Heart Transplant

• What is heart transplantation?
• How many people are receiving heart transplants?
• Who can receive a heart transplant?
• Who is ineligible for a heart transplant?
• What tests are performed before a transplant?
• What happens before the transplant?
• What questions can be asked before a transplant?
• What happens during the procedure?
• What usually happens after the transplant?
• Complications

What is heart transplantation?

Heart transplantation is the surgical removal and replacement of a diseased heart by that of a donor who has died. The first heart transplant was performed in South Africa in 1967. The following year the first heart transplant in Australia was performed at St Vincent’s Hospital in Sydney.

How many people are receiving heart transplants?

On average 70 people receive a heart transplant per year in Australia, with a similar number on the waiting list in corresponding years.

Who can receive a heart transplant?

There are many reasons why a person might need a heart transplant but they all come down to the fact that the heart of the patient is failing and will in a little while no longer be able to sustain life.

Examples of indications or criteria that must be met before you can receive a heart transplant are:

• Patients with end stage heart disease
• Ischemic heart disease which constitutes about 50% of patients
• Cardiomyopathies which contribute to about 40% of patients
• Valvular and congenital heart defects

Generally the heart transplant should significantly improve the patient’s life expectancy and quality of life. Approximate survival values for heart transplantation are 80%, 70% and 55% at 1, 5 and 10 years respectively.

Who is ineligible for a heart transplant?

There are several conditions that make a person unsuitable for a heart transplant. Such contraindications include:

• Serious lung disease such as pulmonary hypertension, recent pulmonary embolism/infarction
• An active infection
• Continued excess alcohol consumption
• Significant disease of the blood vessels especially those in the brain
• Cancer

What tests are performed before a transplant?

Generally tests before a heart transplant include:

• Blood tests which include infectious diseases such as HIV and hepatitis tests
• Chest x-ray
• Electrocardiogram (ECG)
• Coronary angiogram
• Echocardiogram
• Cardiopulmonary test
• Ultrasound of abdomen and blood vessels
• Breathing test/pulmonary function tests
• Stool sample to detect blood
• Measurements of pressures in heart chambers (cardiac catheterization)

What happens before the transplant?

On the day a heart becomes available, you will probably be in hospital or you will be called to come in. Usually there will be two teams involved with you on the day. One will harvest the available heart and the other will perform the operation, sometimes the same team does both. You will be informed that a heart has become available by one of the doctors. From here things can happen very quickly. You will be changed into a gown and taken to the preoperative waiting area until the surgical team is ready for you.

During this waiting period you will have an interview with the anaesthetist who will ask you questions about your past medical history and then put you to sleep as this procedure is carried out under general anaesthesia. It is possible that you may already have had this interview at some point in which case you will quickly be put to sleep and the surgery begun.

What questions can be asked before a transplant?

Any and all questions that are on the patients mind should be asked before the operation and the medical team should be more than happy to answer these.

What happens during the procedure?

Generally the transplant surgery takes about 4 hours. During the operation a bypass machine is used to maintain the oxygen and blood supply to the rest of the body.

Most of the old heart will be cut out and the new one will be attached to the blood vessels.

What usually happens after the transplant?

Activity can slowly be increased over the next 6-8 weeks. Cardiac rehabilitation is an excellent way to get your full strength back, and most centres have an in house program that patients must attend. Care should be taken to watch for possible signs of infection which could include:

• Fever
• Sore throat
• Shortness of breath
• Cough
• Redness, swelling, or drainage from your incision.

If any of these are noticed the doctor must be notified immediately.

In this vein care must be taken in handling animals and the patient should avoid cleaning litter boxes or birdcages because of the risk of infection.

Schedules following a transplant can vary between transplant centres but normally a patient will be expected to:

• Undergo endomyocardial biopsies; blood tests – renal and liver function tests, cyclosporine levels every month for the first 3 months after discharge home.
• Every 2 months for the next 6 months, and the 6-monthly visits until year 2.
• At 2-years post transplant:
  • cardiac catheterization and angiography to screen for coronary microvascular disease (chronic rejection).
• After 2 years, follow-up is generally annually.

Complications

The most common complications are:

1. Infection
2. Acute rejection
3. Chronic rejection
4. Cancer

References

1. Australia T. Transplant statistics for organ by year. [Website] 2007  [cited 2008 22nd Feruary]; Available from: [URL Link]
2. Deng MC. Orthotopic heart transplantation: highlights and limitations. Surgical Clinics of North America. 2004;84:243-55.
3. Blom AS, Acker MA. The Surgical Treatment of End-Stage Heart Failure. Current Problems in Cardiology. 2007;32(10):553-99.
4. Wagoner LLE. Management of the cardiac transplant recipient: roles of the transplant cardiologist and primary care physician. The American journal of the medical sciences. 1997;314(3):173-84.
5. Al-khaldi A, Robbins RC. New Directions in Cardiac Transplantation. Annual Review of Medicine. 2006;57(1):455-71.
6. Talley NOC, S. Examination Medicine. 5th ed: Churchil livingstone; 2004.
7. Tjandra JJ CG, Kaye AH, Smith J. Texbook of Surgery. 3rd ed: Blacwell Publishing; 2006.
8. Brozena SC TCGL. A prospective study of continuous intravenous milrinone therapy for status IB patients awaiting heart transplant at home. Journal of Heart and Lung Transplant. 2004;23:1082-186.