Before, During, and After 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 heart disease that is severe enough that it will lead to death without a transplant, also known as end-stage heart failure.

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 fifteen years after surgery.

 Most of these patients would not survive a year, possibly two years, without this life-saving surgery.

The Heart's Function

The heart is the organ that is responsible for moving blood throughout the body. The heart pumps blood to the lungs to be oxygenated, then pumps the blood to the rest of the body to distribute the oxygen, then returning to the heart where the process begins again. This happens many thousands of times a day, with each heartbeat another contraction of the heart muscle that is pushing blood to various parts of the body.

Who Needs a Transplant?

Some of the symptoms that are present when a person is starting to have heart problems are easily mistaken for something else until they are severe enough that medical attention is necessary. Others are only present in more severe cases, and not all patients have each of these symptoms.

Some of the more common signs of heart problems are:

  • Irregular heartbeat
  • Rapid heart rate
  • Coughing or wheezing
  • Exercise intolerance
  • Nausea 
  • Decreased appetite
  • Confusion
  • Blood tinged mucus
  • Chest pain
  • Lightheadedness
  • Fatigue
  • Shortness of Breath
  • Edema

The road to a heart transplant typically begins with symptoms, such as fatigue, that lead to medical tests that show a heart problem of some type.

Some children are born with significant heart problems, others develop over time with aging and for some, one event leads to significant heart damage.

The patient typically begins treatment with a cardiologist, a physician who manages their heart disease with medications, procedures and may recommend surgical intervention if needed. Some people are able to control their heart disease in this manner for decades, or even for the rest of their life.

For some, their heart disease continues to worsen until there is nothing more than can be done with medication and standard procedures and surgeries. When this occurs, if the patient is believed to be a candidate for transplantation, the cardiologist will refer the patient to a transplant center. This means the doctor seeing the patient recommends the patient be seen at the transplant center for a potential transplant.

End-Stage Heart Disease

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, when heart disease is severe enough to significantly shorten the lifespan of the patient, and when other therapies are unable to improve the function of the heart, a transplant may be considered as an option for treatment.

Before the Transplant List

Getting on the transplant list is not as simple as having a visit with a surgeon, the process is complex, can be lengthy and touches on far more than just the lab results and tests.

Being approved to be on the transplant list at a transplant center will initially begin with determining if the patient is suitable for a transplant. First will be the determination of whether or not the patient is a candidate for a heart transplant. Simply put, does the patient need a new heart? If they do, then there will be additional testing to determine if they can handle the physical stress of the surgery and recovery of a heart transplant.

If the potential rewards outweigh the risks and challenges of surgery, the patient is considered a good candidate for transplant.

This is just the beginning. Tests will be done to examine the patient’s genetic makeup, so when a donor heart becomes available tests can be done to see if the donor and the recipient are a good match or if there is a strong 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.

The transplant center will also work with the patient to determine if they will be able to financially handle the bills associated with transplantation and if their insurance is adequate to cover surgery and the additional lifelong expenses. Social workers at the transplant center may help the patient obtain insurance or sign up for state and federal programs that can assist with transplant expenses.

The Transplant List

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. This means they are added to a database that is used to allocate organs to recipients. 

The “transplant list” is a database of potential donors and recipients and there are literally thousands of lists generated in a given month, each one unique and based on a specific donor.

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.

Contraindications

There are some general contraindications to receiving a transplanted organ, 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 for a transplant.

  • Current addictive behavior including illegal drugs, alcohol, and nicotine
  • Cancer that will not be corrected by a transplant, in the past or likely to return
  • Inability to manage post-transplant regimen
  • Severe vascular disease
  • Dementia
  • Presence of an additional life-ending disease 
  • Active Infection
  • Irreversible pulmonary hypertension
  • Severe disease of another organ (for some a dual transplant, such as a heart-kidney combination is possible)

Organ Donation

Most donor hearts become available for transplantation when a person becomes brain dead, and they or their family members elect to donate their organs. Not every donor heart is 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.

The donor and recipient must also have compatible blood types and have genetic markers that show a suitable match. 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. 

Surgery Risks

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

Finding a Surgeon

For many people, the decision of who should be the transplant surgeon is a matter of location, the nearest reasonable transplant center is the one selected and their cardiothoracic surgeons will be the ones providing care. 

For others in larger cities, there may be multiple transplant centers to choose from. In this case, the patient may be referred to the one that is their physician’s preference, or where they are in-network with insurance or the location that is closest to their home.

Not all transplant centers do every possible type of organ transplant surgery. Some centers may provide many types of transplant surgeries, others may only provide kidney or liver transplants. Typically, large university teaching hospitals will offer all types of organ transplants while smaller regional facilities may not. 

The Procedure

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.

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

Recovery

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. 

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 80-95 percent survive the first year, and each year following approximately 96 percent of those individuals survive.

The average life of an adult after a heart transplant surgery is 11 years, which will 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. 

Keep in mind that this 11-year average survival means that fifty percent of adult heart transplant patients live more than 11 years after their transplant surgery, a number that had been steadily improving over the last several decades.

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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