Heart transplantation is the most advanced treatment for end-stage heart disease, the final phase of the disease when there is no effective medical or surgical treatment. The most common procedure is to take a working heart from a recently deceased organ donor and implant it into the patient.
A number of different conditions can damage your heart to the point where other treatments are unsuccessful and a transplant is the best chance for cure. These include:
- Congenital heart disease
- Coronary artery disease
- Heart failure
- Pulmonary hypertension
- Valvular heart disease
Other conditions may exclude a patient from consideration for a transplant, such as irreversible pulmonary hypertension, cancer, HIV, active drug or alcohol addiction, acute mental incompetence and severe muscle loss due to malnutrition, called cardiac cachexia. A number of other conditions are evaluated on an individual basis to determine transplant suitability.
Your heart specialist may ask that you be evaluated for a heart transplant if he or she believes that your heart disease is so advanced that there are no other treatment options and that you would be a good candidate for this surgery.
Once it is determined that you would benefit from transplant surgery, your name will be placed on a waiting list to receive a donor heart. There currently are not enough donor hearts available for the people who need them. Regulations state that hearts must go to the sickest patients first in a given area.
Research currently is being done to evaluate devices that potentially could act as a “bridge” to transplantation by replacing heart function with a machine until a donor heart is available.
The pre-transplant evaluation includes assessment of both the cardiac and extra-cardiac systems. Stable patients usually are able to complete the standard pre-transplant selection protocol on an outpatient basis.
One of the most important components of the cardiac evaluation is an assessment of pulmonary vascular health. If the patient has pulmonary hypertension, it is essential to determine its severity and potential for cure. These trials are conducted in the hospital with right heart catheterization and continuous hemodynamic monitoring often for periods of six to 12 hours.
Additional routine components of the cardiac assessment include:
- Non-invasive studies to evaluate the function of the heart muscle, including echocardiography and radionuclide scans
- Perfusion tests, which measure the amount of blood flow to tissue, including resting and stress radionuclide scans or echocardiography
- The measurement of maximal oxygen uptake during standard exercise studies
Some patients also may need formal cardiac catheterization, including coronary angiography and ventriculography, myocardial biopsy and electrophysiologic studies.
In addition, there are a number of non-heart-related tests and other components that are part of the pre-transplant evaluation, including:
- Pulmonary function testing including spirometry and arterial blood gases
- Lab tests for kidney and liver function
- Interviews with the social worker, transplant coordinator and psychiatrist
- Infectious disease screening including serology and skin testing
- Immunogenetics including blood and tissue typing as well as checking your human leukocyte antigens (HLA) level
- Cancer screening that includes chest X-rays and stools samples for everyone; mammograms, breast and pelvic exams for women; and prostate-specific antigen (PSA) and prostate exams for men
Depending on your specific situation, additional tests may be run during the initial screening.
While the main focus of the evaluation is to determine whether the patient is a suitable candidate for transplantation, the team also works with the patient and family to resolve any potentially reversible conditions such as smoking, drug addition, obesity, mental distress, financial problems and so on.
Patients deemed to be acceptable candidates for transplantation are put on the donor waiting list. Patients may be supported by a variety of medications and devices, including pacemakers, defibrillators and ventricular assistance devices until they can be transplanted.
After the transplant has been performed, the patient is taken into ICU to recover. When they wake up, they will be transferred to a recovery unit in order to be rehabilitated. How long they remain in hospital post-transplant depends on the patient’s general health and how well the new heart is working. Doctors typically like the new recipients to leave hospitals within 1 to 2 weeks after surgery due to a high risk of infection while in a hospital.
Once the patient is released, they will have to return to the hospital for regular check-ups and rehabilitation sessions. They may also require emotional support. As the patient adjusts to their transplant, the number of visits to the hospital will decrease over time. The patient will have to remain on immunosuppressant medication to avoid the possibility of rejection.
Post-operation survival periods now average 15 years.