maintain a high index of suspicion. Too frequently, otherwise stable transplant recipients present with advanced disease and require urgent intervention.

Cardiac catheterization should be undertaken after thoughtful consideration, but when indicated it is important to proceed. Renal function must be carefully monitored in these patients, particularly because most receive potentially nephrotoxic agents (cyclosporine or tacrolimus). When transplant recipients undergo cardiac catheterization, adequate intravascular hydration must be maintained and nephrotoxic contrast volume should be minimized. With appropriate attention to these details, catheterization can be accomplished safely.

When cardiac operation is necessary, transplant recipients present several management challenges. Cannulation for cardiopulmonary bypass must assure adequate perfusion of the transplanted organ, and catheter trauma to the relevant anastomoses must be avoided. Similarly, the choice of a prosthetic material for valvular replacement might require special consideration. For example, reoperation may be particularly undesirable in these patients because of relatively poor healing, and the challenges of immunosuppressant management. Therefore, an artificial, instead of a porcine valve might be selected.

Transient postoperative deterioration of renal function is relatively common after cardiopulmonary bypass. Accordingly, it is important to maintain intravascular volume during the early postoperative period. Management may require continuing right heart monitoring for a longer postoperative period to provide objective parameters for judicious fluid replacement. Again, we recommend enteral dosing of maintenance immunosuppressive drugs whenever feasible. Additionally, it is important to consider potentially important drug interactions when prescribing medications for patients with cardiac disease.

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