Heart Transplantation

(Transplant-Heart, Heart Transplant, Cardiac Transplant)

Procedure overview

What is a heart transplant?

A heart transplant is a surgical procedure performed to remove the diseased heart from a patient and replace it with a healthy one from an organ donor. In order to remove the heart from the donor, two or more doctors must declare the donor brain-dead.

Before a person can be put on a waiting list for a heart transplant, a doctor makes the determination that there is no other treatment option available for the person's heart failure.

About the heart

Click Image to Enlarge

The heart is the hardest working muscle in the human body. Located almost in the center of the chest, the adult human heart is about the size of one fist.

At an average rate of 80 times a minute, the heart beats about 115,000 times in one day or 42 million times in a year. During an average lifetime, the human heart will beat more than 3 billion times, pumping an amount of blood that equals about 1 million barrels. Even when a person is at rest, the heart is continuously hard at work.

How the heart works

The cardiovascular system, composed of the heart and blood vessels, is responsible for circulating blood throughout your body to supply the tissues with oxygen and nutrients.

The heart is the muscle that pumps blood filled with oxygen and nutrients through the blood vessels to the body tissues. It is made up of:

• Four chambers (two atria and two ventricles) that receive blood from the body (the atria) and pump out blood to it (the ventricles).
  • The right atrium receives blood from the body, which is low in oxygen and high in carbon dioxide.
  • The right ventricle pumps the blood from the right atrium into the lungs to provide it with oxygen and remove carbon dioxide.
  • The left atrium receives blood from the lungs, which is rich in oxygen.
  • The left ventricle pumps the blood from the left atrium into the body, supplying all organs with blood.
• Blood vessels, which compose a network of arteries and veins that carry blood throughout the body.
  • Arteries transport blood from the heart to the body tissues.
  • Veins carry blood back to the heart.
• Four valves to prevent backward flow of blood.
  • Each valve is designed to allow the forward flow of blood and prevent backward flow.
• An electrical system of the heart that stimulates contraction of the heart muscle.

Reasons for the procedure

Heart transplantation is performed to replace a failing heart that cannot be adequately treated by other means.

Congestive heart failure (CHF)

End-stage heart failure is a disease in which the heart muscle is failing severely in its attempt to pump blood through the body, and in which all other available treatments are no longer helping to improve the heart's function. End-stage heart failure is the final stage of heart failure. Heart failure, also called congestive heart failure, or CHF, is a condition that occurs when the heart is unable to pump blood sufficiently. Despite its name, a diagnosis of heart failure does NOT mean the heart is about to stop beating. The term "failure" refers to the fact that the heart muscle is failing to pump blood in the normal manner because it has become weakened.

Some causes of CHF, or weakening of the heart muscle, may include, but are not limited to, the following:

• Heart attack (also called myocardial infarction, or MI)
• Viral infection of the heart muscle
• High blood pressure (hypertension)
• Valvular heart disease
• Congenital (present at birth) heart conditions
• Cardiac arrhythmias (irregular heartbeats)
• Pulmonary hypertension (elevated blood pressure within the lungs' blood vessels)
• Alcoholism or drug abuse
• Chronic lung diseases, such as emphysema or chronic obstructive pulmonary disease
• Cardiomyopathy (an enlargement of the heart muscle)
• Anemia (low red blood cell count)

There may be other reasons for your doctor to recommend heart transplantation.

Risks of the procedure

As with any surgery, complications may occur. Potential risks associated with heart transplantation may include, but are not limited to, the following:

• Infection
• Bleeding during or after the surgery
• Blood clots that can cause heart attack, stroke, or lung problems
• Breathing problems
• Kidney failure
• Coronary arteriopathy (similar to coronary artery disease)

The new heart may be rejected by the body's immune system. Rejection is the body's normal reaction to a foreign object or tissue. When a new heart is transplanted into a recipient's body, the immune system reacts to what it perceives as a threat and attacks the new organ, not realizing that the transplanted heart is beneficial. To allow the transplanted organ to survive in a new body, medications must be taken to trick the immune system into accepting the transplant and not attacking it as a foreign object.

The medications used to prevent or treat rejection have side effects. The exact side effects will depend on the specific medications that are taken.

Contraindications for heart transplantation include, but are not limited to, the following:

• Current or recurring infection that cannot be treated effectively
• Metastatic cancer. This is when cancer has spread from its primary location to one or more additional locations in the body
• Severe medical problems preventing the ability to tolerate the surgical procedure
• Serious conditions other than heart disease that would not improve after transplantation
• Noncompliance with treatment regimen

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Before the procedure

Because of the wide range of information necessary to determine eligibility for transplant, the evaluation process is carried out by a transplant team. The team includes a transplant surgeon, a transplant cardiologist (doctor specializing in the treatment of the heart), one or more transplant nurses, a social worker, and a psychiatrist or psychologist. Additional team members may include a dietician, a chaplain, and/or an anesthesiologist.

Components of the transplant evaluation process include, but are not limited to, the following:

• Psychological and social evaluation. Psychological and social issues involved in organ transplantation, such as stress, financial issues, and support by family and/or significant others are assessed. These issues can significantly affect the outcome of a transplant.
• Blood tests. Blood tests are performed to help determine a good donor match and to help improve the chances that the donor organ will not be rejected.
• Diagnostic tests. Diagnostic tests may be performed to assess your lungs as well as your overall health status. These tests may include X-rays, ultrasound procedures, computed tomography (CT scan), pulmonary function tests, and dental examinations. Women may receive a Pap test, gynecology evaluation, and a mammogram.
• Other preparations. Several immunizations will be given to decrease the chances of developing infections that can affect the transplanted heart.

The transplant team will consider all information from interviews, your medical history, physical examination, and diagnostic tests in determining your eligibility for heart transplantation.

Once you have been accepted as a transplant candidate, you will be placed on the United Network for Organ Sharing (UNOS) list. When a donor organ becomes available, heart recipients are selected based on the severity of their condition and their blood type. You will be notified and told to come to the hospital immediately so you can be prepared for the transplant.

The following steps will precede the transplant:

• Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
• You will be asked to sign a consent form that gives your permission to do the surgery. Read the form carefully and ask questions if something is not clear.
• You should begin to fast once you are notified that a heart has become available.
• You may receive a sedative prior to the procedure to help you relax.
• Based on your medical condition, your doctor may request other specific preparation.

During the procedure

Heart transplantation requires a stay in a hospital. Procedures may vary depending on your condition and your doctor's practices.

Generally, heart transplantation follows this process:

1. You will be asked to remove any jewelry or other objects that may interfere with the procedure.
2. You will be asked to remove your clothing and will be given a gown to wear.
3. An intravenous (IV) line will be started in your hand or arm prior to the procedure for injection of medication and to administer IV fluids, if needed. Additional catheters will be inserted in your neck and wrist to monitor the status of your heart and blood pressure, as well as for obtaining blood samples. Alternate sites for the additional catheters include the subclavian (under the collarbone) area and the groin.
4. A catheter will be inserted into your bladder to drain urine.
5. If there is excessive hair at the surgical site, it may be clipped off.
6. Heart transplant surgery will be performed while you are asleep under general anesthesia. A tube will be inserted through your mouth into your lungs. The tube will be attached to a ventilator that will breathe for you during the procedure.
7. The anesthesiologist will continuously monitor your heart rate, blood pressure, and blood oxygen level during the surgery.
8. The skin over the surgical site will be cleansed with an antiseptic solution.
9. The doctor will make an incision (cut) down the center of the chest from just below the Adam's apple to just above the navel.
10. The sternum (breastbone) will be divided in half with a special operating instrument. The doctor will separate the two halves of the breastbone and spread them apart to expose the heart.
11. Tubes will be inserted into the chest so that the blood can be pumped through your body by a cardiopulmonary bypass machine (heart-lung machine).
12. Once the blood has been completely diverted into the cardiopulmonary bypass machine for pumping, the diseased heart will be removed.
13. The donor heart will be sewn into place. Once the new heart is in place, blood vessels will be connected.
14. When the transplant procedure has been completed, the blood circulating through the cardiopulmonary bypass machine will be allowed back into the heart and the tubes to the machine removed. The heart will be shocked with small paddles to restart the heartbeat.
15. Once your new heart begins to beat again, the doctor will observe the heart to assess the function of the heart and to make sure there are no leaks where the blood vessels are connected.
16. Temporary wires for pacing may be inserted into the heart. These wires can be attached to a pacemaker and your heart can be paced, if needed, during the initial recovery period.
17. The sternum will be rejoined and sewn together with small wires.
18. The skin over the sternum will be sewn back together. The incision will be closed with sutures or surgical staples.
19. Tubes will be inserted into your chest to drain blood and other fluids from around the heart. These tubes will be connected to a suction device to drain fluids away from the heart.
20. A sterile bandage or dressing will be applied.

After the procedure

In the hospital

After the surgery you may be taken to the recovery room before being taken to the intensive care unit (ICU) to be closely monitored for several days. Alternatively, you may be taken directly to the ICU from the operating room. You will be connected to monitors that will constantly display your electrocardiogram (ECG or EKG) tracing, blood pressure, other pressure readings, breathing rate, and your oxygen level. Heart transplant surgery requires an in-hospital stay of seven to 14 days, or longer.

You will have a tube in your throat so that your breathing may be assisted with a ventilator until you are stable enough to breathe on your own. The breathing tube may remain in place for a few hours up to several days, depending on your situation.

You may have a thin, plastic tube inserted through your nose into your stomach to remove air that you swallow. The tube will be removed when your bowels resume normal function. You will not be able to eat or drink until the tube is removed.

Blood samples will be taken frequently to monitor the status of the new heart, as well as other body functions, such as the lungs, kidneys, liver, and blood system.

You may be on special IV drips to help your blood pressure and your heart, and to control any problems with bleeding. As your condition stabilizes, these drips will be gradually decreased and turned off as your condition allows.

After the breathing tube is out, your nurse will assist you to cough and take deep breaths every two hours. This will be uncomfortable due to soreness, but it is extremely important that you do this in order to keep mucus from collecting in your lungs and possibly causing pneumonia.

You may receive pain medication as needed, either by a nurse, or by administering it yourself through a device connected to your intravenous line.

Once the breathing and stomach tubes have been removed and your condition has stabilized, you may start liquids to drink. Your diet may be gradually advanced to more solid foods as you tolerate them.

Your immunosuppression (anti-rejection) medications will be closely monitored to make sure you are receiving the optimum dose and the best combination of medications.

Nurses, respiratory therapists, and physical therapists will work with you as you begin physical therapy and breathing exercises.

When your doctor decides you are ready, you will be moved from the ICU to a private room on a postsurgical unit or transplant unit. Your recovery will continue to progress. Your activity will be gradually increased as you get out of bed and walk around for longer periods of time. Your diet will be advanced to solid foods as tolerated.

Nurses, pharmacists, dietitians, physical therapists, and other members of the transplant team will teach you how to take care of yourself once you are discharged from the hospital.

At home

Once you are home, it will be important to keep the surgical area clean and dry. Your doctor will give you specific bathing instructions. The sutures or surgical staples will be removed during a follow-up office visit, if they were not removed before leaving the hospital.

You should not drive until your doctor tells you to. Other activity restrictions may apply.

Follow-up visits will be scheduled frequently after returning home from the hospital. These visits may include blood tests, chest X-ray, and biopsy (removal of tissue from the heart for examination under a microscope.) The transplant team will explain the schedule for these tests. The rehabilitation program will continue for many months.

Notify your doctor to report any of the following:

• Fever and/or chills that may be a sign of infection or rejection
• Redness, swelling, or bleeding or drainage from the incision site
• Increase in pain around the incision site
• Difficulty breathing

Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

What is done to prevent rejection?

To allow the transplanted heart to survive in your body, you will be given medications for the rest of your life to fight rejection. Each person may react differently to medications, and each transplant team has preferences for different medications. The anti-rejection medications most commonly used include:

• Cyclosporine
• Tacrolimus
• Azathioprine
• Mycophenolate mofetil
• Prednisone
• Sirolimus
• Methotrexate

New anti-rejection medications are continually being approved. Doctors tailor medication regimes to meet the needs of each individual patient.

Usually, several anti-rejection medications are given initially. The doses of these medications may change frequently, depending on your response. Because anti-rejection medications affect the immune system, persons who receive a transplant will be at higher risk for infections. A balance must be maintained between preventing rejection and making you very susceptible to infection.

Some of the infections you will be especially susceptible to include oral yeast infection (thrush), herpes, and respiratory viruses. You should avoid contact with crowds and anyone who has an infection for the first few months after your surgery.

What are the signs of rejection?

The following are some of the most common symptoms of rejection. However, each individual may experience symptoms differently. Symptoms may include:

• Fever
• Fluid collection in the lung
• Decreased oxygen level in the blood
• Shortness of breath

The symptoms of rejection may resemble other medical conditions or problems. Consult your transplant team with any concerns you have. Frequent visits to and contact with the transplant team are essential.