Abstract
Purpose
To describe the cardiovascular effects of neuraxial blockade in a heart transplant patient.
Clinical features
A 69-yr-old 70-kg male underwent orthotopic heart transplant (bicaval anastomosis technique) for ischemic cardiomyopathy. Five months after transplantation, the patient underwent a transurethral bladder tumour resection under spinal anesthesia. Two millilitres of bupivacaine 0.75% (15 mg) were injected intrathecally at L3–4 and the patient remained seated for approximately 20 sec prior to assuming the lithotomy position. Subsequently, both blood pressure (BP) and heart rate (HR) diminished gradually (BP and HR immediately pre-spinal: 113 mmHg (mean arterial pressure) and 92 beats·min−1, respectively; nadir BP and HR: 94 mmHg (16.8% decrease) 30 min postspinal and 73 beats·min−1 (20.7% decrease) 40 min postspinal, respectively). HR and mean BP were highly correlated (r = 0.9410,P < 0.0001, R2 = 0.8854). The dermatome level of neuraxial anesthesia, determined by sensitivity to pin prick, was T8 (five minutes) and T6 (ten minutes) postinjection of spinal anesthetic. Control patients (n = 10) undergoing elective urological procedures with identical anesthesia management demonstrated very similar cardiovascular responses.
Conclusions
Although cardiac transplant patients may tolerate neuraxial anesthesia admirably, a fall in HR may ensue which theoretically could have important physiological consequences. It is argued that the change in HR in the transplanted patient was mediated by mechanisms intrinsic to the transplanted heart and/or by reduced catecholamine secretion from the adrenal medulla. It is emphasized that HR changes observed in cardiac transplant patients do not necessarily imply reinnervation of the transplanted organ.
Résumé
Objectif
Décrire les effets cardiovasculaires du blocage neuraxial chez un greffé cardiaque.
Éléments cliniques
Un homme de 69 ans et 70 kg a subi une transplantation cardiaque orthotopique, selon la technique d’anastomose bicave, pour une cardiomyopathie ischémique. Cinq mois après, il a subi la résection transurétrale d’une tumeur vésicale sous rachi-anesthésie. L’injection intrathécale de 2 mL de bupivacaïne à 0,75% (15 mg) a été faite à L3–4 et le patient est demeuré assis environ 20 sec avant d’adopter la position de lithotomie. La tension artérielle (TA) et la fréquence cardiaque (FC) ont ensuite diminué graduellement (TA et FC juste avant la rachianesthésie : 113 mmHg (tension artérielle moyenne) et 92 battements·min−1 ; TA et FC minimales : 94 mmHg (baisse de 16,8 %) 30 min après la rachianesthésie et 73 battements·min−1 (baisse de 20,7 %) 40 min après la rachianesthésie. La FC et la TA moyenne ont été en forte corrélation (r =0,9410, P < 0,0001, R 2 =0,8854). Le niveau de l’anesthésie neuraxiale, déterminé par la sensibilité à la piqûre, était de T8 (cinq minutes) et T6 (dix minutes) après l’injection de l’anesthésique rachidien. Des patients (n = 10) qui ont subi ultérieurement une intervention urologique réglée avec une anesthésie identique ont démontré des réponses cardiovasculaires similaires.
Conclusion
Même si les greffés cardiaques peuvent tolérer admirablement l’anesthésie neuraxiale, une chute de la FC peut survenir et entraïner, en théorie, d’importantes conséquences physiologiques. On peut penser que la modification de la FC chez les greffés relevait de mécanismes intrinsèques au cœur transplanté et/ou de la sécrétion réduite de catécholamines provenant de la médullaire surrénale. Il faut souligner que les changements de FC chez les greffés cardiaques ne touche pas nécessairement la réinnervation de l’organe transplanté.
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References
Stainback R. Orthotopic cardiac transplantation: a model of the denervated heart.In: Robertson D, Biaggioni I (Eds). Disorders of the Autonomic Nervous System. Luxembourg: Harwood Academic Publishers; 1995: 335–74.
Stinson EB, Griepp RB, Schroeder JS, Dong EJr, Shumway NE. Hemodynamic observations one and two years after cardiac transplantation in man. Circulation 1972; 65: 1183–94.
Pope SE, Stinson EB, Daughters GT II, Schroeder JS, Ingels NB Jr, Alderman EL. Exercise response of the denervated heart in long-term cardiac transplant recipients. Am J Cardiol 1980; 46: 213–8.
Kavanagh T, Yacoub MH, Mertens DJ, Kennedy J, Campbell RB, Sawyer P. Cardiorespiratory responses to exercise training after orthotopic cardiac transplantation. Circulation 1988; 77: 162–71.
Smith ML, Ellenbogen KA, Eckberg DL, Sheehan HM, Thames MD. Subnormal parasympathetic activity after cardiac transplantation. Am J Cardiol 1990; 66: 1243–6.
Ehrman J, Keteyian S, Fedel F, Rhoads K, Levine TB, Shepard R. Cardiovascular responses of heart transplant recipients to graded exercise testing. J Appl Physiol 1992; 73: 260–4.
Givertz MM, Hartley LH, Colucci WS. Long-term sequential changes in exercise capacity and chronotropic responsiveness after cardiac transplantation. Circulation 1997; 96: 232–7.
Raczak G, La Rovere MT, Mortara A, et al. Arterial baroreflex modulation of heart rate in patients early after heart transplantation: lack of parasympathetic reinnervation. J Heart Lung Transplant 1999; 18: 399–406.
Stark RP, McGinn AL, Wilson RF. Chest pain in cardiac-transplant recipients. Evidence of sensory reinnervation after cardiac transplantation. N Engl J Med 1991; 324: 1791–4.
Akosah K, Olsovsky M, Mohanty PK. Dobutamine stress-induced angina in patients with denervated cardiac transplants. Clinical and angiographic corrolates. Chest 1995; 108: 695–700.
Bernardi L, Valle F, Leuzzi S, et al. Non-respiratory components of heart rate variability in heart transplant recipients: evidence of autonomic reinnervation? Clin Sci 1994; 86: 537–45.
Lord SW, Clayton RH, Mitchell L, Dark JH, Murray A, McComb JM. Sympathetic reinnervation and heart rate variability after cardiac transplantation. Heart 1997; 77: 532–8.
van de Borne P, Neubauer J, Rahnama M, et al. Differential characteristics of neural circulatory control: early versus late after cardiac transplantation. Circulation 2001; 104: 1809–13.
Rudas L, Pflugfelder PW, Menkis AH, Novick RJ, McKenzie FN, Kostuk WJ. Evolution of heart rate responsiveness after orthotopic cardiac transplantation. Am J Cardiol 1991; 68: 232–6.
Lord SW, Brady S, Holt ND, Mitchell L, Dark JH, McComb JM. Exercise response after cardiac transplantation: correlation with sympathetic reinnervation. Heart 1996; 75: 40–3.
Bengel FM, Uberfuhr P, Schiepel N, Nekolla SG, Reichart B, Schwaiger M. Effect of sympathetic reinnervation on cardiac performance after heart transplantation. N Engl J Med 2001; 345: 731–8.
Schwaiblmair M, von Scheidt W, Uberfuhr P, et al. Functional significance of cardiac reinnervation in heart transplant recipients. J Heart Lung Transplant 1999; 18: 838–45.
Schwaiger M, Hutchins GD, Kalff V, et al. Evidence for regional catecholamine uptake and storage sites in the transplanted human heart by positron emission tomography. J Clin Invest 1991; 87: 1681–90.
Wilson RF, Christensen BV, Olivari MT, Simon A, White CW, Laxson DD. Evidence for structural sympathetic reinnervation after orthotopic cardiac transplantation in humans. Circulation 1991; 83: 1210–20.
Fallen EL, Kamath MV, Ghista DN, Fitchett D. Spectral analysis of heart rate variability following human heart transplantation: evidence for functional reinnervation. J Auton Nerv Syst 1988; 23: 199–206.
Ramaekers D, Ector H, Vanhaecke J, van Cleemput J, van de Werf F. Heart rate variability after cardiac transplantation in humans. Pacing Clin Electrophysiol 1996; 19(12 Pt 1): 2112–9.
Uberfuhr P, Frey AW, Reichart B. Vagal reinnervation in the long term after orthotopic heart transplantation. J Heart Lung Transplant 2000; 19: 946–50.
Scherrer U, Vissing S, Morgan BJ, Hanson P, Victor RG. Vasovagal syncope after infusion of a vasodilator in a heart-transplant recipient. N Engl J Med 1990; 322: 602–4.
Rudas L, Pflugfelder PW, Kostuk WJ. Vasodepressor syncope in a cardiac transplant recipient: a case of vagal re-innervation? Can J Cardiol 1992; 8: 403–5.
Giannattasio C, Grassi G, Mancia G. Vasovagal syncope with bradycardia during lower body negative pressure in a heart transplant recipient. Blood Press 1993; 2: 309–11.
Bernardi L, Valenti C, Wdowczyck-Szulc J, et al. Influence of type of surgery on the occurrence of parasympathetic reinnervation after cardiac transplantation. Circulation 1998; 97: 1368–74.
Mason JW, Harrison DC. Electrophysiology and electropharmacology of the transplanted human heart.In: Narula OS (Ed). Cardiac Arrhythmias: Electrophysiology, Diagnosis and Management. Baltimore: Williams and Wilkins Company; 1979: 66–81.
Toledo E, Pinhas I, Aravot D, Almog Y, Akselrod S. Functional restitution of cardiac control in heart transplant patients. Am J Physiol 2002; 282: R900–8.
Birnie D, Green MS, Veinot JP, Tang AS, Davies RA. Interatrial conduction of atrial tachycardia in heart transplant recipients: potential pathophysiology. J Heart Lung Transplant 2000; 19: 1007–10.
Grinstead WC, Smart FW, Pratt CM, et al. Sudden death caused by bradycardia and asystole in a heart transplant patient with coronary arteriopathy. J Heart Lung Transplant 1991; 10: 931–6.
Backman SB, Gilron I, Robbins R. Protamine-induced hypotension and bradycardia in a cardiac transplant patient. Can J Anaesth 1997; 44: 520–4.
DiBiase A, Tse TM, Schnittger I, Wexler L, Stinson EB, Valantine HA. Frequency and mechanism of bradycardia in cardiac transplant recipients and need for pacemakers. Am J Cardiol 1991; 67: 1385–9.
Blinks JR. Positive chronotropic effect of increasing right atrial pressure in the isolated mammalian heart. Am J Physiol 1956; 186: 299–303.
Bernardi L, Salvucci F, Suardi R, et al. Evidence for an intrinsic mechanism regulating heart rate variability in the transplanted and the intact heart during submaximal dynamic exercise? Cardiovasc Res 1990; 24: 969–81.
Bexton RS, Milne JR, Cory-Pearce R, English TA, Camm AJ. Effect of beta blockade on exercise response after cardiac transplantation. Br Heart J 1983; 49: 584–8.
Strack AM, Sawyer WB, Platt KB, Loewy AD. CNS cell groups regulating the sympathetic outflow to adrenal gland as revealed by transneuronal cell body labeling with pseudorabies virus. Brain Res 1989; 491: 274–96.
Backman SB, Sequeira-Martinho H, Henry JL. Adrenal versus nonadrenal sympathetic preganglionic neurones in the lower thoracic intermediolateral nucleus of the cat: physiological properties. Can J Physiol Pharmacol 1990; 68: 1447–56.
Backman SB, Stein RD, Polosa C. Organization of the sympathetic innervation of the forelimb resistance vessels in the cat. Anesth Analg 1999; 88: 320–5.
Rothman SA, Jeevanandam V, Combs WG, et al. Eliminating bradyarrhythmias after orthotopic heart transplanation. Circulation 1996; 94(Suppl II): II–278-82.
Herre JM, Barnhart GR, Llano A. Cardiac pacemakers in the transplanted heart: short term with the biatrial anastomosis and unnecessary with the bicaval anastomosis. Curr Opin Cardiol 2000; 15: 115–20.
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Allard, R., Hatzakorzian, R., Deschamps, A. et al. Decreased heart rate and blood pressure in a recent cardiac transplant patient after spinal anesthesia. Can J Anesth 51, 829–833 (2004). https://doi.org/10.1007/BF03018459
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DOI: https://doi.org/10.1007/BF03018459