Friday, December 23, 2011

Heart Transplants

          A heart transplant is surgery to remove a person’s diseased heart and replace it with a healthy heart from a deceased donor. Ninety percent of heart transplants are done on patients who have end-stage heart failure.
Heart failure is a condition in which the heart is damaged or weakened and can’t pump enough blood to meet the body’s needs. End-stage means the condition has become so severe that all treatments, other than heart transplant, have failed.
Heart transplants are done as a life-saving measure for end-stage heart failure when medical treatment and less drastic surgery have failed.

       Because donor hearts are in short supply, patients who need a heart transplant go through a careful selection process. They need to be sick enough to need a new heart, yet healthy enough to receive it. Survival rates for people receiving heart transplants have improved over the past 5 to 10 years, especially in the first year after the transplant.
About 88 percent of patients survive the first year after transplant surgery, and 72 percent survive for 5 years. The 10-year survival rate
Excerpted from “Heart Transplant,” by the National Heart, Lung, and Blood Institute (NHLBI,, part of the National Institutes of Health, October 2009.
is close to 50 percent, and 16 percent of heart transplant patients survive 20 years.
After the surgery, most heart transplant recipients (about 90 percent) can come close to resuming their normal lifestyles. However, fewer than 40 percent return to work for many different reasons.
The Heart Transplant Process
The heart transplant process starts when doctors refer patients who have end-stage heart failure to a heart transplant center for evaluation. Patients found to be eligible for a heart transplant are placed on a waiting list for a donor heart.
Heart transplant surgery is done in a hospital when a suitable donor heart is found. After the transplant, patients are started on a lifelong health care plan. The plan involves multiple medicines and frequent medical checkups.
When a Heart Transplant Is Needed
Referral to a Heart Transplant Center
Most patients referred to a heart transplant center have end-stage heart failure. Of these patients, close to half have heart failure as a result of coronary heart disease (also called coronary artery disease).
Others have heart failure caused by hereditary conditions, viral infections of the heart, or damaged heart valves and muscles. (Some medicines, alcohol, and pregnancy can damage the heart valves and muscles.)
Most patients considered for a heart transplant have tried other, less drastic treatments and have been hospitalized a number of times for heart failure.
Eligibility for a Heart Transplant
The heart transplant specialists at the heart transplant center will determine whether a patient is eligible for a transplant. Specialists often include the following:
• Cardiologist (a doctor who specializes in diagnosing and treating heart problems)
• Cardiovascular surgeon (a doctor who does the transplant surgery)
• Transplant coordinator (a person who makes arrangements for the surgery, such as transportation of the donor heart)
• Social worker
• Dietitian
• Psychiatrist
In general, patients selected for heart transplants have severe end-stage heart failure, but are healthy enough to have the transplant. Heart failure is considered end stage when all possible treatments—such as medicine, implanted devices and surgery—have failed. Patients who have the following conditions might not be candidates for heart transplant surgery because the procedure is less likely to be successful.
• Advanced age
• Poor blood circulation throughout the body, including the brain
• Kidney, lung, or liver diseases that can’t be reversed
• History of cancer or malignant tumors
• Inability or unwillingness to follow lifelong medical instructions after a transplant
• Pulmonary hypertension (high blood pressure in the lungs) that can’t be reversed
• Active infection throughout the body
Although there’s no widely accepted upper age limit for a heart transplant, most transplant surgery is done on patients younger than 70 years old.
What to Expect before a Heart Transplant
The Heart Transplant Waiting List
Patients who are eligible for a heart transplant are placed on a waiting list for a donor heart. This waiting list is part of a national allocation system for donor organs run by the Organ Procurement and Transplantation Network (OPTN).
OPTN has policies in place to make sure donor hearts are given out fairly. These policies are based on urgency of need, the organs that are available for transplant, and the location of the patient who is receiving the heart (the recipient). Organs are matched for blood type and size of donor and recipient.
The Donor Heart
Guidelines on how a donor heart is selected require that the donor meet the legal requirement for brain death and that the appropriate consent forms are signed.
Guidelines suggest that the donor be younger than 65 years old, have little or no history of heart disease or trauma to the chest, and not be exposed to hepatitis or HIV. The guidelines also recommend that the donor heart not be without blood circulation for more than 4 hours.
Waiting Times
Approximately 3,000 people in the United States are on the waiting list for a heart transplant on any given day. About 2,000 donor hearts are available each year. Wait times vary from days to several months and will depend on a recipient’s blood type and condition.
A person may be taken off the list for some time if he or she has a serious medical event such as a stroke, infection, or kidney failure.
Time spent on the waiting list plays a part in who receives a donor heart. For example, if a donor heart becomes available and two recipients have equal need, the recipient who has been waiting longer usually will get the heart.
Ongoing Medical Treatment
Patients on the waiting list for a donor heart receive ongoing treatment for heart failure and other medical conditions. Treating arrhythmias (irregular heartbeats), for example, is very important because they can cause sudden cardiac arrest in people who have heart failure.
As a result, many transplant centers will place implantable cardio verter defibrillators (ICDs) in patients before surgery. An ICD is a small device that’s placed in the chest or abdomen to help control life-threatening arrhythmias.
Another treatment that may be recommended to waiting list patients is an implanted mechanical pump called a ventricular assist device (VAD). This device helps the heart pump blood. Regular outpatient care for waiting list patients may include frequent exercise testing, assessing the strength of the heartbeat, and right cardiac catheterization (a test to measure blood pressure in the right side of the heart).
Contact with the Transplant Center during the Wait
People on the waiting list often are in close contact with their trans-plant centers. Most donor hearts must be transplanted within 4 hours after removal from the donor.
At some heart transplant centers, recipients get a pager so the center can contact them at any time. They’re asked to tell the trans-plant center staff if they’re going out of town. Recipients often need to be prepared to arrive at the hospital within 2 hours of being notified about a donor heart.
Not all patients who are called to the hospital will get a heart trans-plant. Sometimes, at the last minute, doctors find that a donor heart isn’t suitable for a patient. Other times, patients from the waiting list are called to come in as possible substitutes, in case something hap-pens with the selected recipient.
What to Expect during a Heart Transplant
Just before the heart transplant surgery, patients will get general anesthesia. The term “anesthesia” refers to a loss of feeling and aware-ness. General anesthesia temporarily puts you to sleep.
A bypass machine is hooked up to the arteries and veins of the heart. The machine pumps blood through the patient’s lungs and body while the diseased heart is removed and the donor heart is sewn into place.
What to Expect after a Heart Transplant In the Hospital
The amount of time a heart transplant recipient spends in the hospital will vary with each person. It often involves 1 to 2 weeks in the hospital and 3 months of monitoring by the transplant team at the heart transplant center.
Monitoring may include frequent blood tests, lung function tests, EKGs (electrocardiograms), echocardiograms, and biopsies of the heart tissue.
A heart biopsy is a standard test used to see whether your body is rejecting the new heart. It might be done often in the weeks after a transplant.
During a heart biopsy, a tiny grabbing device is inserted into a vein in the neck or groin (upper thigh). The device is threaded through the vein to the right atrium of the new heart to take a small tissue sample. The tissue sample is checked for signs of rejection.
While in the hospital, your health care team may recommend that you start a cardiac rehabilitation (rehab) program. Cardiac rehab is a medically supervised program that helps improve the health and well-being of people who have heart problems.
Cardiac rehab includes counseling, education, and exercise training to help you recover. Rehab may start with a member of the rehab team helping you sit up in a chair or take a few steps. Over time, you’ll increase your activity level.
Watching for Signs of Rejection
The new heart is a foreign body that your immune system may attack if you’re not getting enough medicine to suppress your immune system after the surgery.
You and the transplant team will work together to protect the new heart by watching for signs of rejection. These signs include the following:
• Shortness of breath
• Fever
• Fatigue (tiredness)
• Weight gain (retaining fluid in the body)
• Reduced amounts of urine (problems in the kidneys can cause this)
You and the team also will work together to manage the transplant medicines and their side effects, prevent infections, and continue treatment of ongoing medical conditions.
You may be asked to check your temperature, blood pressure, and pulse when you go home.
Preventing Rejection
You’ll need to take medicine to suppress your immune system so that it doesn’t reject the new heart.
These transplant medicines are called immunosuppressants. They’re a combination of medicines that are tailored to your situation. Often, they include cyclosporine, tacrolimus, MMF (mycophenolate mofetil), and steroids such as prednisone.
Your doctors may need to change or adjust your transplant medicines if they aren’t working well or if you have too many side effects.
Managing Transplant Medicines and Their Side Effects
You’ll have to manage multiple medicines. It’s helpful to set up a routine for taking medicines at the same time each day and for refilling prescriptions. It’s crucial to never run out of medicine. Always using the same pharmacy may help.
Keep a list of all your medicines with you at all times in case of an accident. When traveling, keep extra doses of medicine with you, not packed in your luggage. Bring your medicines with you to all doctor visits.
Side effects from medicines can be serious. Side effects include risk of infection, diabetes, osteoporosis (thinning of the bones), high blood pressure, kidney disease, and cancer—especially lymphoma and skin cancer.
Discuss any side effects of the medicines with your transplant team. Your doctors may change or adjust your medicines if you’re having problems. Make sure your doctors know all of the medicines you’re taking.
Preventing Infection
Some transplant medicines can increase your risk of infection. You may be asked to watch for signs of infection, including fever, sore throat, cold sores, and flu-like symptoms.
Signs of possible chest or lung infections could include shortness of breath, cough, and a change in the color of sputum (spit). The incision (cut) from your surgery must be checked for redness, swelling, or drainage. It’s especially important to look for signs of infection because transplant medicines often can mask these signs.
Talk to your doctor about what steps you should take to reduce your risk of infection. For example, your doctor may recommend that you avoid contact with animals or crowds of people in the first few months after your transplant.
Regular dental care also is important. Your doctor may prescribe antibiotics before any dental work to prevent infections.
Many successful pregnancies have occurred after heart transplant surgeries; however, special care is important. If you’ve had a heart transplant, talk with your doctor before planning a pregnancy.
Emotional Issues and Support
Having a heart transplant may cause fear, anxiety, and stress. While you’re waiting for a heart transplant, you may worry that you won’t live long enough to get a new heart. After surgery, you may feel overwhelmed, depressed, or worried about complications.
All of these feelings are normal for someone going through major heart surgery. It’s important to talk about how you feel with your health care team. Talking to a professional counselor also can help. If you’re feeling very depressed, your health care team or counselor may prescribe medicines to make you feel better.
Support from family and friends also can help relieve stress and anxiety. Let your loved ones know how you feel and what they can do to help you.
Risks of a Heart Transplant
Although heart transplant surgery is a life-saving measure, it has many risks. Careful monitoring, treatment, and regular medical care can prevent or help manage some of these risks.
Risks of heart transplant include the following:
• Failure of the donor heart
• Complications from medicines
• Infection
• Cancer
• Problems that arise from not following a lifelong health care plan
Failure of the Donor Heart
Over time, the new heart may fail due to the same reasons that caused the original heart to fail. Failure of the donor heart also can occur if your body rejects the donor heart or if cardiac allograft vasculopathy (CAV) develops. CAV is a blood vessel disease. Patients who have a heart transplant that fails can be considered for another transplant (called a retrains plant).
Primary Graft Dysfunction
The most frequent cause of death in the first 30 days after transplant is primary graft dysfunction. This occurs if the new donor heart fails and isn’t able to function.
Factors such as shock or trauma to the donor heart or narrowed blood vessels in the recipient’s lungs can cause primary graft dysfunction. Medicines (for example, inhaled nitric oxide and intravenous nitrates) may be used to treat this condition.
Rejection of the Donor Heart
Rejection is one of the leading causes of death in the first year after transplant. The recipient’s immune system sees the new heart as a foreign body and attacks it.
During the first year, 25 percent of heart transplant patients have signs of a possible rejection at least once. Half of all possible rejections happen in the first 6 weeks after surgery, and most happen with-in 6 months of surgery.
Cardiac Allograft Vasculopathy
CAV is a chronic (ongoing) disease in which the walls of the coronary arteries in the new heart become thick, hard, and lose their elasticity. CAV can destroy blood circulation in the new heart and cause serious damage.
CAV is a leading cause of donor heart failure and death in the years following transplant surgery. CAV can cause heart attack, heart failure, dangerous arrhythmias, and sudden cardiac arrest. To detect CAV, your doctor may recommend coronary angiography yearly and other tests, such as stress echocardiography or intravascular ultrasound.
Complications from Medicines
Taking daily medicines that stop the immune system from attacking the new heart is absolutely critical, even though the medicine combinations have serious side effects.
Cyclosporine and other medicines can cause kidney damage. Kidney damage affects more than 25 percent of patients in the first year after transplant. Five percent of transplant patients will develop end stage kidney disease within 7 years.
When the immune system—the body’s defense system—is suppressed, the risk of infection increases. Infection is a major cause of hospital admission for heart transplant patients and a leading cause of death in the first year after transplant.
Suppressing the immune system leaves patients at risk of cancers and malignancies. Malignancies are a major cause of late death in heart transplant patients, accounting for nearly 25 percent of heart transplant deaths 3 years after transplant.
The most common malignancies are tumors of the skin and lips (patients at highest risk are older, male, and fair-skinned) and malignancies in the lymph system, such as non-Hodgkin lymphoma.
Other Complications
High blood pressure develops in more than 70 percent of heart transplant patients in the first year after transplant and in nearly 95 percent of patients within 5 years.
High levels of cholesterol and triglycerides in the blood develop in more than 50 percent of heart transplant patients in the first year after transplant and in 84 percent of patients within 5 years.
Osteoporosis can develop or worsen in heart transplant patients. This condition thins and weakens the bones.
Complications from Not Following a Lifelong Health Care Plan
Not following a lifelong health care plan increases the risk of all heart transplant complications. Heart transplant patients are asked to closely follow their doctors’ instructions and check their own health status throughout their lives.
Lifelong health care includes taking multiple medicines on a strict schedule, watching for signs and symptoms of complications, keeping all medical appointments, and stopping unhealthy behaviors (such as smoking).


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