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Transplant Surgeries


Heart Transplant

Heart Transplant Treatment in India

Overview

A heart transplant is the surgical replacement of a patients' diseased heart with a donor's healthy heart. A donor is a person who has died and pre-registered as a heart donor, or his family has agreed to donate his organs.

Since the positive outcome of the first human heart transplant in 1967, the heart transplant procedure has changed to an established treatment for advanced heart disease.

Indications for Heart Transplant

A heart transplant is usually reserved for people who have tried medications or other surgeries, but their conditions haven't sufficiently improved.

Some conditions may eventually require a heart transplant: 

  • Congestive Heart Failure: In this condition, the heart muscle gets weaker, and it fails to pump blood efficiently.
  • Coronary heart disease: It is a build-up of fatty substances in the arteries supplying blood to the heart, which block or interrupt blood flow to the heart.
  • Cardiomyopathy: During this, the walls of the heart have become stretched, thickened or stiff.
  • Congenital heart disease: These are the birth defects that affect the normal workings of the heart.

 Why Heart transplantation is done?

Heart transplantation is performed when other treatments for heart problems haven't worked. If not treated, it may lead to heart failure. In adults, heart failure can be caused by several conditions:

  • Coronary artery disease
  • A weakening of the heart muscle (cardiomyopathy)
  • Congenital heart defect (heart problem with birth)
  • Failure of a previous heart transplant
  • Heart valve disease
  • Amyloidosis
  • Dangerous recurring abnormal heart rhythms (ventricular arrhythmias) that are not controlled by other treatments 

Another organ transplant (liver, lung or kidney) may be performed at the same time as a heart transplant in people with certain conditions at select medical centers. It is known as multi organ transplants.

 Multiorgan transplants include: 

  • Heart-liver transplant: This procedure is an option for people with particular heart and liver conditions.
  • Heart-kidney transplant: This procedure can be an option for people with heart failure in addition to kidney failure.
  • Heart-lung transplant: In rare circumstances, doctors may suggest this procedure for people with severe heart and lung diseases if the conditions aren't able to be treated by only a lung transplant or heart transplant. 

Factors that may affect the eligibility for a heart transplant

A heart transplant can't be considered as the right treatment for everyone. There may be certain factors that indicate whether you're not the right candidate for a heart transplant. However, each case is considered individually by the transplant center, but a heart transplant may not be regarded as appropriate if a patient: 

  • Is of advanced age as it may interfere with the ability to recover after the surgery.
  • Has another medical condition that could shorten your life, even after receiving a donor heart, such as a serious liver, kidney or lung disease.
  • Has an active infection
  • Has a recent medical history of cancer
  • Are not willing to make lifestyle changes necessary to keep your donor heart-healthy, such as not drinking alcohol or not smoking 

What can you expect?

 Before procedure 

  • Cardiologist determines whether you are eligible for a heart transplant or not. Your Psychological and social evaluation is also considered.
  • Based on your assessment, if you are considered suitable for a heart transplant, then you will be registered onto the transplant waiting list.
  • Diagnostic test- These tests will help to access the overall health of the recipient.
  • Blood test: Your blood tests are done to determine a good donor match.
  • Test such as ultrasound, x-ray, CT scan, pulmonary function test and dental examination are done.
  • Others- several immunizations are given to prevent infections. 

During Procedure 

  • Heart transplantation usually takes between 4-6 hours.
  • Once a donor's heart becomes available, a surgeon removes the heart from the donor's body, and it is stored in a special solution. The transplant surgery needs to be performed at the earliest after the donor's heart removed from his body.
  • The procedure is performed under general anaesthesia.
  • The patient is placed on a heart-lung machine for the surgery.
  • The surgeon makes an incision in the sternum to get access to the heart.
  • The diseased heart is removed.
  • The donor's healthy heart is placed in the patient's body, and blood vessels are connected.
  • After the completion of the procedure, the heart will get restarted.
  • When the heart begins to pump the blood, and the condition is stable, the heart-lung machine will be turned off.
  • The tube is attached to drain fluid from the heart.
  • The sternum will be joined and sutured together with wires.

  After procedure 

  • After the operation, the patient is moved to the intensive care unit.
  • A ventilator is attached so that breathing will be assisted.
  • To check the functioning of the new heart, the blood samples will be taken frequently.
  • Immunosuppressant medicine will be given.
  • You will have a wound along the sternum
  • It is important to keep the surgical area clean and dry. The patient is advised to avoid strenuous activities until the sternum is fully healed, which can take up to three or four months.
  • There will follow- up after the surgery, which may include a blood test, X-Ray or other tests.
  • You are advised to attend all your appointments; this allows the doctor to monitor your health and alter medications if needed.
  • You should take the prescribed medication on time.
  • After a heart transplant, the patient should make the necessary   lifestyle changes such as Don't smoke (help to keep your heart healthy), eat a healthy, balanced diet, control cholesterol and blood pressure, maintain a healthy weight by doing regular physical activity
  • Maintain personal and food hygiene to avoid infection. 

 

The Heart Transplant Waiting List

Patients who are eligible for a heart transplant are added to a waiting list for a donor heart. This waiting list is part of a national allocation system for donor organs. The Organ Procurement and Transplantation Network (OPTN) runs this system.

OPTN has policies in place to make sure donor hearts are given out fairly. These policies are based on urgency of need, available organs, 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 for how a donor heart is selected require that the donor meet the legal requirement for brain death and that the correct consent forms are signed.

Guidelines suggest that the donor should 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 recommend that the donor heart should not be without blood circulation for more than 4 hours.

Waiting Times

There could be a waiting time of upto 3 months to get a donor heart.

Just before heart transplant surgery, the patient will get general anesthesia. The term "anesthesia" refers to a loss of feeling and awareness. General anesthesia temporarily puts you to sleep.

Surgeons use open-heart surgery to do heart transplants. The surgeon will make a large incision (cut) in the patient’s chest to open the rib cage and operate on the heart.

A heart-lung bypass machine is hooked up to the heart’s arteries and veins. The machine pumps blood through the patient's lungs and body during the surgery.

The surgeon removes the patient’s diseased heart and sews the healthy donor heart into place. The patient’s aorta and pulmonary arteries are not replaced as part of the surgery.

Heart Transplant

Heart Transplant

Figure A shows where the diseased heart is cut for removal. Figure B shows where the healthy donor heart is sutured (stitched) to the recipient's arteries and veins.

Heart transplant surgery usually takes about 4 hours. Patients often spend the first days after surgery in the intensive care unit of the hospital.

Staying in the Hospital

The amount of time a heart transplant recipient spends in the hospital varies. Recovery 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 that can show whether your body is rejecting the new heart. This test is often done 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 suggest 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

Your body will regard your new heart as a foreign object. You’ll need medicine to prevent your immune system from attacking the heart.

You and the transplant team will work together to protect the new heart. You’ll watch for signs and symptoms that your body is rejecting the organ. These signs and symptoms include:

  • Shortness of breath
  • Fever
  • Fatigue (tiredness)
  • Weight gain (retaining fluid in the body)
  • Reduced amounts of urine (problems in the kidneys can cause this sign)

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.

Your doctors may ask you 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 medicines are called immunosuppressants.

Immunosuppressants are 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 after having a heart transplant. 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 include shortness of breath, cough, and a change in the color of sputum (spit).

Watching closely for these signs is important because transplant medicines can sometimes mask them. Also, pay close attention to signs of infection at the site of your incision (cut). These signs can include redness, swelling, or drainage.

Ask your doctor what steps you should take to reduce your risk of infection. For example, your doctor may suggest 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 or dentist may prescribe antibiotics before any dental work to prevent infections.

Pregnancy

Many successful pregnancies have occurred after heart transplant surgeries; however, special care is needed. 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. Talk about how you feel with your health care team. Talking to a professional counselor also can help.

If you’re very depressed, your doctor may recommend medicines or other treatments that can improve your quality of life.

Joining a patient support group may help you adjust to life after a heart transplant. You can see how other people who have had the surgery have coped with it. Talk with your doctor about local support groups or check with an area medical center.

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.

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.

The risks of having a heart transplant include:

  • Failure of the donor heart
  • Complications from medicines
  • Infection
  • Cancer
  • Problems that arise from not following a lifelong care plan after surgery

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 retransplant).

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 narrow blood vessels in the recipient's lungs can cause primary graft dysfunction. Doctors may prescribe medicines (for example, inhaled nitric oxide and intravenous nitrates) 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 object and attacks it.

During the first year, heart transplant patients have an average of one to three episodes of rejection. Rejection is most likely to occur within 6 months of the transplant 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 less stretchy. 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 crucial, even though the medicines 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. 

Infection

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. It also is a leading cause of death in the first year after transplant.

Cancer

Suppressing the immune system leaves patients at risk for cancers and malignancies. Malignancies are a major cause of late death in heart transplant patients.

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's 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 Care Plan

Not following a lifelong 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, going to all medical checkups, and making healthy lifestyle changes (such as quitting smoking).



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