Use of Sugammadex in a Heart Transplant Recipient: Review of the Unique Physiology of the Transplanted Heart

Abstract

before mediastinoscopy demonstrated a normal left ventricular size and function, with an ejection fraction of 65% and no posttransplant complications like tricuspid regurgitation. He was undergoing regular myocardial biopsies and had no documented evidence of graft rejection. He also had a stable sinus rhythm. On the day of surgery, the patient was given his morning doses of medications. Preoperative vital signs included a heart rate (HR) of 95 beats/min and blood pressure (BP) of 156/80 mmHg. The plan was to proceed with general anesthesia. The patient was given hydrocortisone (100 mg IV) and was premedicated with midazolam (2 mg IV). On the patient’s arrival in the operating room, all standard monitors were applied, including a pulse oximeter, electrocardiogram (ECG) monitoring with leads II and V5, noninvasive BP monitoring, and capnography. The patient underwent preoxygenation for 5 minutes and received fentanyl (1 mg/kg). Propofol (2-3 mg/kg) was titrated, and rocuronium (0.6 mg/kg) was administered. After the patient underwent atraumatic intubation, the radial artery was cannulated for beatto-beat BP, blood gas, and blood glucose monitoring. Anesthesia was maintained with 1.5% to 2.0% sevoflurane and a nitrous oxide and oxygen mixture (60:40). The surgery was uneventful, and the patient’s condition was hemodynamically stable throughout the procedure. At the end of surgery, the muscle relaxant was reversed with sugammadex (2 mg/kg) and the patient’s airway was extubated after return of airway reflexes. The injection of sugammadex did not cause significant changes in HR, ECG, or BP values. He was admitted to the postanesthesia care unit and had an uneventful postoperative recovery. No anesthesia complications were noted, and he was discharged 2 days after the surgery. DISCUSSION The preoperative assesment of a heart transplant recipient undergoing noncardiac surgery should focus on cardiac function; risks of rejection; infection; drug interactions; and function of other organs, particularly the kidney and liver, which may be compromised as a result of either immunosuppressive therapy or dysfunction of the transplanted heart. The patient in this report was assessed for graft rejection; his last myocardial biopsy demonstrated no evidence of graft rejection, and transthoracic echocardiogram showed a wellfunctioning graft. Blood count, coagulation profile, and all biochemical parameters were found to be normal. Hypertension is one of the common side effects of immunosuppressive therapy, and the patient in this case had a history of hypertension that was treated with amlodipine. On the day of surgery, he was given his morning doses of his medications and was normotensive throughout the procedure.