- Heart Transplant Center
- Heart Disease (Coronary Artery Disease) Slideshow Pictures
- Atrial Fibrillation Slideshow: Causes, Tests and Treatment
- Take the Heart Disease Quiz!
- Patient Comments: Heart Transplant - Indications
- Find a local Cardiothoracic Surgeon in your town
- Introduction to heart transplant
- What is a heart transplant?
- Who needs a heart transplant?
- What are the results of a heart transplant?
- What are the complications of a heart transplant?
- How does a heart transplant patient know if he or she is rejecting the donor organ or developing an infection?
- How is rejection of the organ diagnosed and monitored?
- Why aren't more heart transplants done?
- What is the future of heart transplant?
Introduction to heart transplant
The idea of replacing a bad organ with a good one has been documented in ancient mythology. The first real organ transplants were probably skin grafts that may have been done in India as early as the second century B.C. The first heart transplant in any animal is credited to Vladimer Demikhov. Working in Moscow in 1946, Demikhov switched the hearts between two dogs. The dogs survived the surgery. The first heart transplant in human beings was done in South Africa in 1967 by Dr. Christiaan Barnard; the patient only lived 18 days. Most of the research that led to successful heart transplantation took place in the United States at Stanford University under the leadership of Dr. Norman Shumway. Once Stanford started reporting better results, other centers started doing heart transplants. However, successful transplantation of a human heart was not ready for widespread clinical application until medications were developed to prevent the recipient from "rejecting" the donor heart. This happened in 1983 when the Food and Drug Administration (FDA) approved a drug called cyclosporine (Gengraf, Neoral). Before the advent of cyclosporine, overall results of heart transplant were not very good.
What is a heart transplant?
Believe it or not, heart transplantation is a relatively simple operation for a cardiac surgeon. In fact, the procedure actually consists of three operations.
The first operation is harvesting the heart from the donor. The donor is usually an unfortunate person who has suffered irreversible brain injury, called "brain death". Very often these are patients who have had major trauma to the head, for example, in an automobile accident. The victim's organs, other than the brain, are working well with the help of medications and other "life support" that may include a respirator or other devices. A team of physicians, nurses, and technicians goes to the hospital of the donor to remove donated organs once brain death of the donor has been determined. The removed organs are transported on ice to keep them alive until they can be implanted. For the heart, this is optimally less than six hours. So, the organs are often flown by airplane or helicopter to the recipient's hospital.
The second operation is removing the recipient's damaged heart. Removing the damaged heart may be very easy or very difficult, depending on whether the recipient has had previous heart surgery (as is often the case). If there has been previous surgery, cutting through the scar tissue may prolong and complicate removal of the heart.
The third operation is probably the easiest; the implantation of the donor heart. Today, this operation basically involves the creation of only five lines of stitches, or "anastomoses". These suture lines connect the large blood vessels entering and leaving the heart. Remarkably, if there are no complications, most patients who have had a heart transplant are home about one week after the surgery. The generosity of donors and their families makes organ transplant possible.
Quick GuideHeart Disease: Causes of a Heart Attack
Who needs a heart transplant?
There are not enough donor hearts available for everyone who may need a hear transplant. Therefore, there is a careful selection process in place to assure that hearts are distributed fairly and to those who will benefit most from the donor heart. The heart is just a pump, although a complicated pump. Most patients require a transplant because their hearts can no longer pump well enough to supply blood with oxygen and nutrients to the organs of the body. A smaller number of patients have a good pump, but a bad "electrical conduction system" of the heart. This electrical system determines the rate, rhythm and sequence of contraction of the heart muscle. There are all kinds of problems that can occur with the conduction system, including complete interruption of cardiac function causing sudden cardiac death.
While there are many people with "end-stage" heart disease with inadequate function of the heart, not all qualify for a heart transplant. All the other important organs in the body must be in pretty good shape. Transplants cannot be performed in patients with active infection, cancer, or bad diabetes mellitus; patients who smoke or abuse alcohol are also not good candidates. It's not easy to be a transplant recipient. These patients need to change their lifestyle and take numerous medications (commonly more than 30 different medications). Hence, all potential transplants patients must undergo psychological testing to identify social and behavioral factors that could interfere with recovery, compliance with medications, and lifestyle changes required after transplantation.
Moreover, needing a heart and being a suitable candidate are not enough. The potential donor heart must be compatible with the recipient's immune system to decrease the chance of problems with rejection. Finally, this precious resource, the donor organ, must be distributed fairly. The United Network for Organ Sharing (UNOS) is in charge of a system that is in place to assure equitable allocation of organs to individuals who will benefit the most from transplantation. These are usually the sickest patients.
What are the results of a heart transplant?
When all potential problems are considered, the results of transplantation are remarkably good. Keep in mind that heart failure is a very serious and life-threatening disease. In patients with severe forms of heart failure that require transplantation, the one year mortality rate (that is the percent of patients who die in within one year) is 80%. Overall, five year survival in patients with any form of heart failure is less than 50%. Compare these outcomes with cardiac transplant. After heart transplant, five year survival averages about 50%-60%. One year survival averages about 85%-90%.
What are the complications of a heart transplant?
One might ask, "Why is survival no better than it is after a heart transplant?" As part of our defense mechanism to fight off infection and even cancer, our bodies have an "immune system" to recognize and eliminate foreign tissues such as viruses and bacteria. Unfortunately, our immune system also attacks transplanted organs. This is what happens when organs are rejected; they are recognized as foreign by the body. Rejection can be controlled with powerful "immunosuppressive" medications. If there is not enough immunosuppression the organ can reject acutely. Even when it seems that there is no active rejection, there may be more subtle chronic rejection that consists of a growth of tissue, something like scar tissue, which causes blockage of the blood vessels of the heart. The blockage of the vessels is the process that ultimately causes the transplanted heart to fail. It is this chronic rejection that is the major limiting factor for the long-term success of heart transplantation.
Unfortunately, immunosuppression is a double-edged sword. While immunosuppression blocks rejection, because it suppresses the immune system, transplant patients are more susceptible to infection and cancers of various types. Among older transplantation patients, as survival has improved, more patients are eventually dying from cancers.
How does a heart transplant patient know if he or she is rejecting the donor organ or developing an infection?
This is not an easy question to answer because many of the symptoms and signs of rejection and infection are the same. These include:
- malaise (feeling lousy),
- fever, and
- "flu-like symptoms", such as chills, headaches, dizziness, diarrhea, nausea and/or vomiting.
The more specific symptoms and signs of infection will vary greatly depending upon the site of infection within the body. Transplant patients who experience any of these findings need to seek medical attention immediately. The transplant physician will then do tests to determine whether the transplanted heart is functioning normally or not. If there is no evidence of rejection, a thorough search for infection will be performed so that the patient can be treated appropriately.
How is rejection of the organ diagnosed and monitored?
Currently, the gold standard for monitoring rejection is the endomyocardial biopsy. This is a simple operation for the experienced cardiologist and can be done as an outpatient procedure. First, a catheter is put into the jugular vein in the neck. From there, the catheter is advanced into the right side of the heart (right ventricle) using an x-ray method calledfluoroscopy for guidance. The catheter has a bioptome at its end, a set of two small cups which can be closed to pinch off and remove small samples of heart muscle. The tissue is processed and placed on glass slides to be reviewed under the microscope by a pathologist. Based on the findings, the pathologist can determine whether or not there is rejection.
Immunosuppressive therapy is then adjusted, for example, increased if rejection is present. Investigators have tried to develop less invasive methods to monitor for rejection. There is a new high-tech analysis that can be done in a sample of blood that is very promising and much easier for the patient than the endomyocardial biopsy. This test looks at the expression of specific genes in cells in the blood. The amount of expression of key genes indicates whether or not rejection is occurring. While this method has not replaced the endomyocardial biopsy as the gold standard, it has decreased the frequency of biopsies for many patients.
Why aren't more heart transplants done?
It's not easy to qualify for a heart transplant. One has to have a very bad heart but an otherwise healthy body. However, the major limiting factor is the availability of donor hearts. For many reasons, individuals and families refuse to donate organs that could be life-saving to others. Sometimes, even when an organ is available, there is no good match. Other times, there is no way to get the heart to a suitable recipient in time for the organ to still be viable. Cost is another reason, although less frequent, why more heart transplants aren't done. The cost is always at least a few hundred thousand dollard. Not all insurers will pay for heart transplant. The longer the recipient lives, the more expensive the transplant. Of course, if the heart lasts longer, the benefit is also greater to the patient and to society.
What is the future of heart transplant?
There are several ways to help patients with end-stage heart disease. One is to get more donors for heart transplant. This will require teaching people the benefits of transplantation in hope of changing society's attitudes. Better methods of preserving organs and preventing and treating rejection are constantly being developed. In the end, however, there will never be enough donor hearts. Indeed, artificial hearts already exist but have a limited life-span. Patients with artificial hearts are at high risk of developing infection and blood clots related to the device. Better devices are being developed all the time. What about the use of animal organs, also called xenotransplantation? These organs are too "foreign" and thus the problems with rejection are currently insurmountable.
Healthy Heart Resources
Mancini, Donna, M.D. "Indications and contraindications for cardiac transplantation." UptoDate. Updated Mar. 21, 2016
Heart Transplant - Indications
Have you or a loved one received a heart transplant? What were the circumstances?Post View 1 Comment
Heart Transplant - Complications
Did you or someone you know experience heart transplant complications? What were your experiences?Post
Heart Transplant - Organ Donation
Are you an organ donor? Why or why not?Post
Top Heart Transplant Related Articles
Cardiomyopathy (Dilated)Dilated Cardiomyopathy is a condition where the heart's ability to pump blood is decreased because the heart's main pumping chamber is enlarged and weakened. Symptoms of dilated cardiomyopathy include chest pain, heart failure, swelling of the lower extremities, fatigue, weight gain, fainting, palpitations, dizziness and blood clots.
Cardiomyopathy (Restrictive)Restrictive cardiomyopathy, the rarest form of cardiomyopathy, is a condition in which the walls of the lower chambers of the heart (the ventricles) are abnormally rigid and lack the flexibility to expand as the ventricles fill with blood. The pumping or systolic function of the ventricle may be normal but the diastolic function (the ability of the heart to fill with blood) is abnormal. Therefore, it is harder for the ventricles to fill with blood, and with time, the heart loses the ability to pump blood properly, leading to heart failure.
Congestive Heart Failure (CHF) OverviewCongestive heart failure (CHF) refers to a condition in which the heart loses the ability to function properly. Heart disease, high blood pressure, diabetes, myocarditis, and cardiomyopathies are just a few potential causes of congestive heart failure. Signs and symptoms of congestive heart failure may include fatigue, breathlessness, palpitations, angina, and edema. Physical examination, patient history, blood tests, and imaging tests are used to diagnose congestive heart failure. Treatment of heart failure consists of lifestyle modification and taking medications to decrease fluid in the body and ease the strain on the heart. The prognosis of a patient with congestive heart failure depends on the stage of the heart failure and the overall condition of the individual.
Cosmetic Surgery PicsThinking about getting plastic surgery? Check out before and after pictures of popular cosmetic surgery procedures, including: liposuction, tummy tuck, breast implants, rhinoplasty (nose job), neck lift, and more.
Heart failure (congestive) is caused by many conditions including coronary artery disease, heart attack, cardiomyopathy, and conditions that overwork the heart. Symptoms of heart failure include
- congested lungs,
- fluid and water retention,
- fatigue and weakness, and
- rapid or irregular heartbeats.
There are two types of congestive heart failure, systolic or left-sided heart failure; and diastolic or right-sided heart failure. Treatment, prognosis, and life-expectancy for a person with congestive heart failure depends upon the stage of the disease.
Illustrations of the HeartThe muscle that pumps blood received from veins into arteries throughout the body. See a picture of the Heart and learn more about the health topic.
Heart: How the Heart WorksThe heart is a very important organ in the body. It is responsible for continuously pumping oxygen and nutrient-rich blood throughout your body to sustain life. It is a fist-sized muscle that beats (expands and contracts) 100,000 times per day, pumping a total of five or six quarts of blood each minute, or about 2,000 gallons per day.
HemapheresisApheresis (hemapheresis, pheresis) is a process of removing a specific component from the blood of a donor or patient that contains disease-provoking elements. Forms of apheresis include:
- leukapheresis or leukopheresis,
- lymphopheresis or lymphapheresis, and
- myasthenia gravis,
- severe rheumatoid arthritis,
- vacuities, and more.
mycophenolate mofetil hydrochloride-injection
mycophenolate mofetil-oralMycophenolate mofetil (CellCept) is a drug prescribed for the prophylaxis of organ rejection in people receiving kidney, heart, or liver transplants. Side effects, drug interactions, warnings, precautions, dosing, storage, pregnancy, and breastfeeding safety information should be reviewed prior to taking this drug.
Myocardial BiopsyA myocardial biopsy can also be referred to as a heart biopsy or a cardiac biopsy. This is an invasive procedure to detect heart disease that involves using a bioptome (a small catheter with a grasping device on the end) to obtain a small piece of heart muscle tissue that is sent to a laboratory for analysis.
ShockMedical shock is a life-threatening medical condition. There are several types of medical shock, including:
- septic shock,
- anaphylactic shock,
- cardiogenic shock,
- hypovolemic shock, and
- neurogenic shock.
- heart attack,
- heart failure,
- heavy bleeding (internal and external),
- spinal cord injury,
- severe burns,
- chronic vomiting or
Sudden Cardiac DeathSudden cardiac arrest is an unexpected, sudden death caused by sudden cardiac arrest (loss of heart function). Causes and risk factors of sudden cardiac arrest include (not inclusive):
- abnormal heart rhythms (arrhythmias),
- previous heart attack,
- coronary artery disease,
- high cholesterol,
- Wolff-Parkinson-White Syndrome,
- ventricular tachycardia or ventricular fibrillation after a heart attack,
- congenital heart defects,
- history of fainting,
- heart failure,
- diabetes, and
- drug abuse.
Surgery QuestionsSurgery is the branch of medicine that employs operations in the treatment of disease or injury. Prior to surgery you might consider asking your surgeon questions about the operation (procedure).
Vancomycin-Resistant Enterococci (VRE)Vancomycin-resistant enterococci (VRE) infection is the most common type of infection acquired by patients while hospitalized. Patients at risk for VRE are those who are already ill, and hospitalized, including individuals with diabetes, elderly, ICU patients, kidney failure patients, or patients requiring catheters. Enterococci can survive for months in the digestive tract and female genital tract. Other risk factors for acquiring VRE include those how have been previously treated with vancomycin and combinations of other antibiotics. Treatment of VRE is generally with other antibiotics other than vancomycin. Prevention of VRE can be achieved by proper hand hygiene.