Various forms of mechanical circulatory support have evolved to meet the growing number of patients with advanced heart failure. Implantable left ventricular assist devices (LVADs), in particular, have emerged as a durable means to bridge patients to cardiac transplantation who might otherwise not survive the wait for an available donor heart. As such, an ever-increasing proportion of heart transplantations are performed in the setting of a previously implanted LVAD. These present uniquely challenging reoperative cases for the surgeon performing the transplantation; the hazards of sternal re-entry and difficulty of mediastinal adhesiolysis are especially pronounced. To facilitate subsequent LVAD explantation and heart transplantation, certain operative measures can be taken at the time of LVAD implantation. These include positioning of the outflow graft lateral to the right atrium, a safe distance away from the overlying sternum. Limited dissection between the aorta and pulmonary artery (PA), with lower placement of the outflow graft on the ascending aorta, can simplify the aortic anastomosis at the time of transplantation. An additional protective measure is the placement of a GORE-TEX (W. L. Gore & Associates, Inc.; Newark, DE, USA) or CorMatrix (CorMatrix; Roswell, GA, USA) patch to bridge the pericardial edges and shield cardiac structures during subsequent sternal re-entry. Patients with LVAD and other reoperative patients awaiting transplantation should undergo chest computed topography scan to assess the proximity of mediastinal structures to the posterior sternum. This information may help gauge whether a peripheral cannulation strategy might be necessary. In that setting, the authors prefer side-graft axillary artery and percutaneous femoral venous cannulation to afford rapid institution of cardiopulmonary bypass during re-entry.

A critical facet to successful heart transplantation is careful coordination of timing between the implanting and procuring teams to minimize the cold ischemic time of the cardiac allograft. The goal is to keep that interval <4 hours. Ideally, the recipient cardiectomy is completed upon arrival of the donor heart. This necessitates effective and frequent communication between the two teams, taking specific time variables into consideration:

It is vitally important that appropriate broad-spectrum antibiotics and immunosuppressive agents are administered immediately prior to, or promptly after, anesthetic induction. Many centers have adopted a preoperative checklist or “time-out” before making
skin incision, to confirm that these medications have been infused. Similarly, it is essential to verify that blood products are immediately available for transfusion, especially in reoperative cases. Standard monitoring lines include Swan–Ganz PA catheter and arterial line. To facilitate subsequent transvenous endomyocardial biopsies for rejection surveillance, it is preferable to avoid central venous access in the right internal jugular vein. The right subclavian vein may also be unavailable for access if right axillary artery cannulation is anticipated by the surgeon performing the implantation. Bladder temperature is routinely monitored via a Foley catheter temperature probe.