What is a 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 healthy enough to go through the transplant process.
Why might I need a heart transplant?
You may need a heart transplant if your heart is failing and cannot be treated by other means.
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 all other available treatments are no longer helping to improve the heart's function. 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 conditions 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.
What are the risks of a heart transplant?
As with any surgery, complications may occur. Potential risks of a heart transplant may include:
- 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 can cause serious heart muscle damage.
- Failure of the donor heart
The new heart may be rejected by your body's immune system. 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.
- 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.
There may be other risks depending on your specific health condition. Be sure to discuss any concerns with your healthcare provider before the surgery.
How do I get ready for a heart transplant?
Not everyone is a candidate for heart transplant. Because of the wide range of information needed to know if a person is eligible for transplant, the evaluation process is carried out by a transplant team. The team includes 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, and a psychiatrist or psychologist. Other team members may include a dietitian, a chaplain, 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. Blood tests are needed to help find a good donor match and help improve the chances that the donor heart will not be rejected.
- Diagnostic tests. Diagnostic tests may be done 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.
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 be told and 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 not clear.
- 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.
What happens during a heart transplant?
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:
- You will be asked to remove any jewelry or other objects that may interfere with the procedure.
- You will be asked to remove your clothing and will be given a gown to wear.
- You will be placed on the operating table, lying on your back.
- An intravenous (IV) line will be started 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.
- A soft, flexible tube (Foley catheter) will be put into your bladder to drain urine.
- A tube will be put through your mouth or nose into your stomach to drain stomach fluids.
- If there is a lot of hair on your chest, it may be shaved off.
- 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.
- The anesthesiologist will watch your heart rate, blood pressure, and blood oxygen level during the surgery.
- The skin over your chest will be cleaned with an antiseptic solution.
- 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.
- The breastbone (sternum) will be cut in half. The surgeon will separate the two halves of the breastbone and spread them apart to reach your heart.
- 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.
- Once the blood has been completely diverted into the bypass machine and is being pumped by the machine, your diseased heart will be removed.
- The donor heart will be sewn into place. Once your new heart is in place, blood vessels will be connected carefully so there are no leaks.
- 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. The heart will be shocked with small paddles to restart the heartbeat.
- Once your new heart begins to beat, the healthcare team will watch the heart to see how it’s working and make sure there are no leaks.
- Wires for pacing may be put into the heart. These wires can be attached to a pacemaker outside your body for a short time and your new heart can be paced, if needed, during the initial recovery period.
- The sternum will be rejoined and sewn together with small wires like those sometimes used to repair a broken bone.
- The skin over the sternum will be sewn back together. The incision will be closed with sutures or surgical staples.
- 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.
- A sterile bandage or dressing will be applied.
What happens after a heart transplant?
In the hospital
After the surgery, you may be taken to a recovery room before being taken to the intensive care unit (ICU) to be closely monitored for several days. Or you may be taken directly to the ICU from the operating room. You will be connected to machines that will constantly display your electrocardiogram (ECG) tracing, blood pressure, other pressure readings, breathing rate, and your oxygen level. Heart transplant surgery requires an in-hospital stay of 7 to 14 days, or even longer.
You will have a tube in your throat so that your breathing can be assisted with 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, the breathing tube will be removed.
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 in order 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, these medicines will be gradually decreased and stopped. If you have pacing wires in your heart, they will be removed, too.
Once the breathing and stomach tubes have been removed and you are stable, you may start to drink liquids. Your diet may be gradually advanced to more solid foods as you tolerate them.
Your anti-rejection (immunosuppression) medicines will be closely watched 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. Your activity will be gradually increased 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.
Arrangements will be made for you to go home and a follow-up visit with your healthcare provider will be scheduled.
Once you are home, it will be important to keep the surgical area clean and dry. You will be given specific bathing instructions. The sutures or surgical staples will be removed during a follow-up office visit, if they were not removed before leaving the hospital.
You should not drive until your healthcare provider tells you to. 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. A biopsy uses a thin needle to remove tissue from the heart so it can be looked at 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
- Difficulty breathing
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.
Usually several anti-rejection medicines are given 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. A balance must be kept 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. About 4 to 6 tiny tissue samples are then taken through the catheter and the tissue is checked in the lab for signs of rejection. If rejection is found, your anti-rejection medications may be adjusted. 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
- The risks and benefits of the test or procedure
- When and where you are to have the test or procedure and who will do it
- When and how will you get the results
- How much will you have to pay for the test or procedure