Heart transplantation is performed on patients with end-stage heart failure or some other life-threatening heart disease. Before a doctor recommends heart transplantation for a patient, all other possible treatments for his or her disease must have been tried. The purpose of heart transplantation is to extend and improve the life of a person who would otherwise die from heart failure. Most patients who receive a new heart were so sick before transplantation that they could not live a normal life. Replacing a patient's diseased heart with a healthy, functioning donor heart often allows the recipient to return to normal daily activities.
Precautions
Because healthy donor hearts are in short supply, strict rules dictate who should or should not get a heart transplant. Patients who have conditions that might cause the new heart to fail should not have a heart transplant. Similarly, patients who may be too sick to survive the surgery or the side effects of the drugs they must take to keep their new heart working would not be good transplant candidates.
Patients who have any of the following conditions may not be eligible for heart transplantation:
mental illness or any condition that would make a patient unable to take the necessary medicines on schedule
continuing alcohol or drug abuse
Description
Patients with end-stage heart disease that threatens their life even after medical treatment may be considered for heart transplantation. Potential candidates must have a complete medical examination before they can be put on the transplant waiting list. Many types of tests are done, including blood tests, x rays, and tests of heart, lung, and other organ function. The results of these tests indicate to doctors how serious the heart disease is and whether or not a patient is healthy enough to survive the transplant surgery.
Organ waiting list
A person approved for heart transplantation is placed on the heart transplant waiting list of a heart transplant center. All patients on a waiting list are registered with the United Network for Organ Sharing (UNOS). UNOS has organ transplant specialists who run a national computer network that connects all the transplant centers and organ-donation organizations.
When a donor heart becomes available, information about it is entered into the UNOS computer and compared to information from patients on the waiting list. The computer program produces a list of patients ranked according to blood type, size of the heart, and how urgently they need a heart. Because the heart must be transplanted as quickly as possible, the list of local patients is checked first for a good match. After that, a regional list, and then a national list, are checked. The patient's transplant team of heart and transplant specialists makes the final decision as to whether a donor heart is suitable for the patient.
The transplant procedure
When a heart becomes available and is approved for a patient, it is packed in a sterile cold solution and rushed to the hospital where the recipient is waiting.
A specialist in cardiovascular anesthesia gives the patient general anesthesia.
Intravenous antibiotics are usually given to prevent bacterial wound infections.
The patient is put on a heart/lung machine, which performs the functions of the heart and lungs and pumps the blood to the rest of the body during surgery. This procedure is called cardiopulmonary bypass.
After adequate blood circulation is established, the patient's diseased heart is removed.
The donor heart is attached to the patient's blood vessels.
After the blood vessels are connected, the new heart is warmed up and begins beating. If the heart does not begin to beat immediately, the surgeon may start it with an electrical shock.
The patient is taken off the heart/lung machine.
The new heart is stimulated to maintain a regular beat with medications for two to five days after surgery, until the new heart functions normally on its own.
Heart transplant recipients are given immunosuppressive drugs to prevent the body from rejecting the new heart. These drugs are usually started before or during the heart transplant surgery. Immunosuppressive drugs keep the body's immune system from recognizing and attacking the new heart as foreign tissue. Normally, immune system cells recognize and attack foreign or abnormal cells, such as bacteria, cancer cells, and cells from a transplanted organ. The drugs suppress the immune cells and allow the new heart to function properly. However, they can also allow infections and other adverse effects to occur to the patient.
Because the chance of rejection is highest during the first few months after the transplantation, recipients are usually given a combination of three or four immunosuppressive drugs in high doses during this time. Afterwards, they must take maintenance doses of immunosuppressive drugs for the rest of their lives.
National Transplant Waiting List By Organ Type (June 2000)
Organ Needed
Number Waiting
Kidney
48,349
Liver
15,987
Heart
4,139
Lung
3,695
Kidney-Pancreas
2,437
Pancreas
942
Heart-Lung
212
Intestine
137
Cost and insurance coverage
The total cost for heart transplantation varies, depending on where it is performed, whether transportation and lodging are needed, and on whether there are any complications. The costs for the surgery and first year of care are estimated to be about $250,000. The medical tests and medications after the first year cost about $21,000 per year.
Insurance coverage for heart transplantation varies depending on the policy. Most commercial insurance companies pay a certain percentage of heart transplant costs. Medicare pays for heart transplants if the surgery is performed at Medicare-approved centers. Medicaid pays for heart transplants in 33 states and in the District of Colombia.
Preparation
Before patients are put on the transplant waiting list, their blood type is determined so a compatible donor heart can be found. The heart must come from a person with the same blood type as the patient, unless it is blood type O. A blood type O heart can be transplanted into a person with any type of blood.
A panel reactive antibodies (PRA) test is also done before heart transplantation. This test tells doctors whether or not the patient is at high risk for having a hyperacute reaction against a donor heart. A hyperacute reaction is a strong immune response against the new heart that happens within minutes to hours after the new heart is transplanted. If the PRA shows that a patient has a high risk for this kind of reaction, then a crossmatch is done between a patient and a donor heart before transplant surgery. A crossmatch checks how close the match is between the patient's tissue type and the tissue type of the donor heart.
Most people are not high risk and a crossmatch usually is not done before the transplant because the surgery must be done as quickly as possible after a donor heart is found.
While waiting for heart transplantation, patients are given treatment to keep the heart as healthy as possible. They are regularly checked to make sure the heart is pumping enough blood. Intravenous medications may be used to improve cardiac output. If these drugs are not effective, a mechanical pump can help keep the heart functioning until a donor heart becomes available. Inserted through an artery into the aorta, the pump assists the heart in pumping blood.
Aftercare
Immediately following surgery, patients are monitored closely in the intensive care unit (ICU) of the hospital for 24–72 hours. Most patients need to receive oxygen for four to 24 hours following surgery. Blood pressure, heart function, and other organ functions are carefully monitored during this time.
Heart transplant patients start taking immunosuppressive drugs before or during surgery to prevent immune rejection of the heart. High doses of immunosuppressive drugs are given at this time, because rejection is most likely to happen within the first few months after the surgery. A few months after surgery, lower doses of immunosuppressive drugs usually are given and must be taken for the rest of the patient's life.
For six to eight weeks after the transplant surgery, patients usually come back to the transplant center twice a week for physical examinations and medical tests. These tests check for any signs of infection, rejection of the new heart, or other complications.
In addition to physical examination, the following tests may be done during these visits:
taking of a small tissue sample from the donor heart (endomyocardial biopsy) to check for signs of rejection
During the physical examination, the blood pressure is checked and the heart sounds are listened to with a stethoscope to determine if the heart is beating properly and pumping enough blood. Kidney and liver function are checked because these organs may lose function if the heart is being rejected.
An endomyocardial biopsy is the removal of a small sample of the heart muscle. This is done with a very small instrument that is inserted through an artery or vein and into the heart. The heart muscle tissue is examined under a microscope for signs that the heart is being rejected. Endomyocardial biopsy is usually done weekly for the first four to eight weeks after transplant surgery and then at longer intervals after that.
Risks
The most common and dangerous complications of heart transplant surgery are organ rejection and infection. Immunosuppressive drugs are given to prevent rejection of the heart. Most heart transplant patients have a rejection episode soon after transplantation, but doctors usually diagnose it immediately when it will respond readily to treatment. Rejection is treated with combinations of immunosuppressive drugs given in higher doses than maintenance immunosuppression. Most of these rejection situations are successfully treated.
Infection can result from the surgery, but most infections are a side effect of the immunosuppressive drugs. Immunosuppressive drugs keep the immune system from attacking the foreign cells of the donor heart. However, the suppressed immune cells are also unable to adequately fight bacteria, viruses, and other microorganisms. Microorganisms that normally do not affect persons with healthy immune systems can cause dangerous infections in transplant patients taking immunosuppressive drugs.
Patients are given antibiotics during surgery to prevent bacterial infection. Patients may also be given an antiviral drug to prevent virus infections. Patients who develop infections may need to have their immunosuppressive drugs changed or the dose adjusted. Infections are treated with antibiotics or other drugs, depending on the type of infection.
Other complications that can happen immediately after surgery are:
bleeding
pressure on the heart caused by fluid in the space surrounding the heart (pericardial tamponade)
irregular heart beats
reduced cardiac output
increased amount of blood in the circulatory system
decreased amount of blood in the circulatory system
About half of all heart transplant patients develop coronary artery disease 1–5 years after the transplant. The coronary arteries supply blood to the heart. Patients with this problem develop chest pains called angina. Other names for this complication are coronary allograft vascular disease and chronic rejection.
Outcomes
Heart transplantation is an appropriate treatment for many patients with end-stage heart failure. The outcomes of heart transplantation depend on the patient's age, health, and other factors. About 73% of heart transplant patients are alive four years after surgery.
After transplant, most patients regain normal heart function, meaning the heart pumps a normal amount of blood. A transplanted heart usually beats slightly faster than normal because the heart nerves are cut during surgery. The new heart also does not increase its rate as quickly during exercise. Even so, most patients feel much better and their capacity for exercise is dramatically improved from before they received the new heart. About 85% of patients return to work and other daily activities. Many are able to participate in sports.
BOOKS
Bellenir, Karen, and Peter D. Dresser, eds. Cardiovascular Diseases and Disorders Sourcebook. Detroit: Omnigraphics, 1995.
Texas Heart Institute. Heart Owner's Handbook. New York: John Wiley and Sons, 1996.
ORGANIZATIONS
American Council on Transplantation. P.O. Box 1709, Alexandria, VA 22313. 1-800-ACT-GIVE.
Health Services and Resources Administration, Division of Organ Transplantation. Room 11A-22, 5600 Fishers Lane, Rockville, MD 20857.
United Network for Organ Sharing (UNOS). 1-800-24-DONOR.
OTHER
Craven, John, and Susan Farrow. "Surviving Transplantation." SupportNET Publications, 1996-1997.
"Facts About Heart and Heart/Lung Transplants." National Heart, Lung, and Blood Institute. 27 Nov. 1998. 3 Mar. 1998 <http://www.nhlbi.nih.gov/index.htm>.
