Heart
Transplantation
(Transplant-Heart,
Heart Transplant, Cardiac Transplant)
What
is a heart transplant?
A heart
transplant is a surgical procedure performed to
remove the diseased heart from a patient and replace
it with a healthy one from an organ donor. In
order to remove the heart from the donor, two
or more physicians must declare the donor brain-dead.
Before
a person can be put on a waiting list for a heart
transplant, a physician makes the determination
that there is no other treatment option available
for the person's heart failure.
About
the heart:
The
heart is the hardest working muscle in the human
body.
Located almost in the center of the chest, the
adult human heart is about the size of two fists
held side-by-side.
At an
average rate of 80 times a minute, the heart beats
about 115,000 times in one day or 42 million times
in a year. During an average lifetime, the human
heart will beat more than 3 billion times - pumping
an amount of blood that equals about 1 million
barrels. Even at rest, the heart is continuously
hard at work.
How
the heart works:
The
cardiovascular system, composed of the heart and
blood vessels, is responsible for circulating
blood throughout your body to supply the body
with oxygen and nutrients.
The
heart is the muscle that pumps blood filled with
oxygen and nutrients through the blood vessels
to the body tissues. It is made up of:
- Four chambers (two
atria and two ventricles) that receive blood
from the body and pump out blood to it.
- The atria receive
blood coming back to the heart.
- The ventricles
pump the blood out of the heart.
- Blood vessels, which
compose a network of arteries and veins that
carry blood throughout the body.
- Arteries transport
blood from the heart to the body tissues.
- Veins carry blood
back to the heart.
- Four valves to prevent
backward flow of blood.
- Each valve is designed
to allow the forward flow of blood and prevent
the backward flow.
- An electrical system
of the heart that stimulates contraction of
the heart muscle.
Heart
transplantation is performed to replace a failing
heart that cannot be adequately treated by other
means.
Congestive
heart failure (CHF):
End-stage
heart failure is a disease in which the heart
muscle is failing severely in its attempt to pump
blood through the body, and in which 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. Heart
failure, also called congestive heart failure,
or CHF, is a condition that occurs when the heart
is unable to pump blood sufficiently. Despite
its name, a diagnosis of heart failure does NOT
mean the heart is about to stop beating. The term
"failure" refers to the fact that the heart muscle
is failing to pump blood in the normal manner
because it has become weakened.
Some
causes of CHF, or weakening of the heart muscle,
may include, but are not limited to, the following:
- heart attack (also
called myocardial infarction, or MI)
- high blood pressure
(hypertension)
- valvular heart disease
- congenital (present
at birth) heart conditions
- cardiac arrhythmias
(irregular heartbeats)
- pulmonary hypertension
(elevated blood pressure within the lungs' blood
vessels)
- alcoholism or drug
abuse
- chronic lung diseases,
such as emphysema or chronic obstructive pulmonary
disease
- cardiomyopathy (an
enlargement of the heart muscle)
- anemia (low red blood
cell count)
There
may be other reasons for your physician to recommend
heart transplantation.
As with
any surgery, complications may occur. Potential
risks associated with heart transplantation may
include, but are not limited to, the following:
- infection
- bleeding during or
after the surgery
- blood clots that can
cause heart attack, stroke, or lung problems
- breathing problems
- kidney failure
- coronary arteriopathy
(similar to coronary artery disease)
The
new heart may be rejected. Rejection is a normal
reaction of the body to a foreign object or tissue.
When a new heart is transplanted into a recipient's
body, the immune system reacts to what it perceives
as a threat and attacks the new organ, not realizing
that the transplanted heart is beneficial. To
allow the transplanted organ to survive in a new
body, medications must be taken to trick the immune
system into accepting the transplant and not attacking
it as a foreign object.
The
medications used to prevent or treat rejection
have side effects. The exact side effects will
depend on the specific medications that are taken.
Contraindications
for heart transplantation include, but are not
limited to, the following:
- current or recurring
infection that cannot be treated effectively
- metastatic cancer -
cancer that has spread from its primary location
to one or more additional locations in the body
- severe medical problems
preventing the ability to tolerate the surgical
procedure
- serious conditions
other than heart disease that would not improve
after transplantation
- noncompliance with
treatment regimen
There
may be other risks depending upon your specific
medical condition. Be sure to discuss any concerns
with your physician prior to the procedure.
Because
of the wide range of information necessary to
determine eligibility for transplant, the evaluation
process is carried out by a transplant team. The
team includes a transplant surgeon, a transplant
cardiologist (physician specializing in the treatment
of the heart), one or more transplant nurses,
a social worker, and a psychiatrist or psychologist.
Additional team members may include a dietician,
a chaplain, and/or an anesthesiologist.
Components
of the transplant evaluation process include,
but are not limited to, the following:
- psychological and
social evaluation : Psychological and social
issues involved in organ transplantation, such
as stress, financial issues, and support by
family and/or significant others are assessed.
These issues can significantly impact the outcome
of a transplant.
- blood tests : Blood
tests are performed to help determine a good
donor match and to help improve the chances
that the donor organ will not be rejected.
- diagnostic tests :
Diagnostic tests may be performed to assess
your lungs as well as your overall health status.
These tests may include x-rays, ultrasound procedures,
computed tomography (CT scan), pulmonary function
tests, and dental examinations. Women may receive
a Pap test, gynecology evaluation, and a mammogram.
- other preparations
: Several immunizations will be given to decrease
the chances of developing infections that can
affect the transplanted heart.
The
transplant team will consider all information
from interviews, your medical history, physical
examination, and diagnostic tests in determining
your eligibility for heart transplantation.
Once
you have been accepted as a transplant candidate,
you will be placed on the United Network for Organ
Sharing (UNOS) list. When a donor organ becomes
available, heart recipients are selected based
on the severity of their condition and their blood
type. You will be notified and told to come to
the hospital immediately so you can be prepared
for the transplant.
The
following steps will precede the transplant:
- Your physician will
explain the procedure to you and offer you the
opportunity to ask any questions that you might
have about the procedure.
- 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 something is not clear.
- You should begin to
fast once you are notified that a heart has
become available.
- You may receive a sedative
prior to the procedure to help you relax.
- The area around the
surgical site may be shaved.
- Based upon your medical
condition, your physician may request other
specific preparation.
Heart
transplantation requires a stay in a hospital.
Procedures may vary depending on your condition
and your physician’s practices.
Generally,
heart transplantation 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.
- An intravenous (IV)
line will be started in your hand or arm prior
to the procedure for injection of medication
and to administer IV fluids, if needed. Additional
catheters will be inserted in your neck and
wrist to monitor the status of your heart and
blood pressure, as well as for obtaining blood
samples. Alternate sites for the additional
catheters include the subclavian (under the
collarbone) area and the groin.
- A catheter will be
inserted into your bladder to drain urine.
- Heart transplant surgery
will be performed while you are asleep under
general anesthesia. A tube will be inserted
through your mouth into your lungs. The tube
will be attached to a ventilator that will breathe
for you during the procedure.
- The anesthesiologist
will continuously monitor your heart rate, blood
pressure, and blood oxygen level during the
surgery.
- The skin over the surgical
site will be cleansed with an antiseptic solution.
- The physician will
make an incision (cut) down the center of the
chest from just below the Adam's apple to just
above the navel.
- The sternum (breastbone)
will be divided in half with a special operating
instrument. The physician will separate the
two halves of the breastbone and spread them
apart to expose the heart.
- Tubes will be inserted
into the chest so that the blood can be pumped
through your body by a cardiopulmonary bypass
machine (heart-lung machine).
- Once the blood has
been completely diverted into the cardiopulmonary
bypass machine for pumping, the diseased heart
will be removed.
- The donor heart will
be sewn into place. Once the new heart is in
place, blood vessels will be connected.
- When the transplant
procedure has been completed, the blood circulating
through the cardiopulmonary bypass machine will
be allowed back into the heart and the tubes
to the machine removed. The heart will be shocked
with small paddles to restart the heartbeat.
- Once your new heart
begins to beat again, the physician will observe
the heart to assess the function of the heart
and to make sure there are no leaks where the
blood vessels are connected.
- Temporary wires for
pacing may be inserted into the heart. These
wires can be attached to a pacemaker and your
heart can be paced, if needed, during the initial
recovery period.
- The sternum will be
rejoined and sewn together with small wires.
- The skin over the sternum
will be sewn back together. The incision will
be closed with sutures or surgical staples.
- Tubes will be inserted
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.
- A sterile bandage/dressing
will be applied.
In
the hospital:
After
the surgery you may be taken to the recovery room
before being taken to the intensive care unit
(ICU) to be closely monitored for several days.
Alternatively, you may be taken directly to the
ICU from the operating room. You will be connected
to monitors that will constantly display your
electrocardiogram (ECG or EKG) tracing, blood
pressure, other pressure readings, breathing rate,
and your oxygen level. Heart transplant surgery
requires an in-hospital stay of seven to 14 days,
or longer.
You
will have a tube in your throat so that your breathing
may be assisted with a ventilator until you are
stable enough to breathe on your own. The breathing
tube may remain in place for a few hours up to
several days, depending on your situation.
You
may have a thin, plastic tube inserted through
your nose into your stomach to remove air that
you swallow. The tube will be removed when your
bowels resume normal function. You will not be
able to eat or drink until the tube is removed.
Blood
samples will be taken frequently to monitor the
status of the new heart, as well as other body
functions, such as the lungs, kidneys, liver,
and blood system.
You
may be on special IV drips to help your blood
pressure and your heart, and to control any problems
with bleeding. As your condition stabilizes, these
drips will be gradually decreased and turned off
as your condition allows.
After
the breathing tube is out, your nurse will assist
you to cough and take deep breaths every two 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.
You
may receive pain medication as needed, either
by a nurse, or by administering it yourself through
a device connected to your intravenous line.
Once
the breathing and stomach tubes have been removed
and your condition has stabilized, you may start
liquids to drink. Your diet may be gradually advanced
to more solid foods as you tolerate them.
Your
immunosuppression (anti-rejection) medications
will be closely monitored to make sure you are
receiving the optimum dose and the best combination
of medications.
Nurses,
respiratory therapists, and physical therapists
will work with you as you begin physical therapy
and breathing exercises.
When
your physician decides you are ready, you will
be moved from the ICU to a private room on a post-surgical
unit or transplant unit. Your recovery will continue
to progress. Your activity will be gradually increased
as you get out of bed and walk around for longer
periods of time. Your diet will be advanced to
solid foods as tolerated.
Nurses,
pharmacists, dietitians, physical therapists,
and other members of the transplant team will
teach you how to take care of yourself once you
are discharged from the hospital.
At
home:
Once
you are home, it will be important to keep the
surgical area clean and dry. Your physician will
give you 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 physician tells you
to. Other activity restrictions may apply.
Follow-up
visits will be scheduled frequently after returning
home from the hospital. These visits may include
blood tests, chest x-ray, and biopsy (removal
of tissue from the heart for examination under
a microscope.) The transplant team will explain
the schedule for these tests. The rehabilitation
program will continue for many months.
Notify
your physician to report any of the following:
- fever and/or chills
- may be a sign of infection or rejection
- redness, swelling,
or bleeding or drainage from the incision site
- increase in pain around
the incision site
- difficulty breathing
Your
physician may give you additional or alternate
instructions after the procedure, depending on
your particular situation.
What
is done to prevent rejection?
To allow
the transplanted heart to survive in your body,
you will be given medications for the rest of
your life to fight rejection. Each person may
react differently to medications, and each transplant
team has preferences for different medications.
The anti-rejection medications most commonly used
include:
- cyclosporine
- tacrolimus
- azathioprine
- mycophenolate mofetil
- prednisone
New
anti-rejection medications are continually being
approved. Physicians tailor medication regimes
to meet the needs of each individual patient.
Usually,
several anti-rejection medications are given initially.
The doses of these medications may change frequently,
depending upon your response. Because anti-rejection
medications affect the immune system, persons
who receive a transplant will be at higher risk
for infections. A balance must be maintained 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.
What
are the signs of rejection?
The
following are some of the most common symptoms
of rejection. However, each individual may experience
symptoms differently. Symptoms may include:
- fever
- fluid collection in
the lung
- decreased oxygen level
in the blood
- shortness of breath
The
symptoms of rejection may resemble other medical
conditions or problems. Consult your transplant
team with any concerns you have. Frequent visits
to and contact with the transplant team are essential.
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