undergo surveillance blood cultures on the first post-operative day and pathogen-specific anti-biotic therapy should be administered for an appropriate duration of time.Level of Evidence: C.Recommendation on the Transplantation of Hearts from Donors with Potential Drug Toxicities:4Brieke A. Krishnamani R. Rocha M.J. et al.Influence of donor cocaine use on outcome after cardiac transplantation: analysis of the United Network for Organ Sharing Thoracic Registry.J Heart Lung Transplant. 2008; 27: 1350-1352Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 5De La Zerda D.J. Cohen O. Beygui R.E. et al.Alcohol use in donors is a protective factor on recipients' outcome after heart transplantation.Transplantation. 2007; 83: 1214-1218Crossref PubMed Scopus (3) Google Scholar, 6Smith J.A. Bergin P.J. Williams T.J. Esmore D.S. Successful heart transplantation with cardiac allografts exposed to carbon monoxide poisoning.J Heart Lung Transplant. 1992; 11: 698-700PubMed Google Scholar, 7Snyder J.W. Unkle D.W. Nathan H.M. Yang S.L. Successful donation and transplantation of multiple organs from a victim of cyanide poisoning.Transplantation. 1993; 55: 425-427Crossref PubMed Google Scholar, 8Navia J.L. Atik F.A. Marullo A. et al.Bench repair of donor aortic valve with minimal access orthotopic heart transplantation.Ann Thorac Surg. 2005; 80: 313-315Abstract Full Text Full Text PDF PubMed Scopus (5) Google ScholarClass IIa1Hearts from donors with a history of past or current non-intravenous (IV) cocaine abuse can be used for transplantation provided cardiac function is normal and LVH is absent.Level of Evidence: C.2In light of current information, the use of hearts from donors with a history of “alcohol abuse” remains uncertain, but is should probably be considered unwise.Level of Evidence: C.3The use of hearts from donors who have died of carbon monoxide intoxication can be recommended with caution, although the safety has not been completely established. It is recommended that these hearts be used provided there is a normal donor electrocardiogram (ECG) and echocardiogram, minimal elevation of cardiac markers, minimal inotropic requirements, a relatively short ischemic time, a favorable donor to recipient weight ratio and a recipient with normal pulmonary vascular resistance.Level of Evidence: C.Recommendations on the Use of Donors with Pre-existing Cardiac Abnormalities:9Laks H. Scholl F.G. Drinkwater D.C. et al.The alternate recipient list for heart transplantation: does it work?.J Heart Lung Transplant. 1997; 16: 735-742PubMed Google Scholar, 10Young J.B. Naftel D.C. Bourge R.C. et al.Matching the heart donor and heart transplant recipient Clues for successful expansion of the donor pool: a multivariable, multiinstitutional report. The Cardiac Transplant Research Database Group.J Heart Lung Transplant. 1994; 13: 353-364PubMed Google ScholarClass I1As far as the function is concerned, a donor heart should not be used in the presence of intractable ventricular arrhythmias, the need for excessive inotropic support (dopamine at a dose of 20 μg/kg/min or similar doses of other adrenergic agents despite aggressive optimization of pre-load and after-load), discreet wall motion abnormalities on echocardiography or left ventricular ejection fraction (LVEF) < 40% despite optimization of hemodynamics with inotropic support.Level of Evidence: B.2A donor heart with a normally functioning bicuspid aortic valve can be used for HT. Anatomically and hemodynamically abnormal aortic and mitral valves may undergo bench repair or replacement with subsequent transplantation of the heart.Level of Evidence: C.Class IIa1The use of donor hearts with obstructive disease in any major coronary artery should be avoided unless the heart is being considered for the alternate list recipients with concomitant coronary bypass surgery.Level of Evidence: C.2It would seem appropriate to use hearts from donors with left ventricular hypertrophy (LVH) provided it is not associated with ECG findings of LVH and LV wall thickness is < 14 mm.Level of Evidence: C.Recommendations on Donor Cardiac FunctionClass I1As far as the function is concerned, a donor heart should not be used in the presence of intractable ventricular arrhythmias, the need for excessive inotropic support (dopamine at a dose of 20 mcg/kg/min or similar doses of other adrenergic agents despite aggressive optimization of preload and after load), discreet wall motion abnormalities on echocardiography or LV ejection fraction < 40% despite optimization of hemodynamics with inotropic support.Level of Evidence: B.Recommendations on Donor-Recipient Size Matching:11Blackbourne L.H. Tribble C.G. Langenburg S.E. et al.Successful use of undersized donors for orthotopic heart transplantation—with a caveat.Ann Thorac Surg. 1994; 57: 1472-1475Abstract Full Text PDF PubMed Google Scholar, 12Sethi G.K. Lanauze P. Rosado L.J. et al.Clinical significance of weight difference between donor and recipient in heart transplantation.J Thorac Cardiovasc Surg. 1993; 106: 444-448PubMed Google ScholarClass I1As a general rule, the use of hearts from donors whose body weight is no greater than 30% below that of the recipient is uniformly safe. Furthermore, a male donor of average weight (70 kg) can be safely used for any size recipient irrespective of weight. Use of a female donor whose weight is more than 20% lower than that of a male recipient should be viewed with caution.Level of Evidence: C.Recommendations on Ischemic Times10Young J.B. Naftel D.C. Bourge R.C. et al.Matching the heart donor and heart transplant recipient Clues for successful expansion of the donor pool: a multivariable, multiinstitutional report. The Cardiac Transplant Research Database Group.J Heart Lung Transplant. 1994; 13: 353-364PubMed Google ScholarClass I1As a general rule the ischemic time should be less than 4 hours. However, there are situations in which ischemic times longer than 4 hours are anticipated. Donor hearts with ischemic times longer than 4 hours should only be accepted when other factors interacting with ischemic time are ideal, including donor young age, normal cardiac function, and absence of inotropic support.Level of Evidence: C.Topic 2: Early Post-operative Care of the Heart Transplant RecipientRecommendations on the Post-operative Monitoring of Heart Transplant Recipients:13Bull D.A. Stahl R.D. McMahan D.L. et al.The high risk heart donor: potential pitfalls.J Heart Lung Transplant. 1995; 14: 424-428PubMed Google Scholar, 14Mackintosh A.F. Carmichael D.J. Wren C. Cory-Pearce R. English T.A. Sinus node function in first three weeks after cardiac transplantation.Br Heart J. 1982; 48: 584-588Crossref PubMed Google Scholar, 15Leonelli F.M. Pacifico A. Young J.B. Frequency and significance of conduction defects early after orthotopic heart transplantation.Am J Cardiol. 1994; 73: 175-179Abstract Full Text PDF PubMed Scopus (11) Google Scholar, 16Leeman M. Van C.M. Vachiery J.L. Antoine M. Leclerc J.L. Determinants of right ventricular failure after heart transplantation.Acta Cardiol. 1996; 51: 441-449PubMed Google Scholar, 17Kimball T.R. Witt S.A. Daniels S.R. Khoury P.R. Meyer R.A. Frequency and significance of left ventricular thickening in transplanted hearts in children.Am J Cardiol. 1996; 77: 77-80Abstract Full Text PDF PubMed Scopus (7) Google Scholar, 18Mahle W.T. Cardis B.M. Ketchum D. et al.Reduction in initial ventricular systolic and diastolic velocities after heart transplantation in children: improvement over time identified by tissue Doppler imaging.J Heart Lung Transplant. 2006; 25: 1290-1296Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 19Asante-Korang A. Fickey M. Boucek M.M. Boucek Jr, R.J. Diastolic performance assessed by tissue Doppler after pediatric heart transplantation.J Heart Lung Transplant. 2004; 23: 865-872Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 20Stinson E.B. Caves P.K. Griepp R.B. et al.Hemodynamic observations in the early period after human heart transplantation.J Thorac Cardiovasc Surg. 1975; 69: 264-270PubMed Google Scholar, 21Rothman S.A. Jeevanandam V. Combs W.G. et al.Eliminating bradyarrhythmias after orthotopic heart transplantation.Circulation. 1996; 94: II278-II282PubMed Google Scholar, 22Zieroth S. Ross H. Rao V. et al.Permanent pacing after cardiac transplantation in the era of extended donors.J Heart Lung Transplant. 2006; 25: 1142-1147Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 23Costanzo-Nordin M.R. Liao Y.L. Grusk B.B. et al.Oversizing of donor hearts: beneficial or detrimental?.J Heart Lung Transplant. 1991; 10: 717-730PubMed Google Scholar, 24Minev P.A. El-Banayosy A. Minami K. et al.Differential indication for mechanical circulatory support following heart transplantation.Intensive Care Med. 2001; 27: 1321-1327Crossref PubMed Scopus (33) Google Scholar, 25Ibrahim M. Hendry P. Masters R. et al.Management of acute severe perioperative failure of cardiac allografts: a single-centre experience with a review of the literature.Can J Cardiol. 2007; 23: 363-367Abstract Full Text PDF PubMed Google Scholar, 26Santise G. Petrou M. Pepper J.R. et al.Levitronix as a short-term salvage treatment for primary graft failure after heart transplantation.J Heart Lung Transplant. 2006; 25: 495-498Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 27Huang J. Trinkaus K. Huddleston C.B. et al.Risk factors for primary graft failure after pediatric cardiac transplantation: importance of recipient and donor characteristics.J Heart Lung Transplant. 2004; 23: 716-722Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 28Mehra M.R. Kobashigawa J. Starling R. et al.Listing criteria for heart transplantation: International Society for Heart and Lung Transplantation guidelines for the care of cardiac transplant candidates—2006.J Heart Lung Transplant. 2006; 25 (1024–2)Google Scholar, 29Bhatia S.J. Kirshenbaum J.M. Shemin R.J. et al.Time course of resolution of pulmonary hypertension and right ventricular remodeling after orthotopic cardiac transplantation.Circulation. 1987; 76: 819-826Crossref PubMed Google Scholar, 30Stobierska-Dzierzek B. Awad H. Michler R.E. The evolving management of acute right-sided heart failure in cardiac transplant recipients.J Am Coll Cardiol. 2001; 38: 923-931Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar, 31Kieler-Jensen N. Lundin S. Ricksten S.E. Vasodilator therapy after heart transplantation: effects of inhaled nitric oxide and intravenous prostacyclin, prostaglandin E1, and sodium nitroprusside.J Heart Lung Transplant. 1995; 14: 436-443PubMed Google ScholarClass I1Peri-operative monitoring of heart transplant recipients should include (1) continuous ECG monitoring; (2) post-operative 12-lead ECG; (3) invasive arterial pressure monitoring; (4) direct measurement of right atrial pressure (RAP) or central venous pressure (CVP); (5) measurement of left atrial or pulmonary artery wedge pressure (PAWP); (6) intermittent measurement of cardiac output (CO); (7) continuous measurement of arterial oxygen saturation; (8) intraoperative transesophageal echocardiogram (TEE); (9) continuous assessment of urinary output.Level of Evidence: C.Recommendations on the Management of Peri-operative Tricuspid Valve Regurgitation:32Jeevanandam V. Russell H. Mather P. et al.Donor tricuspid annuloplasty during orthotopic heart transplantation: long-term results of a prospective controlled study.Ann Thorac Surg. 2006; 82: 2089-2095Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 33Wong R.C. Abrahams Z. Hanna M. et al.Tricuspid regurgitation after cardiac transplantation: an old problem revisited.J Heart Lung Transplant. 2008; 27: 247-252Abstract Full Text Full Text PDF PubMed Scopus (8) Google ScholarClass I1Tricuspid valve regurgitation identified intraoperatively and estimated to be moderate or severe (> 2+), should be re-evaluated by transthoracic echocardiogram (TTE) or TEE within 24 hours of HT and closely monitored for the first few post-operative days. The frequency of subsequent follow-up should be guided by clinical and hemodynamic variables.Level of Evidence: C.Class II1DeVega annuloplasty of the donor tricuspid valve (TV) can be considered to maintain the normal size of the TV annulus.Level of Evidence: C.Recommendations on the Management of Peri-operative Pericardial Effusions:34Hauptman P.J. Couper G.S. Aranki S.F. et al.Pericardial effusions after cardiac transplantation.J Am Coll Cardiol. 1994; 23: 1625-1629Abstract Full Text PDF PubMed Google Scholar, 35Quin J.A. Tauriainen M.P. Huber L.M. et al.Predictors of pericardial effusion after orthotopic heart transplantation.J Thorac Cardiovasc Surg. 2002; 124: 979-983Abstract Full Text Full Text PDF PubMed Scopus (12) Google ScholarClass I1Pericardial effusions occurring after HT should be monitored by echocardiogram.2Percutaneous or surgical drainage should be done when the pericardial effusion causes hemodynamic compromise.Level of Evidence: C.Class IIa1Pericardial effusions that are not hemodynamically compromising do not require drainage unless there is a strong suspicion of an infectious etiology.Level of Evidence: C.Recommendations for Peri-operative Vasoactive Drugs Use in Heart Transplant Recipients36Chen E.P. Bittner H.B. Davis R.D. Van T.P. Hemodynamic and inotropic effects of milrinone after heart transplantation in the setting of recipient pulmonary hypertension.J Heart Lung Transplant. 1998; 17: 669-678PubMed Google Scholar, 37Leyh R.G. Kofidis T. Struber M. et al.Methylene blue: the drug of choice for catecholamine-refractory vasoplegia after cardiopulmonary bypass?.J Thorac Cardiovasc Surg. 2003; 125: 1426-1431Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar, 38Argenziano M. Choudhri A.F. Oz M.C. et al.A prospective randomized trial of arginine vasopressin in the treatment of vasodilatory shock after left ventricular assist device placement.Circulation. 1997; 96: II-90Google Scholar, 39Morales D.L. Garrido M.J. Madigan J.D. et al.A double-blind randomized trial: prophylactic vasopressin reduces hypotension after cardiopulmonary bypass.Ann Thorac Surg. 2003; 75: 926-930Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 40Armitage J.M. Hardesty R.L. Griffith B.P. Prostaglandin E1: an effective treatment of right heart failure after orthotopic heart transplantation.J Heart Transplant. 1987; 6: 348-351PubMed Google Scholar, 41Pascual J.M. Fiorelli A.I. Bellotti G.M. Stolf N.A. Jatene A.D. Prostacyclin in the management of pulmonary hypertension after heart transplantation.J Heart Transplant. 1990; 9: 644-651PubMed Google Scholar, 42Theodoraki K. Tsiapras D. Tsourelis L. et al.Inhaled iloprost in eight heart transplant recipients presenting with post-bypass acute right ventricular dysfunction.Acta Anaesthesiol Scand. 2006; 50: 1213-1217Crossref PubMed Scopus (21) Google Scholar, 43Ardehali A. Hughes K. Sadeghi A. et al.Inhaled nitric oxide for pulmonary hypertension after heart transplantation.Transplantation. 2001; 72: 638-641Crossref PubMed Google Scholar, 44Auler Junior J.O. Carmona M.J. Bocchi E.A. et al.Low doses of inhaled nitric oxide in heart transplant recipients.J Heart Lung Transplant. 1996; 15: 443-450PubMed Google Scholar, 45De Santo L.S. Mastroianni C. Romano G. et al.Role of sildenafil in acute posttransplant right ventricular dysfunction: successful experience in 13 consecutive patients.Transplant Proc. 2008; 40: 2015-2018Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 46Kirklin J.K. Young J.B. McGiffin D.C. Heart transplantation. Churchill Livingstone, Philadelphia2002Google Scholar(See Table 1)Table 1Properties of Intravenous Vasoactive Drugs Used after Heart TransplantationAdapted and reprinted with permission from Kirklin JK, et al.46Kirklin J.K. Young J.B. McGiffin D.C. Heart transplantation. Churchill Livingstone, Philadelphia2002Google ScholarPeripheral vasoconstrictionCardiac contractilityPeripheral vasodilationChronotropic effectArrhythmia riskIsoproterenol0+++++++++++++++Dobutamine0+++++++Dopamine++++++++Epinephrine+++++++++++++Milrinone/enoximone0++++++++Norepinephrine+++++++0++Phenylephrine++++0000Vasopressin++++0000 Open table in a new tab Class I1Continuous infusion of an inotropic agent should be used to maintain hemodynamic stability post-operatively. Inotropic agents should be weaned as tolerated over the first 3 to 5 days. The lowest effective dose should be used.Level of Evidence: C.2The following therapies are suggested:aisoproterenol, 1 to 10 μg/min, orbdobutamine, 1 to 10 μg/kg/min ± dopamine 1 to 10 μg/kg/min, orcisoproterenol, 1 to 10 μg/min ± dopamine 1 to 10 μg/kg/min, ordm