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Anesthesiology:
doi: 10.1097/ALN.0b013e31816dcb73
Correspondence

Anticholinesterase Drugs and the Transplanted Heart

Sawasdiwipachai, Prasert M.D.; Laussen, Peter C. M.B.B.S.; Smoot, Leslie M.D.; McGowan, Francis X. Jr M.D.; Casta, Alfonso M.D.*

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In Reply:—

We appreciate Dr. Backman's thoughtful comments about our article,1 including discussion of data from his studies in humans and denervated feline hearts, which suggest that edrophonium may be more predictable and (consistent with its pharmacology) cause less bradycardia than neostigmine in transplant recipients. He is also correct in noting that denervation hypersensitivity (as well as variable parasympathetic reinnervation) may underlie the bradycardiac effects of neostigmine in some of these patients, although the data that specifically support this mechanism in transplant recipients are in our minds relatively modest and indirect.2,3 We did want to use our case to heighten awareness of the phenomenon of acute humoral rejection. Although humoral mechanisms have been recognized for some time as an important and pathologically distinct form of rejection, potentially useful diagnostic methods and distinct therapies are a more recent development. We also thought this case would be useful to stimulate speculation about the potential interaction of humoral rejection and its consequences with drugs used during an anesthetic; this includes not only anti-cholinergics and anticholinesterases, but also agents that alter myocardial contractility.
Prasert Sawasdiwipachai, M.D.
Peter C. Laussen, M.B.B.S.
Leslie Smoot, M.D.
Francis X. McGowan, Jr., M.D.
Alfonso Casta, M.D.*
*Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts. alfonso.casta@childrens.harvard.edu
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References

1. Sawasdiwipachai P, Laussen PC, McGowan FX, Smoot L, Casta A: Cardiac arrest after neuromuscular blockade reversal in a heart transplant infant. Anesthesiology 2007; 107:663–5

2. Backman SB, Stein RD, Fox GS, Polosa C: Heart rate changes in cardiac transplant patients and in the denervated cat heart after edrophonium. Can J Anaesth 1997; 44:247–54

3. Backman SB, Stein RD, Blank DW, Collier B, Polosa C: Different properties of the bradycardia produced by neostigmine and edrophonium in the cat. Can J Anaesth 1996; 43:731–40

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