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Heart transplant

Definition

Heart transplantation is surgery to remove a damaged or diseased heart and replace it with a healthy donor heart.

Alternative Names

Cardiac transplant; Transplant - heart

Description

Finding a donor heart can be difficult. The heart is donated by someone who has been declared brain-dead but remains on life support. The donor heart must be matched as closely as possible to your tissue type to reduce the chance that your body will reject the new heart.

The patient is put into a deep sleep with general anesthesia, and a cut is made through the breast bone.

• The patient's blood is circulated through a heart-lung bypass machine to keep the blood oxygen-rich during the surgery.
• The patient's diseased heart is removed and the donor heart is stitched in place. The heart-lung machine is disconnected. Blood flows through the transplanted heart.
• Tubes may be inserted to drain air, fluid, and blood out of the chest for several days, to allow the lungs to fully re-expand.

Indications

A heart transplant may be recommended for:

• Severe angina that can no longer be treated with medications or surgeries to repair the coronary arteries
• Severe heart failure, when medicines, other treatments, and surgery no longer help. Possible causes of severe heart failure are:
  • Coronary artery disease
  • Cardiomyopathy (disease of the heart muscle)
  • Heart valve disease with congestive heart failure
• Severe heart defects that were present at birth and cannot be fixed with surgery
• Life-threatening abnormal heart beats or rhythms that do not respond to other therapy

Heart transplant surgery may NOT be recommended for patients who have:

• Had cancer
• Infections such as hepatitis, that are considered to be active
• Insulin-dependent diabetes with poor function of other organs
• Kidney, lung, nerve, or liver disease
• Malnutrition
• Other diseases that affect the blood vessels of the neck and leg
• Smoking, alcohol or drug abuse, or other lifestyle habits that may damage the new heart

The doctor may also recommend against a heart transplant if there is concern that the patient will not be able to comply with the many hospital and doctor's office visits, tests, and medications needed to keep the new heart healthy.

Risks

Risks for any anesthesia are:

• Reactions to medications
• Problems breathing

Risks for any surgery are:

• Bleeding
• Infection

Risks of transplant include:

• Blood clots (deep venous thrombosis)
• Damage to the kidneys, liver, or other body organs from anti-rejection (immunosuppression) medications
• Heart attack or stroke
• Heart rhythm problems
• Increased risk for infections due to anti-rejection (immunosuppression) medications
• Wound infections

Before the Procedure

Once the doctor refers you to a transplant center, you will be evaluated by the transplant team. They will want to make sure that you are a good candidate for transplantation. You will have several visits over the course of several weeks or even months. You will need to have blood drawn and x-rays taken. The following may also be done:

• Blood or skin tests to check for a number of infections
• Tests to evaulate your heart, such as EKG, echocardiogram, cardiac catheterization
• Tests to look for cancer
• Tissue and blood typing, to help make sure your body will not reject the donated heart

You will also want to assess one or more transplant centers to see which would serve you best:

• Ask them how many transplants they perform every year and what their survival rates are. Compare these numbers with those from other centers.
• Ask about support groups they have available and how much help is offered with travel and housing arrangements.

If the transplant team believes you are a good candidate, you will be put on a national waiting list for a heart:

• Your place on the list is based on several factors. Key factors include the type and severity of your heart disease, and the likelihood that a transplant will be successful.
• The amount of time you spend on a waiting list is usually NOT a factor for how soon you get a heart, except in the case of children.

Most, but not all, patients awaiting heart transplants are very ill and need to be in the hospital. Many will require some sort of device to help their heart pump enough blood to the body, mostly often this is a ventricular assist device.

Expectations after surgery

You should expect to stay in the hospital for 7 to 21 days after a heart transplant. The first 24 to 48 hours will likely be in the intensive care unit (ICU).

The recovery period is about 6 months. Often, your transplant team will ask you to stay fairly close to the hospital for the first 3 months. Patients need to have regular check-ups with blood test and x-ray for many years.

Fighting rejection is an ongoing process. The body's immune system considers the transplanted organ an infection and fights it. For this reason, organ transplant patients must take drugs that suppress the body's immune response. Taking medicines and following instructions precisely is very important to preventing rejection.

Biopsies of the heart muscle are often done every month during the first 6 to 12 months after transplant, and the less often after that. This helps the doctor determine if your body is rejecting the new heart, even before symptoms begin.

Outlook (Prognosis)

Heart transplant prolongs the life of a patient who would otherwise die. About 80% of heart transplants are alive 2 years after the operation. The main problem, as with other transplants, is graft rejection. If rejection can be controlled, the patient's survival can be increased to over 10 years.

Drugs that prevent transplant rejection must be taken for the rest of the patient's life. Normal activities can resume as soon as the patient feels well enough and after consulting with the doctor. However, vigorous physical activities should be avoided.

References

Bernstein D. Pediatric Heart and Heart-Lung Transplantation. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th Ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 443.

McCarthy PM. Surgical management of heart failure. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, Pa ; Saunders Elsevier; 2007: chap 27.