Heart Transplant

A heart transplant is surgery to remove the diseased heart from a person and replace it with a healthy one from an organ donor. To remove the heart from the donor, two or more healthcare providers must declare the donor brain-dead.

Before you can be put on a waiting list for a heart transplant, a healthcare provider makes the decision that this is the best treatment choice for your heart failure. A healthcare team also makes sure you are otherwise healthy enough to go through the transplant process.

You may need a heart transplant if your heart is failing and other treatments are not effective.

End-stage heart failure is a disease in which the heart muscle is failing severely in its attempt to pump blood through the body. It means other treatments are no longer working. End-stage heart failure is the final stage of heart failure. Despite its name, a diagnosis of heart failure does not mean the heart is about to stop beating. The term failure means the heart muscle is failing to pump blood normally because it is damaged or very weak, or both.

Some causes of heart failure include:

• Heart attack (myocardial infarction or MI)
• Viral infection of the heart muscle
• High blood pressure
• Heart valve disease
• Heart defects present at birth (congenital)
• Irregular heartbeats (arrhythmias)
• High blood pressure in the lungs (pulmonary hypertension)
• Alcoholism or drug abuse
• Chronic lung diseases, such as emphysema or chronic obstructive pulmonary disease (COPD)
• Heart muscle is enlarged, thick, and stiff (cardiomyopathy)
• Low red blood cell count (anemia)

Your healthcare provider may have other reasons to recommend a heart transplant.

Potential recipients of heart transplants at the INTEGRIS Nazih Zuhdi Transplant Institute must meet the following heart transplant criteria to join the heart transplant list. Criteria for a heart transplant include:

• EF (ejection fraction) < 25%
• Inability to walk 1 block without getting shortness of breath
• One or more hospital admissions in the last 6 months for heart failure exacerbation
• Increasing amounts of diuretics
• Frequent defibrillator shocks
• Intolerant to heart failure medicine

Because of the wide range of information needed to know if a person is eligible for transplant, a transplant team will review the evaluation. The team will include:

• A transplant surgeon
• A transplant cardiologist (doctor specializing in the treatment of the heart)
• Nurse practitioners or physician assistants
• One or more transplant nurses
• A social worker
• A psychiatrist or psychologist
• Other team members may include a dietitian, a chaplain, hospital administrator, and an anesthesiologist (doctor who uses medicines to keep you asleep during surgery)

The transplant evaluation process will include:

• Psychological and social evaluation: Some psychological and social issues that are involved in organ transplant include stress, financial issues, and support from family or significant others. These factors can greatly affect how you do after the transplant.
• Blood tests: You will need blood tests to help find a good donor match and help improve the chances that the donor heart will not be rejected.
• Diagnostic tests: You will need tests to assess your lungs as well as your overall health. These tests may include X-rays, ultrasound procedures, CT scan, pulmonary function tests (PFTs), and dental exams. Women may get a Pap test, gynecology evaluation, and a mammogram.
• Other preparations: You will get several vaccines to decrease the chances of developing infections that can affect the transplanted heart.

The transplant team will consider all the information from interviews, your health history, the findings from your physical exam, and your diagnostic test results when deciding if you are eligible for a heart transplant.

In some cases, a person shouldn’t have a heart transplant. Reasons for this can include:

• Current or repeated infection that does not get better with treatment
• Poor blood circulation throughout the body, including the brain
• Metastatic cancer. This is when cancer has spread from the place it started to one or more other places in the body.
• Severe health problems that would make you unable to tolerate the surgery
• Serious health problems other than heart disease that would not get better after transplant
• Noncompliance with treatment regimen. For instance, not following your healthcare provider's directions, not taking medicines as prescribed, or missing appointments.
• Drug or alcohol abuse

As with any surgery, complications may occur. Potential risks of a heart transplant may include:

• Infection
• Bleeding during or after the surgery
• Blood clots that can cause heart attack, stroke, or lung problems
• Breathing problems
• Kidney failure
• Coronary allograft vasculopathy (CAV). This is a problem with the blood vessels that carry blood to the heart muscle itself. They become thick and hard. This can cause serious heart muscle damage.
• Failure of the donor heart
• Death

Your body's immune system may reject the new heart. Rejection is your body's normal reaction to a foreign object or tissue. When you get a new heart, your immune system reacts to what it sees as a foreign threat and attacks the new organ. To allow the transplanted organ to survive in a new body, you will need to take medicines. The medicines will trick the immune system into accepting the transplant and keep it from attacking it.

You will need to take the medicines to prevent or treat rejection for the rest of your life. These drugs have side effects too. The side effects will depend on the specific medicines you take.

There may be other risks depending on your specific health condition. Be sure to discuss any concerns with your healthcare provider before the surgery.

The transplant team will consider all the information from interviews, your health history, the findings from your physical exam, and your diagnostic test results when deciding if you are eligible for a heart transplant.

Once you have been accepted as a transplant candidate, you will be placed on the United Network for Organ Sharing list. When a donor organ becomes available, candidates are selected based on the severity of their condition, body size, and blood type. If the heart is to be yours, you will need to go to the hospital right away so you can get ready for the transplant. (Most hearts must be transplanted within 4 hours after they’ve been removed from the donor.)

These things will need to be done before the transplant:

• Your healthcare provider will explain the procedure and let you ask questions.
• You will be asked to sign a consent form that gives your permission to do the surgery. Read the form carefully and ask questions if anything is unclear.
• You should not eat or drink anything (fast) as soon as you have been told that a heart has become available.
• You may be given medicine to help you relax (sedative).

Based on your health condition, your healthcare provider may request other specific preparation.

A heart transplant requires open heart surgery and a stay in a hospital. Procedures may vary depending on your condition and your healthcare provider's practice.

Generally, a heart transplant follows this process:

1. You will be asked to remove any jewelry or other objects that may interfere with the procedure.
2. You will change into a hospital gown.
3. A healthcare professional will start an intravenous (IV) line in your hand or arm to inject medicine and to give IV fluids. Additional catheters will be put in blood vessels in your neck and wrist to monitor the status of your heart and blood pressure, and to take blood samples. Other sites for the additional catheters include the under the collarbone and the groin.
4. A soft, flexible tube (Foley catheter) will be put into your bladder to drain urine.
5. A tube will be put through your mouth or nose into your stomach to drain stomach fluids.
6. If there is a lot of hair on your chest, it may be shaved.
7. Heart transplant surgery will be done while you are in a deep asleep (under general anesthesia). Once you are asleep, a breathing tube will be put through your mouth into your lungs. The tube will be attached to a machine (ventilator) that will breathe for you during the surgery.
8. The anesthesiologist will watch your heart rate, blood pressure, and blood oxygen level during the surgery.
9. The skin over your chest will be cleaned with an antiseptic solution.
10. The surgeon will make a cut (incision) down the center of your chest from just below the Adam's apple to just above the navel.
11. The surgeon will cut the breastbone (sternum) in half. He or she will separate the two halves of the breastbone and spread them apart to reach your heart.
12. The surgeon will put tubes into your chest so that your blood can be pumped through your body by a heart-lung (cardiopulmonary bypass) machine while your heart is stopped and replaced.
13. Once the blood has been completely diverted into the bypass machine and is being pumped by the machine, your doctor will remove the diseased heart.
14. The surgeon will sew the donor heart into place. Once your new heart is in place, he or she will connect the blood vessels carefully so there are no leaks.
15. When your new heart is fully connected, the blood circulating through the bypass machine will be allowed back into the heart and the tubes to the machine are removed. Your surgeon will shock the heart with small paddles to restart the heartbeat.
16. Once your new heart starts to beat, the healthcare team will watch the heart to see how it’s working and make sure there are no leaks.
17. Wires for pacing may be put into the heart. Your surgeon can attach these wires to a pacemaker outside your body for a short time to pace your new heart, if needed, during the initial recovery period.
18. The surgeon will rejoin the sternum and sew it together with small wires.
19. The surgeon will sew the skin over the sternum back together. He or she will use sutures or surgical staples to close the incision.
20. Tubes will be put into your chest to drain blood and other fluids from around the heart. These tubes will be connected to a suction device to drain fluids away from the heart as it heals.
21. A sterile bandage or dressing will be applied.

In the Hospital

• After the surgery, someone will take you to the recovery room or the intensive care unit (ICU) and monitor you closely for several days. A nurse will connect you to machines that will display your electrocardiogram (ECG) tracing, blood pressure, other pressure readings, breathing rate, and your oxygen level. Heart transplant surgery requires a hospital stay of 7 to 14 days, or even longer.
• You will have a tube in your throat that connects to a breathing machine (ventilator) until you are stable enough to breathe on your own. The breathing tube may stay in for a few hours up to several days, depending on your case. As you recover and start to breathe on your own, the breathing machine will be adjusted to allow you to take over more of the breathing. When you are able to breathe completely on your own and are able to cough, your doctor will remove the breathing tube.
• After the breathing tube is out, a nurse will help you cough and take deep breaths every 2 hours. This will be uncomfortable due to soreness, but it is extremely important that you do this to keep mucus from collecting in your lungs and possibly causing pneumonia. Your nurse will show you how to hug a pillow tightly against your chest while coughing to help ease the discomfort.
• You may get pain medicine as needed, either by a nurse, or by giving it yourself by pushing a button attached to a device connected to your IV line.
• You may have a thin, plastic tube that goes through your nose and into your stomach to remove air that you swallow. The tube will be taken out when your bowels are working normally. You will not be able to eat or drink until the tube is removed.
• Blood samples will be taken often to monitor your new heart, as well as other body functions. These include your lungs, kidneys, liver, and blood system.
• You may be on special IV medicines to help your blood pressure and your heart, and to control any problems with bleeding. As your condition stabilizes, your doctor will gradually decrease, then stop, these medicines. If you have pacing wires in your heart, he or she will remove those too.
• Once your doctor removes the breathing and stomach tubes and you are stable, you may start to drink liquids. You can gradually add more solid foods as you can handle them.
• Your healthcare team will closely watch your anti-rejection (immunosuppression) medicines to make sure you are getting the right dose and the best combination of medicines.
• Nurses, respiratory therapists, and physical therapists will work with you as you begin physical therapy and breathing exercises.
• When your healthcare provider decides you are ready, you will be moved from the ICU to a private room on a surgical unit or transplant unit. Your recovery will continue there. You can gradually increase your activity as you get out of bed and walk around for longer periods. You can eat solid foods as tolerated.
• Nurses, pharmacists, dietitians, physical therapists, and other members of the transplant team will teach you what you will need to do to take care of yourself when you go home.
• Your healthcare team will arrange for you to go home and schedule a follow-up visit with your healthcare provider.

At Home

• Once you are home, it will be important to keep the surgical area clean and dry. Your doctor will give you specific bathing instructions. During a follow-up visit, your doctor will remove the sutures or surgical staples, if they were not removed before leaving the hospital.
• Do not drive until your healthcare provider tells you it's OK. Other activity restrictions may apply.

You will need frequent follow-up visits after transplant.

These visits may include blood tests, chest X-rays, and biopsy. In a biopsy, your doctor uses a thin needle to remove tissue from the heart so he or she can examine it under a microscope. The transplant team will explain the schedule for these visits and tests. The rehab program will continue for many months.

Tell your healthcare provider right away if you have any of the following:

• Fever, chills, or both. These may be a sign of infection or rejection.
• Redness, swelling, bleeding, or drainage from the incision site or any of the catheter sites
• Increase in pain around the incision site
• Trouble breathing
• Excessive fatigue
• Low blood pressure

Your healthcare provider may give you other instructions after the procedure, depending on your own case.

To allow the transplanted heart to survive in your body, you will need to take medicines for the rest of your life to fight rejection. Each person may react differently to medicines, and side effects can be serious. Your healthcare provider will tailor medicine plans to meet your needs.

You may get several anti-rejection medicines at first. The doses of these medicines may change often, depending on your response. Because anti-rejection medicines affect the immune system, you will be at higher risk for infections. It's important to keep a balance between preventing rejection and making you very susceptible to infection.

Some of the infections you will be especially susceptible to include oral yeast infection (thrush), herpes, and respiratory viruses. You should avoid contact with crowds and anyone who has an infection for the first few months after your surgery.

Regular dental care also is important. Your healthcare provider or dentist may prescribe antibiotics before any dental work to help prevent infections.

To watch for signs of rejection, you will likely get routine right heart biopsies. A biopsy is typically done once a week in the early period after a transplant, then gradually changed to monthly or longer intervals. The biopsy procedures may eventually stop.

The right heart biopsy procedure may be done as an outpatient or as an inpatient if you are already in the hospital. The procedure involves a right heart catheterization. A special catheter is threaded through a vein in your neck or groin and into the right atrium of your heart. Your doctor takes 4 to 6 tiny tissue samples through the catheter and checks them for signs of rejection. If your doctor finds signs of rejection, he or she may adjust your anti-rejection medicine. The biopsy procedure has its own instructions and risks, and your healthcare provider will discuss these with you.

Before you agree to the test or the procedure make sure you know:

• The name of the test or procedure
• The reason you are having the test or procedure
• What results to expect and what they mean
• The risks and benefits of the test or procedure
• What the possible side effects or complications are
• When and where you are to have the test or procedure
• Who will do the test or procedure and what that person’s qualifications are
• What would happen if you did not have the test or procedure
• Any alternative tests or procedures to think about
• When and how will you get the results
• Who to call after the test or procedure if you have questions or problems
• How much will you have to pay for the test or procedure