Heart Disease: Heart Transplantation Treatment

A heart transplant is the replacement of a person's diseased heart with a healthy donor's heart. The donor is a person who has died and whose family has agreed to donate their loved one's organs.

In the three decades since the performance of the first human heart transplant in 1967, heart transplantation has changed from an experimental operation to an established treatment for advanced heart disease. Approximately 2,300 heart transplants are performed each year in the U. S.

Why Are Heart Transplants Performed?

A heart transplant procedure is considered when heart failure is so severe that it does not respond to all other therapies, but the person's health is otherwise good. The leading reasons why people receive heart transplants are because they have:

• Dilated cardiomyopathy
• Severe coronary artery disease with scarred heart tissue from a heart attack
• Birth defects of the heart

It is important to note that there are many new innovations for the treatment of heart failure, from new medications to pacemakers and new surgical therapies. When determining your treatment options, it is important to be evaluated by a doctor who specializes in heart failure.

Who Is Considered a Candidate for a Heart Transplant?

People who have advanced (end stage) heart failure, but are otherwise healthy may be considered for a heart transplant.

The following basic questions should be considered by you, your doctor, and your family to determine if heart transplantation is right for you.

• Have all other therapies been tried or excluded?
• Are you likely to die without the transplant?
• Are you in generally good health other than the heart or heart and lung disease?
• Can you adhere to the lifestyle changes, including complex drug treatments and frequent examinations, required after a transplant?

If you answered no to any of the above questions, heart transplantation may not be for you. Also, if you have additional medical problems, such as other severe diseases, active infections, or severe obesity, you most likely will not be considered a candidate for transplant.

What Is the Process for Getting a Heart Transplant?

In order to get a heart transplant, you must first be placed on a transplant list. But, before you can be placed on the transplant list, you must go through a careful screening process. A team of heart doctors, nurses, social workers and bioethicists review your medical history, diagnostic test results, social history and psychological test results to see if you are able to survive the procedure and then comply with the continuous care needed to live a long healthy life.

Once you are approved, you must wait for a donor to become available. This process can be long and stressful. A supportive network of family and friends is needed to help you through this time. The health care team will monitor you closely to keep your heart failure in control. The hospital must know where to contact you at all times should a heart become available.

How Are Donors Found?

Donors for heart transplants are individuals who may have recently died or become brain dead, which means that although the their body is being kept alive by machines, the brain has no sign of life. Many times, these donors died as a result of a car accident, severe head injury or a gunshot wound.

Donors give their permission for organ donation before their death; the donor's family must also give consent for organ donation at the time of the donor's death.

Donor organs are located through the United Network for Organ Sharing (UNOS) computerized national waiting list. This waiting list assures equal access and fair distribution of organs when they become available. When a heart becomes available for transplantation, it is given to the best possible match, based on blood type, body size, UNOS status (based on the recipient's medical condition) and the length of time the recipient has been waiting. The race and gender of the donor have no bearing on the match.

Unfortunately, not enough hearts are available for transplant. At any given time, almost 3,500 to 4,000 people are waiting for a heart or heart-lung transplant. A person may wait months for a transplant and more than 25% do not live long enough.

Many people who are waiting for transplantation have mixed feelings because they are aware that someone must die before an organ becomes available. It may help to know that many donor families feel a sense of peace knowing that some good has come from their loved one's death.

What Happens During the Procedure?

Once a donor heart becomes available, a surgeon from the transplant center goes to harvest the donor heart. The heart is cooled and stored in a special solution while being taken to the recipient. The surgeon will make sure the donor heart is in good condition before beginning the transplant surgery. The transplant surgery will take place as soon as possible after the donor heart becomes available.

During the operation, the patient is placed on a heart-lung machine. This machine allows the body to receive vital oxygen and nutrients from the blood even though the heart is being operated on.

Surgeons then remove the patient's heart except for the back walls of the atria, the heart's upper chambers. The backs of the atria on the new heart are opened and the heart is sewn into place.

Surgeons then connect the blood vessels, allowing blood to flow through the heart and lungs. As the heart warms up, it begins beating. Surgeons check all the connected blood vessels and heart chambers for leaks before removing the patient from the heart-lung machine.

It is a complicated operation that lasts from 4 to 10 hours.

Most patients are up and around within a few days after surgery, and if there are no signs of the body immediately rejecting the organ, patients are allowed to go home within 7 to 16 days.

QUESTION

In the U.S., 1 in every 4 deaths is caused by heart disease. See Answer

What Are the Risks Associated With Transplants?

The most common causes of death following a transplant are infection and rejection. Patients on drugs to prevent transplant rejection are at risk for developing kidney damage, high blood pressure, osteoporosis (a severe thinning of the bones, which can cause fractures), and lymphoma (a type of cancer that affects cells of the immune system).

Coronary artery disease develops in almost half the patients who receive transplants. And many of them have no symptoms, such as angina, because they have no sensations in their new hearts.

What Is Rejection?

Normally, the body's immune system protects the body from infection. This occurs when cells of the immune system move around the body, checking for anything that looks foreign or different from the body's own cells.

Rejection occurs when the body's immune cells recognize the transplanted heart as different from the rest of the body and attempts to destroy it. If left alone, the immune system would damage the cells of a new heart and eventually destroy it.

To prevent rejection, patients receive several drugs called immunosuppressants. These drugs suppress the immune system so that the new heart is not damaged. Because rejection can occur anytime after a transplant, immunosuppressive drugs are given to patients the day before their transplant and thereafter for the rest of their lives.

To avoid rejection, heart transplant recipients must strictly adhere to their immunosuppressant drug regimen. Researchers are continually working on safer, more effective and well-tolerated immunosuppressant medications. However, too much immunosuppression can lead to serious infections. Without an active enough immune system, a patient can easily develop severe infections. For this reason, medications are also prescribed to fight infections.

The myocardial biopsy: Heart transplant recipients are carefully monitored for signs of rejection. Doctors frequently take samples of small pieces of the transplanted heart to inspect under a microscope. Called a biopsy, this procedure involves advancing a thin tube called a catheter through a vein to the heart. At the end of the catheter is a bioptome, a tiny instrument used to snip off a piece of tissue. If the biopsy shows damaged cells, the dose and kind of immunosuppressive drug may be changed. Biopsies of the heart muscle are usually performed weekly for the first 3 to 6 weeks after surgery, then every 3 months for the first year, and then yearly thereafter.

It is vital for you to be aware of the possible signs of rejection and infection so you can report them to your doctors and be treated immediately.

Signs of rejection include:

• Fever over 100°F (38°C)
• "Flu-like" symptoms such as chills, aches, headaches, dizziness, nausea and/or vomiting
• Shortness of breath
• New chest pain or tenderness
• Fatigue or generally feeling "lousy"
• Elevation in blood pressure

With too much immunosuppression, the immune system can become sluggish, and a patient can easily develop severe infections. For this reason, medications are also prescribed to fight infections. It is vital for you to be aware of the possible signs of rejection and infection so you can report them to your health care providers and be treated immediately.

Warning signs of infection include:

• Fever over 100°F (38°C)
• Sweats or chills
• Skin rash
• Pain, tenderness, redness or swelling
• Wound or cut that won't heal
• Red, warm or draining sore
• Sore throat, scratchy throat or pain when swallowing
• Sinus drainage, nasal congestion, headaches or tenderness along upper cheekbones
• Persistent dry or moist cough that lasts more than two days
• White patches in your mouth or on your tongue
• Nausea, vomiting or diarrhea
• Flu-like symptoms (chills, aches, headache or fatigue) or generally feeling "lousy"
• Trouble urinating: pain or burning, constant urge or frequent urination
• Bloody, cloudy or foul-smelling urine

If you have any of these symptoms of rejection or infection, notify your doctor right away.

Can a Person Lead a Normal Life After a Transplant?

With the exception of having to take lifelong medication to keep the body from rejecting the new heart, many heart transplant recipients lead long and productive lives.

However, there are some things to keep in mind.

Medications. As mentioned, after a heart transplant, patients must take several medications. The most important are those to keep the body from rejecting the transplant. These medications, which must be taken for life, can cause significant side effects, including high blood pressure, fluid retention, excessive hair growth, bone thinning osteoporosis and possible kidney damage. To combat these problems, additional drugs are often prescribed.

Exercise. Heart transplant recipients can exercise and are encouraged to exercise to improve the function of the heart and to avoid weight gain. However, due to changes in the heart related to the transplant, patients should speak to their doctor or cardiac rehabilitation specialist before beginning an exercise program. Because the nerves leading to the heart are cut during the operation, the transplanted heart beats faster (about 100 to 110 beats per minute) than the normal heart (70 beats per minute). The new heart also responds more slowly to exercise and doesn't increase its rate as quickly as before.

Diet. After transplant, the patient may need to follow a special diet, which may involve many of the same dietary changes made prior to surgery. A low-fat, low-sodium diet will decrease the risk of heart disease, high blood pressure and fluid retention. Your doctor will discuss your specific dietary needs, and a registered dietitian can help you understand specific dietary guidelines.

How Long Can a Person Live After a Heart Transplant?

How long you live after a transplant depends on many factors, including age, general health and response to the transplant. Recent figures show that 75% of heart transplant patients live at least 5 years after surgery. Nearly 85% return to work or other activities they previously enjoyed. Many patients enjoy swimming, cycling, running or other sports.

Is a Heart Transplant Covered by Insurance?

In most cases, the costs related to a heart transplant are covered by health insurance. More than 80% of commercial insurers and 97% of Blue Cross/Blue Shield plans offer coverage for heart transplants. Medicaid programs in 33 states and the District of Columbia also reimburse for transplants. Medicare will cover heart transplants in Medicare-eligible patients if the operation is performed at an approved center.

It is important to do your own research and find out if your specific health insurance provider covers this treatment, and if you will be responsible for any costs.

Reviewed by the doctors at The Cleveland Clinic Heart Center.
Edited by Charlotte E. Grayson, MD, June 2004, WebMD.

WebMD Medical Reference