This document discusses considerations for anaesthesia in patients who have undergone renal transplantation and require non-transplant surgery. Key points include: 1. Renal transplant patients have altered physiology due to immunosuppression and the transplanted organ. Their renal function is usually reduced which can impact drug metabolism and excretion. 2. The main anesthetic goal is to maintain renal perfusion and prevent hypotension, hypovolemia and hypoxia which could further compromise renal function. 3. Immunosuppressive drugs and their interactions, side effects and toxicity must be considered. Maintaining adequate immunosuppression is also important to prevent organ rejection in the perioperative period.

1. ANAESTHESIA FOR RENAL
TRANSPLANT PATIENT FOR
NON-TRANSPLANT
SURGERY
MOD : DR. KAUMUDI
Dr.Arun

2. INTRODUCTION
n POST TRANSPLANT PATIENT
n INCREASED SURVIVAL
• BETTER IMMUNOSUPPRESSIVE REGIMES,
• SURGICAL TECHNIQUES
• POSTOPERATIVE CARE.

3. n After successful kidney transplantation,
most patients are classified as having
National Kidney Foundation stage 2 or 3 CKD
with usual GFRs more than 30 mL/min.
n GFR typically deteriorates by 1.4 to 2.4
mL/min/yr in renal transplant recipients

4. PRE ANAESTHETIC
CONSIDERATIONS
1. IDENTIFICATION OF COMPLICATIONS &
THEIR ANAESTHETIC IMPLICATIONS
2. TOXICITY OF IMMUNOSUPPRESSANTS
3. RELEVANT DRUG INTERACTIONS WITH
IMMUNOSUPPRESSANTS
4. REJECTIONS
5. INFECTIONS

5. CONCERNS IN A
TRANSPLANT RECIPIENT
1) ALTERED FUNCTION/ PHYSIOLOGY RELATED
TO TRANSPLANTED ORGAN
2) ALTERED FUNCTION DUE TO IMMUNO
SUPPRESSION
1) INFECTIONS
2) MALIGNANCIES
3) TOXICITY OF IMMUNOSUPPRESSIVE DRUGS
4) POTENTIAL INTERACTION OF
IMMUNOSUPPRESSIVE DRUGS WITH OTHER
DRUGS
5) POTENTIAL FOR REJECTIONOF
TRANSPLANTED ORGAN

6. n Progression of preexisting CAD as
immunosuppression contributes to the
development of de novo hyperlipidemia,
hypertension, and diabetes.
n Cardiovascular disease is the most common
cause of death in kidney transplant patients.
n GFR -usually reduced,(despite normal
creatinine) -electrolyte abnormalities and
altered drug metabolism

7. COMPLICATIONS AFTER
RENAL TRANSPLANTATION
n EARLY
• HEMORRHAGIC CYSTITIS
• CAPILLARY LEAK
• AGVHD
• PANCYTOPENIA
• CARDIOMYOPATHY
• VENO OCCLUSIVE LIVER DISEASE
• INTERSTITIAL PNEUMONITIS

8. COMPLICATIONS AFTER
RENAL TRANSPLANTATION
n LATE
• CGVHD
• LEUKO ENCEPHALOPATHY
• INFECTION
• SECONDARY MALIGNANCIES
• OBSTRUCTIVE/ RESTRICTIVE LUNG DISEASE
• HYPOTHYROIDISM
• CATARACT

9. IMMUNOSUPPRESSIVE
THERAPY FOR
TRANSPLANT RECIPIENTS
TRIPLE DRUG REGIMEN
1) CYCLOSPORIN / TACROLIMUS
2) GLUCOCORTICOIDS – METHYL
PREDNISOLONE
3) MYCOPHENOLATE MOFETIL/
AZATHIOPRINE

10. CYCLOSPORIN : started 7 days before
transplantation of living donor kidney
1 day after for cadaver kidney
8mg/kg in 2 div doses
then tapered to 3 – 4 mg/kg
TACROLIMUS : starting 1 day after
transplantation of both living & cadaver
kidney transplantation

11. METHYL PREDNISOLONE : 250 mg IV 1hr
before & 6 hrs after surgery
Tapered & maintained for 6 mths
MYCOPHENOLATE MOFETIL : 1 gm iv BD
starting 1 day before Sx & continue for 6
mths

12. TOXICITY RELATED TO
IMMUNOSUPPRESSIVE
DRUGS

13. CYCLOSPORIN A
WATER SOLUBLE
ORAL ABSORPTION UNPREDICTABLE
IV DOSE 1/3 ORAL DOSE

14. TOXICITY
NEPHROTOXICITY
•  RENAL VASC. RESISITANCE
•  RBF
• APPARENT WITHIN A WEEK OF
INITIATION OF THERAPY
• CHRONIC TOXICITY
• AMINOGYCOSIDE + C/c Cs A THERAPY
POTENTIATE NEPHROTOXICITY OF Cs A

15. CYCLOSPORIN A
NEUROTOXICITY
• HEADACHE
• PARESTHESIAS
• TREMOR
• CONFUSION
• FLUSHING
• NEUROPATHIES
• GENERALISED SEIZURES

16. CYCLOSPORIN A
VASCULAR EFFECTS
• HYPERTENSION (INCIDENCE 42-100%)
• DIABETOGENIC
•  TOTAL CHOLESTEROL
CORONARY ARTERY DISEASE

17. CYCLOSPORIN A
METABOLIC EFFECTS
• HYPERKALEMIA
• HYPOMAGNESEMIA
HIRSUITISM
GUM HYPERPLASIA
ANOREXIA
LYMPHOPROLIFERATIVE DISEASES
INFECTIOUS DISEASES

18. TACROLIMUS
INHIBIT T CELL PROLIFERATION
100 TIMES POTENT THAN CYCLOSPORINE
ADVERSE EFFECTS:-
• NEPHROTOXIC
• DM
• NEUROLOGIC – TREMOR, HEADACHE
• ALOPECIA
• BONE MARROW SUPPRESSION
• LYMPHOPROLIFERATIVE DISEASES
• INFECTIOUS DISEASES

19. TACROLIMUS
USED IF NOT TOLERATING Cs A
Cs A STOPPED ONLY AFTER 24 HRS OF
STARTING TACROLIMUS

20. STERIODS
USED IN ALL TRANSPLANT FOR A PERIOD
OF TIME
USED TO PREVENT REJECTION AND AS
PULSE THERAPY FOR TREATMENT OF
ACUTE REJECTION

21. STERIODS
OBESITY
GLUCOSE INTOLERANCE
 SERUM LIPID LEVELS
ACCELERATE CARDIOVASCULAR
DISEASE
MARKED SKIN FRAGILITY
• MINIMISE ADHESIVE TAPES
• PADDED BP CUFFS
• EYES LUBRICATED

22. STERIODS
DELAYED WOUND HEALING
RISK OF OSTEOPOROSIS
• CAREFUL MOVEMENT & POSITIONING
IRRITATE GASTRIC MUCOSA

23. ANTIMETABOLITES
AZATHIOPRINE
MYCOPHENOLATE MOFETIL
• ANTI-NUCLEOTIDE ANTIMETABOLITES
• INHIBIT LYMPHOCYTE PROLIFERATION &
ANTIBODY PRODUCTION

24. AZATHIOPRINE
• BONE MARROW DEPRESSION
• HEPATOTOXICITY
MYCOPHENOLATE
• NO INTERACTION WITH CsA &
PREDNISOLONE
• NEPHROTOXICITY
• HEPATOTOXICITY
• BM DEPRESSION

25. ANTIMETABOLITES
AZATHIOPRINE
MYCOPHENOLATE MOFETIL
• ANTI-NUCLEOTIDE ANTIMETABOLITES
• INHIBIT LYMPHOCYTE PROLIFERATION &
ANTIBODY PRODUCTION

26. DRUGS AFFECTING Cs A &
TACROLIMUS BLOOD
LEVELS
 BLOOD LEVELS
• METOCLOPRAMIDE
• VERAPAMIL
• NICARDIPINE
• CIMETIDINE
• DILTIAZEM
• BROMCRIPTINE
• ERYTHROMYCIN
• KETOCONAZOLE
• CHLOROQUINE

27. DRUGS AFFECTING Cs A &
TACROLIMUS BLOOD
LEVELS
 BLOOD LEVELS
• CARBAMAZEPINE
• PHENOBARBITAL
• PHENYTOIN
• RIFAMPICIN
• OCTREOTIDE
• TICLOPIDINE

28. DRUGS THAT MAY CAUSE
RENAL DYSFUNCTION
WHEN GIVEN WITH Cs A &
TACROLIMUS
NSAIDs
RANITIDINE
CIMETIDINE
AMPHOTERICIN
COTRIMOXAZOLE
GENTAMICIN
MELPHALAN
TACROLIMUS/ Cs A

29. INFECTIONS IN
IMMUNOSUPPRESSED
MAJOR CAUSE OF MORBIDITY &
MORTALITY
1ST MONTH - BACTERIAL INFECTIONS
• WOUND INFECTION - STAPH. AUREUS
• URINARY CATHETER – E. COLI
• PNEUMONIA – PNEUMOCOCCI
OPPURTUNISTIC INFECTIONS MOST
COMMON 30-180 DAYS AFTER
SURGERY
• CMV - COMMONEST
• HERPES
• VARICELLA ZOSTER

30. MYCOBACTERIAL INFECTIONS
SYSTEMIC MYCOSES
NOCARDIOSES
PARASITIC INFECTIONS
• STRONGYLOIDES
• ENTAMEBA
• ACANTHAMEBA

31. ANESTHETIC
CONSIDERATION
The main anesthetic goal is to maintain
renal perfusion and prevent harm to the
already compromised renal function by
avoiding hypoxia, hypovolemia and
hypotension.

32. Pre op Evaluation
History: Establish the cause of renal
failure and duration of treatment.
Need for dialysis postoperatively.
Enquire about fluid restriction if any and
daily urine output.
H/O comorbidities (Hypertension,
diabetes, IHD, connective tissue
disorders) and whether controlled and on
what treatment (dose, frequency).

33. Pre op Evaluation
Enquire about
Exercise Tolerance, Anemia, LVF, Electrolyte
Disturbance, Medications), Gastroesophageal
reflux.
Seek nephrology opinion regarding need for
dialysis in the postoperative period

34. Examination
Measure the patient’s blood pressure in
standing and in sitting position to R/O
autonomic neuropathy.
Flow murmur secondary to anemia and
pericardial rub due to uremic pericarditis.
Look for ankle or sacral edema which may
indicate either right ventricular failure or
hypoproteinemia or both.
Patient’s who are fluid overloaded may
have crepitations

35. REJECTION
MAIN CAUSE OF LATE MORTALITY
PROGRESSIVE DETERIORATION IN
ORGAN FUNCTION TESTS
• AZOTEMIA
• PROTEINURIA
• HYPERTENSION

36. REJECTION
SURGERY DURING PERIOD OF
REJECTION HAVE HIGHER MORBIDITY

37. REJECTION
PRESENTATION:-
PROGRESSIVE DETERIORATION OF
ORGAN FUNCTION
OR
WITH MINIMAL SYMPTOMS FROM
TRANSPLANTED ORGAN &
WITH NON SPECIFIC SYMPTOMS
• POOR APPETITE
• IRRITABILITY
• FATIGUE

38. REJECTION
TIMING :-
MAJORITY WITHIN 3 MONTHS
PEAK TIME – 4-6 WEEKS POST
TRANSPLANT
TREATMENT :-
INCREASING IMMUNOSUPPRESSIVE
TREATMENT
• ADDING ADDL. DRUGS LIKE METHOTREXATE
• AUGMENTATION OF STEROID USE

39. REJECTION
ADEQUATE LEVELS OF
IMMUNOSUPPRESSIVE AGENTS SHOULD
BE MAINTAINED THROUGHOUT THE
PERIOPERATIVE PERIOD

40. Investigations
Full blood count: Normochromic, normocytic anemia
and infection are likely.
Clotting studies: are required if the uraemia is
severe.
Renal function tests (BUN, serum creatinine,
Electrolytes)
ECG: Look for ischemia, arrhythmia, LVH,
conduction blocks or hyperkalemia.
Chest radiograph: Pleural effusions, cardiomegaly,
pulmonary edema
ABG to evaluate the acid base status
LFT if a major surgery is planned; as a baseline value

41. Preoperative
optimization/preparation
If infection / rejection suspected postpone
elective surgery
Continue immunosuppressants
antihypertensive
Adjust dosage according to drug blood levels
For elective surgery, it is prudent to optimize
blood pressure, serum potassium level.

42. Preoperative
optimization/preparation
Avoid unnecessary blood transfusion
because of anemia to avoid sensitization
for future transplantation.
Metoclopramide and H2 receptor
antagonists should be administered if
patient has gastroesophageal reflux.

43. GENERAL ANAESTHETIC
CONSIDERATIONS
Induction of anesthesia
Preoxygenate
Administer induction drugs slowly to minimize
hemodynamic disturbances. If hypotension occurs
despite above, vasopressors can be given titrated
to mean arterial pressure.
If rapid sequence induction is necessary,
suxamethonium can be used if the serum
potassium is < 5.5 mEq/ L,
modified rapid sequence induction can be done
with rocuronium

44. If difficult airway is anticipated;
inhalational induction is a safer option.
.f there is any doubt regarding airway
adequacy, always intubate.
Regional anesthesia can be administered
after weighing the risks and the benefits.
Concern with epidural anesthesia is
platelet dysfunction; increasing the risk of
epidural hematoma.

45. Maintenance of anesthesia
Nitrous oxide can be administered
safely as it does not affect the renal
function.
Isoflurane is the inhalational agent of
choice as only 0.2% undergoes
metabolism and produces low levels of
fluoride ions.
Ventilation should be controlled for
long procedures.

46. Maintenance of anesthesia
Atracurium is preferable as it undergoes Hoffman’s
elimination.
Vecuronium and rocuronium can be used but
smaller top-up doses are required less frequently.
Neuromuscular blockade should be monitored using
a nerve stimulator and top-up doses administered
accordingly.
Fentanyl can be administered safely; half life may be
prolonged particularly if used as an infusion.
Morphine can be used with care as clearance is
reduced

47. If morphine is administered patient should
be monitored for respiratory depression in
the postoperative period.
It should never be used as a continuous
infusion

48. Cs A potentiate :-
• Barbiturates
• Fentanyl
• NDMRs esp. atrac/ vec
So smaller doses & recovery time
prolonged
AZATHIOPRINE
• antagonise NDMR
– Use larger dose
• It may prolong SCh effect

49. Seizure threshold reduced in patients
treated with Cs A & Tacrolimus
• Avoid hyperventilation
Massive fluid infusion periop.
• Dilute Cs A / Tacrolimus
NSAIDs avoided
• Risk of GI hge, nephrotoxicity, hepatic
dysfn

50. Regional techniques :-
• If coagulation status & Platelet count normal
• Azathioprine can cause Thrombocytopenia

51. SPECIFIC ANAES.
CONSIDERATIONS
RENAL FUNCTION SHOULD BE
ASSESSED
• ESP IN PTS ON Cs A / TACROLIMUS
IF IMPAIRED
• PROLONG DRUG ACTION EXCRETED BY
RENAL ROUTE
RISK OF CARDIOVASCULAR DISEASE
• ESP IN DM/ ELDERLY
HIGH INCIDENCE OF HYPERTENSION
• ON C/c ANTIHYPERTENSIVES

52. ADEQUATELY FUNCTIONING KIDNEY
RECIPIENTS
• NORMAL Cr. LEVELS
• GFR lower
CHOOSE DRUGS INDEPENDENT OF
KIDNEY FOR EXCRETION
AVOID NEPHROTOXIC DRUGS

53. MONITORING
Monitor ECG, BP, end-tidal capnometry, pulse
oximetry, temperature and neuromuscular
monitoring.
If large fluid shifts or blood loss is anticipated;
invasive monitoring (central venous pressure
and invasive arterial BP) should be established
to guide fluid replacement.

54. A urinary catheter should be passed to
monitor urine output hourly and should be
maintained at 0.5–1 mL/kg/hr.
If the urine output is low despite good
hydration and BP; mannitol should be
administered as first line treatment
followed by frusemide

55. .IV fluids should be administered
cautiously,
central venous monitoring may be done to
guide volume replacement.
Starches should be avoided in these
patients as it can accumulate and worsen
the renal impairment, gelatine is safe.
Ringer’s lactate can be used if serum
potassium is within the normal limits.
..

56. Forced air warmer and fluid warmer
should be used mandatorily to maintain
normothermia.
Over transfusion of blood to correct
anemia should be avoided as increase in
hematocrit can decrease renal perfusion
and further compromise the renal
function.
.NSAID’s are contraindicated in these
patients, paracetamol can be administered
safely

57. Reversal of neuromuscular
block
Neuromuscular blockade can be reversed
with neostigmine.
Recurarization can occur in the postop and
the recovery staff should be warned about
the same.
Inadequate reversal -it is safer to ventilate
the patient for short-term till complete
neuromuscular recovery occurs

58. POST OPERATIVE CARE
.Oxygen
. ECG, BP and SPO2
ANALGESIA.
WITH ACETAMINOPHEN AVOID NSAIDs
EPIDURAL BLOCK
WOUND INFILTRATION
PERIPHERAL NERVE BLOCK
Early mobilization and physiotherapy

59. POST OP. CARE
Dosages of medications should administered
as per creatinine clearance. :
Cockcroft–Gault equation (eCCr = estimated
creatinine clearance)
eCCr = (140 - Age) × Mass (inkilograms) [0.85
if female] /72 × Serumcre atinine (inmg/dL)

60.  AVOID PREGNANCY FOR A PERIOD OF
2 YRS AFTER TRANSPLANTATION.
 Contraceptive counselling should begin immediately
after transplantation, (ovulatory cycles may begin within
1–2 months of transplantation )
 Low dose oestrogen–progesterone OCP.
 The risk of infection from the use of intrauterine devices
is increased in immunocompromised patients.
 EFFECT OF PREG. ON ALLOGRAFT
MINIMAL BUT FETAL OUTCOME LESS
FAVOURABLE
 45% PREG. BEYOND 28 WKS – ADVERSE OUTCOME
 LIMIT NUMBER OF PREGNANCIES

61. PREGNANCY
Factors that are associated with favorable pregnancy outcomes
include the following:
 Good general health for about 2 years after
transplantation
 No graft rejection in the last year
 Adequate and stable graft function
 No acute infections that might affect the fetus
 Maintenance immunosuppression at stable doses
 Patient compliance with treatment and follow-up
 Normal blood pressure or blood pressure that is well
controlled with one medication
 Normal allograft ultrasonography results

62. Factors that may worsen
pregnancy outcomes
Etiology of the original disease
Chronic allograft dysfunction
Renal insufficiency
Cardiopulmonary diseases
Hypertension
Diabetes mellitus
Obesity
Maternal infection with hepatitis B (HBV) or C
(HCV) or cytomegalovirus (CMV)

63. EFFECT OF PREGNANCY
ON RENAL ALLOGRAFT
Pregnancy does not appear to cause
excessive or irreversible problems
with graft function if the function of
transplant organ is stable prior to
pregnancy

64. EFFECT ON FETUS
GOOD PROGNOSIS SEEN WITH:-
1. GOOD GENERAL CONDITION FOR 2 YRS
AFTER SURGERY
2. STATURE COMPATIBLE WITH GOOD
OBSTETRICAL OUTCOME
3. NO PROTEINURIA
4. NO SIGNIFICANT HYPERTENSION
5. NO e/o GRAFT REJECTION
6. NO e/o PELVICALYCEAL DISTENSION
7. DRUG THERAPY
– PREDISOLONE 15 mg/d or less
– AZATHIOPRINE 2mg/kg/d or less

65. Immunosuppressive drugs in
pregnancy
Glucocorticoids : Adrenal insufficiency and thymic
hypoplasia cleft palate or mental retardation in infants.
(unlikely if the dose of prednisone has been decreased
to 15 mg ).
MOTHER : PROM,infections,aggrevate hypertension.
Azathioprine : low birth weights, prematurity,
jaundice, respiratory distress syndrome and aspiration
,myelosuppression in the fetus.
leukopenia is not usually a problem in the neonate if the
maternal white blood count is maintained at values
higher than 7500/mm3

66. Immunosuppressive drugs in
pregnancy
cyclosporin low birth weights and a higher incidence of
maternal diabetes, hypertension and renal allograft dysfunction.
Cyclosporin metabolism increased during pregnancy -higher
doses may be required.
pregnancies in cyclosporin‐treated women were complicated by
pre‐eclampsia.
Tacrolimus:premature labour,renal dysfunction
FEW DETAILS AVAILABLE WITH USE OF OTHER
DRUGS.

67. Patient self-monitoring of daily blood pressure
Aggressive management of hypertension:
DOC methyldopa
Second-line agents i:clonidine and calcium
channel ,alpha blockers.
contraindicated drugs : angiotensin-converting
enzyme inhibitors and angiotensin receptor
blockers.
Close monitoring of graft function; if rejection is
suspected, consider biopsy .
In cases of acute rejection, steroids are the
preferred drugs

68. SHOULD CONTINUE
• PREDNISOLONE
• AZATHIOPRINE
• Cs A
• FEAR OF ACUTE REJECTION
REQT. OF Cs A INCREASED DURING
PREGNANCY
• INCREASED METABOLISM

69. GUIDELINES FOR MX

70. Obstetric management of
pregnant transplant recipients
 Frequent evaluations, preferably every 2 weeks
 Vaginal delivery (preferred): Usually delayed until
labor onset unless maternal/fetal indications for
induction exist
 Cesarean delivery is only indicated for obstetric
reasons .
 Avoid injury to the allograft by knowing its exact
location
 Antibiotic prophylaxis for all surgical procedures [1]
 Increased steroid dose at labor onset to overcome
the stress of labor and prevent postpartum transplant
rejection

71. EMERGENCY SURGERY
WITH ACUTE GRAFT
REJECTION
SPECIAL PREANAESTHETIC
CONSIDERATIONS ARE :-
1. RISK OF ASPIRATION
-GI HGE/PERFORATION
2. TOXICITY OF IMMUNOSUPPRESSANTS
& RELEVANT DRUG INTERACTIONS
3. RISK OF INFECTIONS
4. AVOIDANCE & CURTAILMENT OF
NEPHROTOXIC INSULT

72. EVALUTE FOR CAD
• Cs A – HYPERTENSION,HYPERGLYCEMIA &
HYPERLIPIDEMIA
PTS ON C/c STEROID THERAPY
• STRESS DOSE OF STEROIDS
INTRAOPERATIVELY
STRICT ASEPSIS FOR INVASIVE
PROCEDURES
BROAD SPECTRUM ANTIBIOTICS

73. Anesthesia for patients after liver
transplantation
Graft function must be assessed
PT-INR excellent marker of synthetic
function
Sterile techniques should be used
Complications due to immunosupressants.
Regional anesthesia is an option if clotting
status is acceptable
A stress dose of corticosteroids may be
needed.
Hepatic blood flow should be maintained.

74. Anesthesia for patients after
lung transplantation
 Recipients may require months to achieve peak
pulmonary function.
 Transplanted lung is especially susceptible to
infection and rejection as a result of its unique
exposure to the external environment.
 Careful preoperative evaluation with PFTs
 Postponement of elective surgical procedures
when allograft rejection or infection is suspected.

75. OTHER CONSIDERATIONS
 Airway hyper responsiveness,
 Loss of the cough reflex,
 Potential for injury to the airway anastomosis
with intubation.
 Increased risk for pulmonary edema, D/T
disruption of the lymphatic drainage in the
transplanted lung

76. Anesthesia for patients after
HEART transplantation
Most issues relate to the absence of autonomic
innervation in the transplanted heart.
Denervation has multiple physiologic effects,
 Higher than normal resting HR (from absence of
vagal tone);
 Absence of cardiac baroreflexes;
 Lack of response to carotid sinus massage,
Valsalva maneuver, laryngoscopy, or tracheal
intubation.

77. Anesthesia for patients after
HEART transplantation
Denervation also affects responses to
medications;
the allograft demonstrates a normal or
augmented response to direct-acting
drugs (e.g., epinephrine),
A blunted response to indirect-acting
agents (e.g., ephedrine),
And no response to vagolytic agents.

78. Chronic allograft rejection
Manifest as accelerated coronary heart disease
and as both systolic and diastolic dysfunction.
Allograft denervation causes any myocardial
ischemia to be silent.
Typical manifestations of chronicrejection
include fatigue, ventricular dysrhythmias,
congestive heart failure, and silent MI on the
ECG.
Patient’s recent cardiac testing must be reviewed.

79. Anesthesia for patients after
HEART transplantation
 Routine periodic evaluation for CAD (stress
testing or coronary angiography) and cardiac
function (echocardiogram or radionuclide
angiography).
 PreoperativeECGs often reveal conduction
abnormalities and may show two P waves (a non
conducted P wave from the native atria and a
conducted P wave from the donor atria).
 Many heart transplant recipients also require
permanent pacemakers, and pacemaker function
should be confirmed during the preoperative
assessment.

81. THANKYOU