What to Expect From a Heart Transplant

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, although a less commonly used method keeps the patient's heart in place. Heart transplantation is done as a treatment for end-stage heart failure—heart disease that is severe enough that it will lead to death without the new organ.

Heart transplantation isn’t considered a cure for heart disease, but rather a treatment that can significantly prolong the life of the heart recipient. On average, an adult patient who receives a donated heart lives an additional 10 years after surgery. Most of these patients would not survive a year, or 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, such as cardiomyopathy, heart failure, and restrictive myopathy. Some are present at birth and others develop over time (e.g., coronary heart disease). 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, you may need a heart transplant if you experience:

• Systolic heart failure: Your heart is enlarged and too weak to pump blood with enough force.
• Diastolic heart failure: Your heart muscle is thick and stiff, and therefore unable to relax and fill with blood between each beat. This is more likely in people age 70 and older.

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 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 would be eligible once they are well.

People who are not candidates for a heart transplant include those with:

• Active infection
• Inability to manage the post-transplant regimen
• 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
• Dementia
• Irreversible pulmonary hypertension
• Severe vascular disease
• Severe disease of another organ (for some, a dual transplant—such as a heart-kidney combination—is possible)
• Presence of an additional terminal disease 

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.

• 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 and 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 those with life-threatening heart and breathing problems. Surgeons remove the damaged heart and lungs and replace them with a healthy heart and lungs from a deceased donor.

This procedure is done very rarely because only a small percentage of people fit the criteria for donating both heart and lungs.

Donor Recipient Selection Process

Once you have been approved for a 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.

Tests will be done to examine your genetic makeup. It is important for you and the donor to be a good genetic match to minimize the chance of rejection.

You will also undergo evaluations to determine if you have the mental capacity to tolerate the transplant process, as well as care for yourself and manage an extensive drug regimen after surgery. Many transplant centers will not perform transplants on individuals who will not be able to care for themselves independently after surgery.

The transplant center will want to determine if you have any addiction issues, particularly if those issues led to the heart disease that is making a heart transplant necessary. For example, if you abused cocaine and it led to heart damage, it will be important that you are no longer abusing the drug. If you are, you 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 your insurance is adequate to cover the procedure and the additional lifelong expenses. The can also help you obtain insurance or sign up for state and federal programs that can assist with transplant expenses as well.

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.

A donor's sex and race do not determine whether or not a recipient can receive their organ. 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.

Individuals with any blood type can donate their heart, but recipient compatibility will be considered when finding a match. Many times, the donor and recipient are close in age, but this is not required.

Finding a Match

Once it's determined that you are a good candidate for a heart transplant, you are placed on the transplant list by the transplant center. This is a database of potential donors and recipients.

The system uses multiple types of criteria to create a list of every potential recipient of every organ donation. A complex algorithm helps determine the order in which patients appear on each list, or whether they appear at all.

Examples of criteria used include:

• Age: 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.
• Severity of illness: Typically, those who are the sickest and those who have waited the longest are at the top of potential recipient lists.
• Location: After a donor heart is removed, preserved, and packed for transport by the medical staff, it must be transplanted into the recipient within four to five hours, so proximity is a factor.
• Blood type: Ensuring compatible blood types is key to reducing the risk of organ rejection.
• Body size: In order for a donor and a recipient to match, they must be approximately the same body size. A heart from a large man could never fit in petite female, and vice versa.

Before Surgery

Once your transplant seems imminent, you'll undergo standard pre-operative testing to ensure you are well enough to withstand the surgery. These tests include:

• Blood tests to check your liver and kidney function, as well as the levels of the many components that make up your blood
• A chest X-ray
• An electrocardiogram (EKG) to see how well your heart is working
• Echocardiograpy, a test that provides a detailed image of your heart. An "echo" as it's called, provides information about the size and shape of your heart and how well its chambers and valves are working.

Surgical Process

The heart transplant procedure begins with arriving at the hospital. Some people may be already hospitalized due to illness when an organ becomes available; others may receive a phone call that a match has been found.

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 fluids and medications that will be given during and after surgery.

Surgery begins in the operating room, where general anesthesia is provided 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 go faster and more smoothly.

The patient is placed on a heart-lung bypass machine so the 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 complete, the chest is closed by wiring the sternum (breastbone) shut and closing the skin with staples, steristrips, or sutures.

In general, this surgery takes three to four hours. It will take closer to six to eight hours, however, for patients who have a ventricular assist device (VAD).

A VAD is a mechanical pump that keeps the heart pumping blood while a patient awaits a transplant. These devices can support the left ventricle (LVAD), the right ventricle (RVAD), or both (BIVAD). For those confined to a hospital bed, the machine's pump is located outside the body and is connected to the heart via tubes inserted in the abdomen. There are also implantable, portable pumps designed for healthier patients or for longer-term use.

In a heart-lung transplant, the procedure is largely the same. An incision is made in the chest, and the surgeon will remove both the heart and lungs. The donated heart is placed first, followed by each of the lungs. The organs are reconnected to the surrounding blood vessels, and the lungs are attached to the windpipe. This procedure typically takes four to six hours.

After a heart (or heart-lung) transplant, you will be taken to the ICU to recover and to slowly wake from sedation over the next day or two. You will remain in the hospital for a week or more.

Complications

In addition to the general risks of surgery, the risks associated with anesthesia and the risks associated with open-heart surgery, there are some additional and significant risks that a patient should consider prior to having surgery.

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 if 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. Lifelong immunosuppressants (calcineurin inhibitors) are necessary to prevent rejection of the donor heart.

During follow-up appointments, which will happen regularly during the year after surgery, doctors will check to ensure medication adherence, ask about side effects, and check for any warning signs that the body is rejecting the 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 the procedure.

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. 

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, as can enlisting help with daily tasks.
• Educating yourself: Learn as much as you can about life post-procedure and ask questions about things you don't understand.

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 dietary 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
• 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 elevated 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. Transplant surgery is risky, but for these patients, death is certain without a new heart. For the patient who finds a match and has a successful transplant surgery, life may be extended for decades.