Recent perioperative challenges in anesthesia during expansion of heart transplantation.

The evolving landscape of heart transplantation requires cardiac anesthesiologists to adapt to new paradigms aimed at expanding donor and recipient pools such as utilizing more donor hearts from older donors, those with higher BMI, left ventricular hypertrophy (LVH), or coronary artery disease, as well as grafts obtained through long-distance procurement and from donors with infectious conditions such as hepatitis C, COVID-19, and HIV. The promising use of devices such as Organ Care System (OCS), Paragonix SherpaPak (SCTS), and Hypothermic Oxygenated Machine Perfusion (HOPE) for preservation of donor hearts, as well as recent increases in donation after circulatory death (DCD) transplants, exemplifies these advancements. In particular, the introduction of beating heart DCD transplants offers the opportunity to minimize ischemic times. However, perioperative complications such as catecholamine-sensitive and resistant vasoplegia, acute right-sided heart dysfunction, primary graft dysfunction (PGD), surgical bleeding, and coagulopathy complicate the picture. The expansion of donor and recipient pools increases the risk of ischemia and reperfusion injury. Despite these challenges, cardiac anesthesiologists must be vigilant in recognizing and managing these complications to ensure the best short and long-term outcomes. For example, novel prediction tools for PGD such as RADIAL and PREDICTA may assist in facilitating earlier intervention in high-risk patients. Finally, the interplay between surgical bleeding, vasoplegia, acute RV dysfunction/failure, and PGD immediately post-transplant provides a significant challenge to cardiac anesthesiologists. By addressing these challenges, they can improve outcomes and play a pivotal role in advancing heart transplantation. Their efforts will make the expansion worthwhile, increasing the availability of donor hearts and enhancing patient care.