Transplant Primer: Heart Transplant

Section 1: Introduction to Transplantation	Section 4: Liver Transplant
Section 2: Heart Transplant	Section 5: Lung Transplant
Section 3: Kidney Transplant	Section 6: Pancreas Transplant

Heart Transplant

Important! Nothing on this page is medical advice. If you need a transplant, please seek the advice and care of qualified transplant physicians. This is a general source of information and does not represent a medical opinion or recommendation.

Doctors may recommend a heart transplant to treat heart failure. Failure may be due to disease or injury, and the two most common categories of disease are coronary artery disease and cardiomyopathy. The person who needs the transplant is evaluated by a heart transplant team and if they are found to be suitable, his or her name is placed on the waitlist. When a donated heart becomes available, it is surgically removed from the donor and transplanted into the patient.

Heart transplantation is very successful -- 85% of patients who receive a heart transplant are alive one year later. Among 4,409 patients who underwent heart transplants in 1997 and 1998, about 79% survived for at least three years afterwards.

Step 1: Evaluating candidates for a heart transplantation
A team of specially trained staff evaluates the patient to establish whether he or she would be a good candidate for a heart transplant. The staff includes people with special skills in a range of areas. The people who may be on the team include:

Cardiologists (medical heart specialists)
Transplant surgeons
Social workers
Nurses
Transplant coordinators

A heart transplant is only offered to people who have irreversible, chronic heart failure. Other medical or surgical treatments for cardiac problems have usually been tried before consideration of heart transplant. The heart failure may have been caused by problems such as:

Coronary artery disease
Cardiomyopathy (weakness of the heart muscle's pumping ability)
Congenital heart disease
Damage to the heart muscle or valves
Failure of an earlier transplant, requiring another heart transplant

Successful heart transplants have been conducted on newborn infants, children and adults including people past the age of 60.

The evaluating team considers many factors to decide whether a person should be placed on the waitlist for a transplant. The person's general health and suitability for major surgery are taken into account. Risk factors such as these are considered carefully and may result in a recommendation against transplant surgery:

Emphysema
Liver or kidney problems
Poor leg circulation
Smoking
Other conditions that may be treated before the transplant. Treatment of these problems improves the chance of success and reduces complications.

A heart transplant would not be performed for people with certain conditions. These include:

Most cancers, unless successfully treated at least five years previously
Infections that cannot be completely treated or cured, such as tuberculosis
Severe lung, liver, or kidney problems that would make the operation too risky

It is a normal reaction of the body to reject the donated organ. Anti-rejection drugs are prescribed to prevent this rejection. The candidate must be willing to take anti-rejection medicines indefinitely to keep the body from rejecting the donor heart. The person will also need lifelong follow-up by health care professionals.

Step 2: Waiting
If a person is a suitable candidate for a heart transplant, their name is put on a waitlist for an organ. Unfortunately, there are many more people on the waitlist than there are organs available each year. There are now more than 4,000 people in the U.S. waiting for a donor heart. Waiting time may extend several years.

People waiting for donor hearts are grouped by the severity of illness and other medical factors such as blood type. Within any given severity of illness and blood type group, hearts are allocated based on the length of time a person has been on the waitlist.

Step 3: The Transplant Surgery
When a donor heart becomes available, time is critical. The heart must be transplanted into the patient receiving the organ within 4 to 5 hours. A team of surgeons and anesthesiologists performs an operation to remove the heart from the donor. Additional surgical teams may be present to remove other organs. After the heart is removed from the donor, it is preserved and packed for transport. Although the donor is brain dead, this procedure is treated like any other operation using standard surgical practices and sterile techniques. Once the operation is complete and the incisions are closed, the donor's body is prepared for funeral or cremation. Organ procurement surgery respects the body and an open casket funeral is possible if desired.

In the meantime, a recipient is located and prepared for surgery as well. Preparation involves administration of general anesthesia, and placement on a cardiopulmonary bypass machine. Because the blood must continue to be oxygenated during the procedure, the cardiopulmonary bypass machine will perform this task until the new heart is transplanted and beating.

Electric shock may be used to start the beating of the newly transplanted heart. When the heart is successfully beating, the surgeons check for any signs of bleeding. Drugs are administered to stabilize the heart rate and blood pressure. The patient will begin recovery in the intensive care unit (ICU).

Step 4: After Transplant Surgery
Following heart transplant surgery, the patient may remain on an artificial breathing machine for the first 12 to 24 hours of recovery. Depending on progress, some patients are moved out of the ICU in a few days. Generally, he or she will also begin eating within the week following surgery.

Because the organ will be identified as foreign by the recipient's immune system, rejection of the new heart is always a possibility. Powerful drugs called immunosuppressants are given starting at the time of heart transplant surgery to try to prevent rejection. Early signs of rejection do not always cause symptoms. Therefore, tiny biopsies of the heart muscle are taken from all recipients on a regular basis for examination under the microscope. To get the biopsy tissue, a small tube is inserted in the neck and down the jugular vein into the heart. If rejection is detected on the biopsy, treatment consists of additional immunosuppression until the rejection episode is reversed.

Prior to discharge, the transplant team reviews information with the patient, gives instructions for follow-up care and medications, and answers the patient's questions. A prescribed rehabilitation program will continue at home including exercise, nutrition, and the continuation of immunosuppression and other medications. The signs of rejection are also discussed with the patient and family.

Step 5: Returning Home
At-home rehabilitation is a gradual process and depends on the individual. The transplant team will give specific instructions. In general, walking is recommended to restore strength, but heavy lifting should be avoided for four to six weeks following transplant surgery. Other activities, such as driving may usually begin when the incision is free of pain. Sexual activity can resume when one is comfortable. A desire to become pregnant should be discussed ahead of time with the transplant team to determine if and when this is recommended.

Follow-up visits are required for check-ups and additional heart tissue biopsies (described in Step 4). These begin soon after returning home. Initially, outpatient visits may occur weekly or even more often, and as time progresses the frequency of follow-up visits usually decreases.

Possible post-operative complications may arise following heart transplant surgery. They include:

Vascular problems (bleeding)
Arrhythmias (irregular heart rhythm)
Lung problems (collapsed lung; pneumonia)
Incision problems

Vascular problems - It is possible for a heart transplant patient to experience bleeding after surgery. There may be leakage from the sutures or oozing from operated surfaces. Reports indicate that this occurs in about 5% of heart transplant patients, and an additional operation may be required within the first 24 to 48 hours after the transplant to resolve the problem.

Irregular heart rhythms may occur following heart transplant surgery. These are usually treated with medication, but may sometimes require placement of a pacemaker.

Other problems include the long-term risks of immunosuppression. These include complications related to too much or too little immunosuppression:

Rejection
Cancer
Infection

Rejection - It is fairly common for a transplant patient to experience rejection episodes. The body's immune system detects the new organ as foreign and may try to reject it. The immunosuppressive medications prevent rejection in 50 to 75% of cases. Changes may be made in the medications including an increase in dosage or the use of additional drugs to stop rejection. Some rejection episodes can cause permanent damage to the new heart. This may result in narrowing of the coronary arteries of the transplanted heart and may reduce longevity of the organ.

Cancer - Studies show that an estimated 6% to 8% of transplant patients will develop cancer over their lifetime with the transplant. This risk is higher than in the general population. Skin cancer is the most common, and it is typically treated successfully. Some cancers result from the effects of the immunosuppressive medications and others are common cancers that occur at a higher rate in immunosuppressed individuals.

Infection - The immunosuppressant medications increase the risk of less serious and common infections such as urinary tract infection. In addition, they are associated with more serious infections like pneumonia. Infection of the sternal incision can be life threatening and difficult to treat. Finally, uncommon infections that do not affect non-immunosuppressed persons can occur.

Section 1: Introduction to Transplantation

Section 3: Kidney Transplant