Description

Finding a donor heart can be difficult. The heart must be donated by someone who is brain-dead but is still 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 it.

You are put into a deep sleep with general anesthesia, and a cut is made through the breastbone.

• Your blood flows through a heart-lung bypass machine while the surgeon works on your heart. This machine does the work of your heart while your heart is stopped, and supplies your body with blood and oxygen.
• Your 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 are inserted to drain air, fluid, and blood out of the chest for several days, to allow the lungs to fully re-expand.
• In some cases, the surgeon will not remove the old heart, but will put the new heart on top of it (heterotopic transplant).

Why the Procedure is Performed

A heart transplant may be done to treat:

• Severe angina that can no longer be treated with medications or other surgeries
• Severe heart failure, when medicines, other treatments, and surgery no longer help
• Severe heart defects that were present at birth and cannot be fixed with surgery
• Life-threatening abnormal heartbeats or rhythms that do not respond to other treatments

Heart transplant surgery may NOT be used in patients who:

• Are malnourished
• Are older than age 55 - 60
• Have had a severe stroke or dementia
• Have had cancer
• Have HIV infection
• Have infections such as hepatitis that are active
• Have insulin-dependent diabetes and other organs that aren't working correctly
• Have kidney, lung, nerve, or liver disease
• Have no family support and do not follow their treatment
• Have other diseases that affect the blood vessels of the neck and leg
• Have pulmonary hypertension (thickening of blood vessels in the lung)
• Smoke or abuse alcohol or drugs, or have other lifestyle habits that may damage the new heart

The doctor may not recommend a heart transplant if the patient may not be able to keep up with the many hospital and doctor's office visits, tests, and medications needed to keep the new heart healthy.

Risks

Risks from any anesthesia are:

• Reactions to medications
• Problems breathing

Risks from any surgery are:

• Bleeding
• Infection

Risks of transplant include:

• Blood clots (deep venous thrombosis)
• Damage to the kidneys, liver, or other organs from anti-rejection medications
• Development of cancer from the drugs used to prevent rejection
• Heart attack or stroke
• Heart rhythm problems
• High cholesterol levels, diabetes, and bone thinning from the use of rejection medications
• Increased risk for infections due to anti-rejection medications
• Rejection of the heart
• Severe coronary artery disease
• 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 a transplant. You will visit many times over 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 infections
• Tests of your kidney and liver
• Tests to evaulate your heart, such as EKG, echocardiogram, and 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 want to look at one or more transplant centers to see which would be best for you:

• Ask them how many transplants they perform every year and what their survival rates are. Compare these numbers with the numbers from other centers.
• Ask what support groups they have available and how much help they offer with travel and housing.
• Ask about the costs of medications you will need to take afterwards.

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 who are waiting for heart transplants are very ill and need to be in the hospital. Many will need some sort of device to help their heart pump enough blood to the body. Most often this is a ventricular assist device (artificial heart-like device).

Outlook (Prognosis)

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). During the first few days after a transplant, you will need close follow-up to make sure that you do not get an infection and your heart is working well.

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. You will need to have regular check-ups with blood tests, x-rays, and echocardiograms 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 your doctor's instructions carefully 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 then less often after that. This helps the doctor determine if your body is rejecting the new heart, even before you have symptoms.

You must take drugs that prevent transplant rejection for the rest of your life. You will need to understand how to take these medications, and know their side effects.

You can go back to your normal activities as soon as you feel well enough, and after talking with your doctor. However, avoid vigorous physical activity.

To make sure that you do not develop coronary disease after a transplant, you will have cardiac catheterization every year.

Outlook (Prognosis)

Heart transplant prolongs the life of patients who would otherwise die. About 80% of heart transplant patients are alive 2 years after the operation. At 5 years, 70% of people will still be alive after a heart transplant.

The main problem, as with other transplants, is rejection. If rejection can be controlled, survival increases to over 10 years.

Alternative Names

Cardiac transplant; Transplant - heart; Transplantation - heart

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.

Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S, et al. International Society of Heart and Lung Transplantation Guidelines. The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. J Heart Lung Transplant. 2010;29(8):914-956.

Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009; 119(14):1977-2016.

Update Date: 5/4/2012

Reviewed by: Shabir Bhimji, MD, PhD, Specializing in General Surgery, Cardiothoracic and Vascular Surgery, Midland, TX. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.