Cardiac Function Decline After General Anesthesia and Cardiac Catheterization in Pediatric Cardiac Transplant Recipients

Background: Pediatric cardiac transplant recipients undergo elective cardiac catheterization and endomyocardial biopsy (CC/EMB) for graft dysfunction surveillance often facilitated by general anesthesia (GA). GA and positive pressure ventilation (PPV) also depress cardiac function confounding the graft's functional assessment. We aimed to evaluate the frequency of cardiac function decline, going from the awake to the anesthetized state, and determine its association with anesthetic and patient-related factors. Methods: Electronic medical records of pediatric heart transplant recipients undergoing CC/EMB under GA/PPV were retrospectively reviewed. Patients with awake normal cardiac function, assessed by same-day preoperative echocardiographic left ventricular shortening fraction (LVSF) >= 28% were included. A priori, groups were: (1) cardiac function decline (post- catheterization under GA, LVSF< 28%), and (2) no cardiac function decline. Univariate and logistic regression analysis accounting for repeated encounters per patient were performed. Results: 225 eligible encounters occurred in 102 patients. Cardiac function declined in 17.3% (39/225) encounters, and in 25% (26/102) of patients. Logistic regression identified independent predictors as: older age (OR 1.4, 95% CI: 1.1-1.7, P = 0.002), angiotensin-converting enzyme inhibitor (ACEI) use (OR 2.5, 95% CI: 1.2-4.3, P = 0.018), and elevated right ventricular end diastolic pressure (RVEDP) (OR 2.4, 95% CI: 1.1-5.4, P = 0.039), with AUC 0.75. Older age and ACEI use (P = 0.001) and, older age and elevated RVEDP (P = 0.037) were correlated. Conclusions: One in 4 patients demonstrated cardiac function decline from the awake to the anesthetized state, occurring most commonly in older children with elevated RVEDP using ACEI. Most cardiac function declines are unrelated to rejection.