What to Expect From a Heart Transplant

What You Should Know About Heart Transplant Surgery

heart chamber and valves
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A heart transplant is a very complex surgical procedure during which a patient’s own heart is surgically removed and replaced with a donor heart. This is done as a treatment for end-stage heart failure—heart disease that is severe enough that it will lead to death without a transplant.

Heart transplantation isn’t considered a cure for heart disease, rather it is a treatment that can significantly prolong the life of the heart recipient. On average a patient who receives a donated heart lives an additional 15 years after surgery. Most of these patients would not survive a year, possibly two years, without this life-saving procedure.

Reasons for a Heart Transplant

There are many heart conditions that can become severe enough to warrant a heart transplant. Some are present at birth and others develop over time. Some conditions are the result of an injury to the heart, such as a heart attack that damages the heart muscle.

Regardless of how the disease process started, the signs that your heart may need to be replaced are a heart that is enlarged and too weak to pump blood with enough force (this is called systolic heart failure), or your heart muscle is thick and stiff, so it can’t relax and fill with blood between each beat. This type is more likely in people age 70 and older, and is called diastolic heart failure. Common causes include:

Who Is Not a Good Candidate?

There are some general contraindications to receiving a heart transplant, though these vary by location, transplant center, and even surgeon. What one transplant center may say is a contraindication to being listed for a transplant may not be an issue for a different transplant center.

Some of these issues may only temporarily prevent transplantation. For example, a patient would not receive a transplant while they have a current high fever and an active infection, but once they are well they would be eligible. People who are not candidates for a heart transplant include those with:

  • Current addictive behavior including illegal drugs, alcohol, and nicotine
  • A history of cancer, a current diagnosis of cancer, or cancer that is likely to return
  • Inability to manage the post-transplant regimen
  • Severe vascular disease
  • Dementia
  • Presence of an additional terminal disease 
  • Active Infection
  • Irreversible pulmonary hypertension
  • Severe disease of another organ (for some a dual transplant, such as a heart-kidney combination is possible)

Types of Heart Transplants

There are two different surgical approaches to heart transplantation. Your surgeon will explain which one is better suited to your specific needs. These approaches are:

  • Orthotopic approach: The more common of the two procedures, the orthotopic approach requires replacing the recipient heart with the donor heart. The recipient receives general anesthesia and is placed on a bypass machine to oxygenate the blood while the heart transplant is being performed. After the recipient’s heart is removed, the donor heart is prepared to fit and implantation begins.
  • Heterotopic approach: With heterotopic transplantation, also called “piggyback” transplantation, the recipient’s heart remains in place the donor heart is placed to the right side of the chest. The procedure is done rarely and is usually reserved for patients with certain forms of pulmonary disease.

Heart-lung transplant

A heart-lung transplant is a surgery for someone with life-threatening heart and breathing problems. Surgeons remove the damaged heart and lungs and replace them with a healthy heart and lungs from the a person who has died. This procedure is done very rarely because only a small percentage of people fit the criteria for donating both heart and lungs.

Heart transplants are the third most common type of transplant in the United States, after kidney and liver transplants. In 2018, 3,408 heart transplants were performed.

Donor Recipient Selection Process

Once you have been approved for a heart transplant, tests will be done to examine your genetic makeup. It is important for the donor and the recipient to be a good genetic match to minimize the chance of rejection.

The donor will also undergo evaluations to determine if they have the mental capacity to tolerate the transplant process and to care for themselves and manage an extensive drug regimen after surgery. Many transplant centers will not transplant individuals who will not be able to care for themselves independently after surgery.

The transplant center will also want to determine if the patient has any addiction issues, particularly if those issues led to the heart disease that is making a heart transplant necessary. For example, if the patient abused cocaine and it led to heart damage, it will be important that the patient is no longer abusing cocaine. If they are, they will not be placed on the transplant list.

Social workers at the transplant center can help you determine how you will pay for the surgery and if their insurance is adequate to cover surgery and the additional lifelong expenses. Social workers may help the patient obtain insurance or sign up for state and federal programs that can assist with transplant expenses.

Once the patient is determined to be a good candidate for a heart transplant they are placed on the transplant list by the transplant center. The “transplant list” is a database of potential donors and recipients. The system uses multiple types of criteria to create a list of every potential organ donation. For example, when a donor heart becomes available, a list is generated with all of the potential recipients who could match with that person, typically with those who are the sickest and those who have waited the longest at the top of the list.

A complex algorithm helps determine the order in which patients appear on each list, or whether they appear at all. If a donor is a blood type that is incompatible with a recipient, the recipient will not appear on that list.

Types of Donors

Donor hearts become available for transplantation when a person has died or is determined to be brain dead and they or their family members elect to donate their organs. Not every donor heart is a fit for every person waiting for an organ. In order for a donor and a recipient to match, they must be approximately the same body size. A heart from a man who is 6’5” tall could never fit in a small female, and likewise, a heart from a petite female would not be able to function well in a large adult. Men can donate to women, and vice versa, and any race can donate to another race without problems. If the donor has an infectious disease, such as hepatitis, a recipient may be located that already has that disease so the organ can still be used.

 Many times, the donor and recipient are close in age, but this is not required. The transplant system tries to maximize the life of a given transplant, so young people tend to be given younger organs in order to provide them with a transplant that could potentially last a lifetime. 

After the donor heart is removed, preserved and packed for transport, it must be transplanted into the recipient within four to five hours

Before Surgery

Before you undergo the actual transplant, you will have to choose a transplant center. Seeing a transplant surgeon requires a referral from your own physician to the transplant center that performs heart transplants near your home. In many cases, there may only be one nearby, but in large cities, you may have multiple options. 

After meeting with the staff at a transplant center, you will be evaluated. This will include a review of your medical records, blood tests, possible imaging studies, and other tests designed to determine if you are well enough to tolerate transplant surgery but sick enough to need a new organ.

When you consider transplant centers, you may want to:

  • Learn about the number and type of transplants the center performs each year
  • Ask about the transplant center's organ donor and recipient survival rates
  • Compare transplant center statistics through the database maintained by the Scientific Registry of Transplant Recipients
  • Consider other services provided by the transplant center, such as support groups, travel arrangements, local housing for your recovery period, and referrals to other resources.

Once a heart becomes available, you will have to get to the transplant center immediately. It's a good idea to have a bag packed with items to make you feel comfortable during your stay (which can be around two weeks), such as pajamas, a robe, slippers, toiletries, and a pillow. You should also arrange to have someone pick you up from the hospital and help you with childcare, if necessary, and other daily responsibilities while you are in the hospital and during your recovery at home.

During the Surgery

The heart transplant procedure begins with arriving at the hospital. For some individuals, they may be hospitalized due to illness when an organ becomes available, for others they may receive a phone call that an organ has become available. 

Once at the hospital, blood is drawn, an IV is placed, and for many, an indwelling catheter such as a PICC line is put in place for the IV fluids and IV medications that will be given during and after surgery.

Surgery begins with going to the operating room, where general anesthesia is provided, typically by an anesthesiologist. Once the patient is asleep, the procedure begins with a large incision in the middle of the chest, cutting through both the skin and bone of the chest to expose the heart. In many cases, two surgeons are operating together to make the transplant process faster and smoother.

The patient is placed on a heart-lung bypass machine so that blood continues to be oxygenated by the lungs and pump to the body. This part of the surgery is key because the heart is then stopped, then removed from the body.

The donor heart is then sewn into place and restarted. Once the heart is beating, and the final work of placing chest tubes for drainage is completed, and the chest is closed by wiring the sternum (breastbone) closed and closing the skin with staples, steristrips, or sutures.

Heart transplant surgery takes around four hours.

The patient is taken to the ICU to recover and to slowly wake from sedation over the next day or even two days. 

Complications

In addition to the general risks of surgery, the risks associated with anesthesia and the risks associated with open heart surgery, heart transplant surgery has some additional significant risks that a patient should consider prior to having surgery. Heart transplant surgery is a very high-risk procedure because the heart is not only stopped but removed and replaced.

Risks include but are not limited to:

  • Blood clots
  • Stroke
  • Anoxic brain injury—brain damage due to a lack of oxygen
  • Death—all surgeries have a risk of death, but the risk is higher than typical with heart transplantation, particularly the heart does not start in the donor's body, or does not function well
  • Acute rejection—the donor's body does not tolerate the transplanted heart

After Surgery

The recovery from a heart transplant procedure lasts several months and may involve cardiac rehabilitation. Most patients are able to leave the hospital within a few weeks of the surgery, return to many of their normal activities within six weeks of surgery, and have reached the end of the recovery phase at the three to six-month mark. You will take immunosuppressants for the rest of your life to prevent rejection of the donor heart.

During your follow-up appointments, which will happen regularly during the year after your surgery, doctors will check to make sure you are taking your medications properly, ask about side effects, and check for any warning signs that your body is rejecting your new organ.

Prognosis

For the average heart transplant patient with a good outcome from surgery, the expectation is an additional decade or more of life after surgery. Approximately 80% to 95% percent of patients survive the first year. The average survival rate of an adult after a heart transplant surgery is 11 years, depending on depend on their age at the time of transplant, how well they follow their surgeon’s instructions, other health issues they may have, their daily routine including diet and exercise, and how well their body tolerates the transplant process. 

The average survival rate of adult heart transplant recipients is 11 years after the surgery, which means that 50% of patients live longer than that. This percentage has been steadily improving over the last several decades.

Support and Coping

It's normal to feel anxious or overwhelmed while waiting for a heart transplant or to have fears about rejection, returning to work, or other issues after a transplant. Seeking the support of friends and family members can help you cope during this stressful time.

Your transplant team can also assist you with other useful resources and coping strategies throughout the transplant process, such as:

  • Joining a support group for transplant recipients. Talking with others who have shared your experience can ease fears and anxiety. Support groups may be in-person or online.
  • Finding vocational rehabilitation services. If you're returning to work, your social worker may be able to connect you with rehabilitation services provided by your home state's department of vocational rehabilitation.
  • Setting realistic goals and expectations. Recognize that life after transplant may not be exactly the same as life before transplant. Having realistic expectations about results and recovery time can help reduce stress.
  • Educating yourself. Learn as much as you can about your procedure and ask questions about things you don't understand. Knowledge is empowering.

Diet and nutrition

Maintaining a healthy weight through diet and exercise can help prevent many common post-transplant complications, including infection, heart attacks, and bone thinning.

Your transplant team should include a nutrition specialist (dietitian) who can discuss your nutrition and diet needs and answer any questions you have after your transplant. Your dietitian's recommendations may include:

  • Eating at least five servings of fruits and vegetables each day
  • Eating lean meats, poultry and fish
  • Eating whole-grain breads, cereals and other products
  • Having enough fiber in your daily diet
  • Drinking low-fat milk or eating other low-fat dairy products to help maintain healthy calcium levels
  • Limiting salt and sodium intake by using fresh herbs and spices to season foods and avoiding processed foods
  • Limiting unhealthy fats, such as saturated fats in butter and red meats
  • Limiting your caffeine and avoiding excessive alcohol intake
  • Staying hydrated by drinking adequate water and other fluids each day
  • Avoiding grapefruit and grapefruit juice, pomegranate and Seville oranges due to their effect on a group of immunosuppressive medications called calcineurin inhibitors
  • Following food safety practices to reduce the risk of infection

Exercise

After a heart transplant, regular exercise helps boost energy levels and increase strength. It also helps you maintain a healthy weight, reduce stress, and prevent common post-transplant complications such as high blood pressure and cholesterol levels.

Your transplant team will recommend a physical activity program based on your individual needs and goals.

Walking, bicycling, swimming, low-impact strength training, and other physical activities you enjoy can all be a part of a healthy, active lifestyle after transplant. But be sure to check in with your transplant team before starting or changing your post-transplant exercise routine.

A Word From Verywell

Heart transplant surgery is often a last resort of treatment for a heart that isn’t functioning well enough to sustain life. It is done when there are no other options left, and the patient will die from heart disease without a donor heart. Transplant surgery is risky, but for these patients, death is certain without a new heart. For the patient who has a successful transplant surgery, life may be extended for decades. This can mean seeing children grow up or having grandchildren, or for pediatric patients, it means living long enough to reach adulthood.

Getting a transplant is often a long wait, terribly expensive and a challenging recovery, but the rewards are often great and the extra years of life are of immeasurable value.

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