heart transplantation

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Heart Transplantation

 

Definition

Heart transplantation, also called cardiac transplantation, is the replacement of a patient's diseased or injured heart with a healthy donor heart.

Purpose

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:
  • active infection
  • pulmonary hypertension
  • chronic lung disease with loss of more than 40% of lung function
  • untreatable liver or kidney disease
  • diabetes that has caused serious damage to vital organs
  • disease of the blood vessels in the brain, such as a stroke
  • serious disease of the arteries
  • 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.
Heart transplant surgery involves the following basic steps:
  • 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.
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
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.

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:
  • laboratory tests to check for infection
  • chest x ray to check for early signs of lung infection
  • electrocardiogram (ECG) to check heart function
  • echocardiogram to check the function of the ventricles in the heart
  • blood tests to check liver and kidney function
  • complete blood counts (CBC) to check the numbers of blood cells
  • 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.

Resources

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). 1100 Boulders Parkway, Suite 500, P.O. Box 13770, Richmond, VA 23225-8770. (804) 330-8500. http://www.unos.org.

Other

"What Every Patient Needs to Know." United Network for Organ Sharing (UNOS). 〈http://www.unos.org/frame_Default.asp?Category=Patients〉.

Key terms

Anesthesia — Loss of the ability to feel pain, caused by administration of an anesthetic drug.
Angina — Characteristic chest pain which occurs during exercise or stress in certain kinds of heart disease.
Cardiopulmonary bypass — Mechanically circulating the blood with a heart/lung machine that bypasses the heart and lungs.
Cardiovascular — Having to do with the heart and blood vessels.
Complete blood count (CBC) — A blood test to check the numbers of red blood cells, white blood cells, and platelets in the blood.
Coronary artery disease — Blockage of the arteries leading to the heart.
Crossmatch — A test to determine if patient and donor tissues are compatible.
Donor — A person who donates an organ for transplantation.
Echocardiogram — A test that visualizes and records the position and motion of the walls of the heart using ultrasound waves.
Electrocardiogram (ECG) — A test that measures electrical conduction of the heart.
Endomyocardial biopsy — Removal of a small sample of heart tissue to check it for signs of damage caused by organ rejection.
End-stage heart failure — Severe heart disease that does not respond adequately to medical or surgical treatment.
Fatigue — Loss of energy; tiredness.
Graft — A transplanted organ or other tissue.
Immunosuppressive drug — Medication used to suppress the immune system.
Inotropic drugs — Medications used to stimulate the heart beat.
Pulmonary hypertension — An increase in the pressure in the blood vessels of the lungs.
Recipient — A person who receives an organ transplant.

heart trans·plan·ta·tion

replacement of a severely damaged heart with a normal heart from a brain-dead donor.

heart transplantation

Etymology: AS, hoerte + L, transplantare
the surgical removal of a donor heart and transfer of the organ to a recipient. The donor heart is usually obtained from an accident victim who was healthy before dying, and it is used to replace the severely diseased heart of another person. Most recipients survive for more than 1 year, and nearly three-fourths are able to return to work. Total ischemic time for the transplanted heart is less than 6 hours between donor and recipient. The heart is transplanted with anastomoses of the aorta, pulmonary artery, and atria; venous return is provided by an anastomosis between the recipient's right atrium and that of the transplanted organ.

heart transplantation

Cardiac transplantation Cardiac surgery The surgical replacement of a defective heart with another, usually donated by an MVA victim; ± 2000 Pts/month–US need HTs; ± 100/month are performed Cause of death Infection, acute or chronic rejection, embolism, pancreatitis, peptic ulcer, etc Actuarial survival 74% at 6.5 yrs; mortality ↑ with ↑ age, > in ♂, more common in Pts without prior dilated cardiomyopathy Reduction of rejection Steroids, immunosuppressants, daclizumab, an IgG1 MAb which blocks high-affinity IL-2 receptors. See Daclizumab.

heart transplantation

The replacement of a heart irremediably damaged by disease with a healthy heart from a donor. Ideal tissue matching is seldom obtained but problems with immunological rejection reactions have largely been overcome.
References in periodicals archive ?
Andreas Zuckermann, MD, has been involved in over 1,000 thoracic transplantations and is currently Staff Surgeon in the Department of Cardiac Surgery at Medical University of Vienna in Austria and Director of the Cardiac Transplantation Program.
Implantation of an experimental total artificial heart improved survival rates before and after cardiac transplantation, according to a report in the August 26 issue of The New England Journal of Medicine.
Patients should be considered for cardiac transplantation if they are 70 years of age.
Assuming that up to 50,000 people with end-stage heart failure are candidates for transplantation13, maximization of donor organ utilization has enormous potential in cardiac transplantation.
Because of progressive worsening of the heart failure, cardiac transplantation was performed.
medical director of the heart failure and cardiac transplantation program at the University of Pennsylvania, Philadelphia.
The approval allows the HeartMate II to be used in patients with New York Heart Association (NYHA) Class IIIB or IV end-stage ventricular failure who have received optimal medical therapy for at least 45 of the last 60 days, and who are not candidates for cardiac transplantation.
A suitable cardiac donor was found, and the patient was taken to the operating room to undergo orthotopic cardiac transplantation.
We therefore report the successful use of this technique in a second patient with refractory chest pain after cardiac transplantation, with the aim of supporting consideration of spinal cord stimulation in this difficult clinical situation.
The HeartMate II was implanted in each patient as a bridge to cardiac transplantation.
This year's meeting will feature an update on the Spanish model of organ procurement, the most successful anywhere in the world, and commemorate the 20th anniversary of infant cardiac transplantation with a presentation from pioneering pediatric surgeon Leonard Bailey, M.