Guidelines and principles for the care of the cardiothoracic transplant patient in the intensive care unit.

Heart and lung transplant recipients require care provided by clinicians from multiple different specialties, each contributing unique expertise and perspective. The period the patient spends in the intensive care unit is one of the most critical times in the perioperative trajectory. Various organizational models of intensive care exist, including those led by intensivists, surgeons, transplant cardiologists, and pulmonologists. Coordinating timely efficient intensive care is an essential and logistically difficult goal. The present work product of the American Society of Transplantation's Thoracic and Critical Care Community of Practice, Critical Care Task Force outlines operational guidelines and principles that may be applied in different organizational models to optimize the delivery of intensive care for the cardiothoracic organ recipient.

An interesting case: bilateral superior vena cava in a patient with end stage renal disease.

A left superior vena cava, which is present in 0.5% of the population, is the result of persistence of the embryonic left anterior cardinal vein and is usually considered a normal variant. We present our experience of an incidental discovery of bilateral superior vena cava during routine evaluation of suspected intra-fistula stenosis in a dialysis-dependent patient with end stage renal disease. Our images were consistent with a left-sided venous structure draining into the heart with an independent right side superior vena cava as evidenced by fluoroscopy. There was also evidence of a 60% intra-fistula stenosis. To conclude, twin superior vena cava may be present as draining vessels independent of each other or as part of a duplicate caval drainage. While cases of persistent left superior vena cava have been associated with disturbances of cardiac impulse formation and conduction no such significant associations have been found in patients with bilateral superior vena cava. However, the variant anatomy may confound efforts during central venous catheterization as well as alter flow characteristics, such that one could postulate that the anatomy may also affect the maturation of an arteriovenous fistula.