Cardiac (Heart) Transplantation

  • Code: SUR073
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Highlights

  • Improves quality of life
  • Restores blood flow through the heart
  • Less risk of complications

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    Overview

    Details of Cardiac (Heart) Transplantation

    The heart is a fist sized shaped organ responsible for pumping oxygenated blood and bringing deoxygenated blood back from various organs in the body. It consists of four chambers right and left atria and ventricles. The left side of the heart carries oxygenated blood from the aorta to the body and the right side receives deoxygenated blood which is then sent to the lungs for purification via the pulmonary artery. The heart being a muscular organ receives blood supply by the coronary arteries. Aging changes and other associated risk factors affect the blood supply to the heart which affect the pumping ability, may cause blockages in the major arteries affecting blood supply which ultimately leads to heart failure. Cardiac transplantation is a surgery done in order to replace a failing or ill heart with a healthy donor heart. It is usually done when all medical and surgical options are exhausted. This helps improve the quality of life and longevity of the patient. A careful screening process is in place to help secure a healthy heart and to make sure the recipient can withstand the surgery.  The operation is usually done in three simple steps that is removal of a donor heart from a patient declared brain dead, removal of the recipient’s diseased heart and lastly implantation of the donor heart into the recipient. In India NOTTO national organ and tissue transplantation committee exists that regulates and facilitates organ transplantation by various outreach programs. Immunosuppressive medications are given post surgery to prevent heart rejection. The prognosis of a patient with cardiac transplantation has improved over the decades that is the one year survival rate of a patient with heart failure is 80%, five year survival rates less than 50% and that post cardiac transplant five year survival is 50-60% and one year 85-90%.

    Science

    Heart failure essentially means that the muscles of the heart are failing in their attempt to pump blood throughout the body. It could be due to a disease or weak heart musculature.

    The causes are mentioned below:

    • Cardiomyopathy- that is weakening of heart muscle 
    • Coronary artery disease
    • Ventricular arrhythmias- abnormal rhythms caused due to bad electrical conduction system of the heart.
    • Cardiac valve disease
    • Congenital heart defects -heart problems one is born with.
    • Failed previous transplant
    • Chronic lung diseases like emphysema and COPD(chronic obstructive lung diseases)
    • Pulmonary hypertension-high blood pressure in the lungs
    • Recurrent unstable ischemia

    There is a possibility of another organ transplant along with the heart in people with certain conditions.

    Multi-organ transplant:

    Heart-kidney transplant in addition to a heart there is kidney failure as well

    Heart-lung transplant-rarely the doctor may suggest this procedure for patients with severe heart and lung diseases.

    Heart liver transplant-done for people with liver disorders.

    According to the recent figures nearly 80% cardiac transplant patients live for atleast two years. The ten year survival rate is nearly 56%. Nearly 85% return to their daily activities.

    1. An intravenous line is started in the patient’s hand or arm to inject medicines or fluids. Additional catheters will be put in blood vessels in neck and wrist to monitor the status of heart and blood pressure, and to take blood samples. 
    2. Foleys catheter is inserted into the ureters to drain urine.
    3. A tube is inserted in the mouth or nose to drain fluids.
    4. An anaesthesiologist injects analgesic along with other medications for anesthesia.
    5. An endotracheal tube is inserted and attached to a mechanical ventilator to aid breathing throughout the surgery. The anesthesiologist monitors the patient’s vital parameters like heart rate, blood pressure and blood oxygen level throughout the surgery.
    6. The cardiothoracic surgeon makes an incision on the chest, cuts through the breastbone and separates them which is known as midline sternotomy.
    7.  Cannulation for bypass is done with an aortic cannula high in the ascending aorta after heparin administration. Venous cannulation via right angle into the superior vena cava or through the posterior right atrium into the superior vena cava and the inferior vena cava cannulation via the posterior right atrium into the heart whilst the perfusionist starts the bypass machine allowing oxygenated blood to be carried to the various organs of the body.
    8. The surgeon then removes the diseased heart from the recipient’s body
    9. In the meantime, the donor’s cardiectomy is carried out by another team of surgeons preserving maximum length of the superior and inferior vena cava along with the intrapericardial portion of the pulmonary veins. Donor heart ischemia should be maintained between four to six hours.
    10. When the recipient heart arrives in the operating room, implantation begins with the left atrium, IVC, aorta, cross clamp removal pulmonary artery and finally SVC.
    11. Weaning from the pulmonary bypass begins with a warm 20 min reperfusion for each hour of ischemic time, after this the patient is gradually weaned of the bypass.
    12. The surgeon applies shock to the heart with small paddles to start the heart beat.
    13. The heart rate is maintained slightly tachycardic around 100-120bpm through infusion of isoprenaline or pacing wires to ensure adequate cardiac output. 
    14. The sternum is then sewn up with small wires
    15. The surgeon then sutures or staples the incision.
    16. Drainage tubes are left in situ to drain the excess blood and fluid around the heart that are connected to a suction device.
    17. The patient is then moved to a recovery room or an intensive care unit and monitored closely fro several days.
    18. The endotracheal tube is kept intact for several day until the patient recovers and is able to breathe on his own.
    19. Blood samples will be taken often to monitor the new heart, as well as other body functions. 
    20. The healthcare team closely monitors the immunosuppressive drugs, nurses, respiratory and physical therapy will gradually begin  
    21. Once the patient is shifted to a transplant unit or private room gradual ambulation is started.

    Heart transplant surgery requires a hospital stay of 7 to 14 days, or even longer. Once discharged the patient is asked to watchout for any rejection signs and begin with a cardiac rehabilitation program.

    Preparation For A Transplant Surgery

    Once the doctor suggest transplant to a patient, the patient undergoes a thorough evaluation-

    • Psychological and social evaluation, stress, financial issues and family and friends support greatly determine how the patient will hold up pre and post surgery.
    • Blood tests: it helps find a suitable donor that will match and help improve the rejection.
    • Diagnostic tests like X ray, CT Scans lung function test ultrasound, in case of females gynecological examination, mammography, Pap smear test, etc.

    The transplant team will consider all this information along with the history, findings from the physical exam and diagnostic tests to decide if the patient is eligible for a transplant.

    Method:

    There are two techniques for heart transplantation:

    1. Lower and Shumway technique: It is a classic technique consisting of four anastomoses that is the right and left atrial, pulmonary arterial and aortic anastomoses.
    2. Orthotopic technique: It is a modification of the classic technique whereby the recipient’s right atrium is completely removed and the donor heart is implanted using bicaval anastomoses.

    The orthotopic technique is widely used. The surgery usually takes between four to six hours and longer if a VAD is fixed 

    Contradictions : 

    There are many people with an ailing heart but not all qualify for cardiac transplants. One may be termed unsuitable for transplant for the following reasons. They are divided into absolute and relative contraindications.

    Absolute contraindications: 

    • Advanced kidney, liver or lung disease
    • Recent history of cancer
    • Life threatening diseases unrelated to heart failure including acute infection or systemic infection like systemic lupus erythematosus, sarcoidosis or amyloidosis
    • Vascular diseases of neck and leg arteries

    Relative contraindications:

    • severe diabetes mellitus with multiple organ dysfunction
    • Patients who smoke and drink
    • Recent thromboembolism such as stroke
    • Severe obesity 
    • Age over 65 years (tends to vary and such patients may be evaluated on an individual basis)

    Ventricular assist devices (VAD): The patients who cannot undergo a transplant surgery generally have this option. A mechanical pump is implanted in the patient’s chest that pumps blood from the lower chambers of the heart to the rest of the body. It is a temporary solution to the patient who is on cardiac transplant waiting list or for those who do not qualify for a transplant.

    Complications:

    • The complications post a cardiac transplant include:
    • Post operative acute infection or sepsis
    • Atrial arrhythmia
    • Increased risk of secondary infections due to immunosuppressive medications
    • Rejection- one of the most important risks of the surgery the human body has an immune system that recognises foreign objects like viruses and bacteria and eliminates them as a result protecting us. The body may take the transplanted heart as a foreign object attacking it. To prevent rejection every recipient receives immunosuppressants.
    • Frequent biopsies are done to check if the body is rejecting the heart within the first year. In a biopsy a tiny sample of the patient’s heart tissue is taken via a tube from the groin or neck to analyze by sending it to the labs. Depending on the pathology report, immunosuppressive drugs are adjusted. Despite being an invasive method, it is quite reliable. There is another alternative in the form of blood sample wherein they check the presence of specific genes in the cells in the blood. The amount of expression of these genes determines the rejection.
    • Coronary allograft vasculopathy: the heart is supplied blood by coronary arteries, these can become thick and hard causing difficulty in the blood supply
    • Cancer- metastatic cancer which can spread from the place it originated from.

    Hospitals

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    FAQ

    What is a cardiac/ heart transplantation?


    Ans: A heart transplant is an operation in which a diseased, failing heart is replaced with a healthier donor heart. Heart transplant is a treatment that's usually reserved for people whose condition hasn't improved enough with medications or other surgeries.


    Why is cardiac/ heart transplant performed?


    Ans: Heart transplants are performed when other treatments for heart problems haven't worked, leading to heart failure. In adults, heart failure can be caused by:

    • A weakening of the heart muscle (cardiomyopathy)
    • Coronary artery disease
    • Heart valve disease
    • A heart problem since birth  with (congenital heart defect)
    • Dangerous recurring abnormal heart rhythms (ventricular arrhythmias) not controlled by other treatments
    • Failure of a previous heart transplant
    Who Is Considered a Candidate for a Heart Transplant?


    Ans: 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 a person, the doctor, and their family to determine if a heart transplant is right for them:

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


    Ans: Heart transplant surgery lasts for approximately four hours. During that time, one will be placed on a heart-lung machine to keep blood circulating throughout their body.

    The surgeon will remove their heart, leaving the pulmonary vein openings and the back wall of the left atrium intact. They’ll do this to prepare them to receive the new heart.

    Once the doctor stitches the donor heart into place and the heart begins beating, they’ll be removed from the heart-lung machine. In most cases, the new heart will begin to beat as soon as blood flow is restored to it. Sometimes an electric shock is required to prompt a heartbeat.


    What is the recovery like post heart transplant?


    Ans: After their surgery is finished, they’ll be taken to the intensive care unit (ICU). One will be constantly monitored, given pain medication, and outfitted with drainage tubes to remove excess fluid from their chest cavity.

    After the first day or two after the procedure, one will most likely be moved from the ICU. However, one will remain in the hospital as they continue to heal. Hospital stays range from one to three weeks, based on their individual rate of recovery.

    One will be monitored for infection, and their medication management will begin. Antirejection medications are crucial to ensure that the body doesn’t reject the donor organ. One may be referred to a cardiac rehabilitation unit or center to help them adjust to their new life as a transplant recipient

    Recovery from a heart transplant can be a long process. For many people, a full recovery can span up to six months.


    What are the complications involved in heart transplant?


    Ans: 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.


    How do they Prevent Rejection from heart transplant?


    Ans: One will need to take medicine to suppress their 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 their situation. Often, they include cyclosporine, tacrolimus, MMF (mycophenolate mofetil), and steroids (such as prednisone).

    The doctors may need to change or adjust their transplant medicines if they aren't working well or if they have too many side effects.


    What does the Follow-up involve after the surgery?


    Ans: Frequent follow-up appointments are crucial to the long-term recovery and management of a heart transplant. Their medical team will perform blood tests, heart biopsies through catheterization, and echocardiograms on a monthly basis for the first year after the operation to ensure that the new heart is functioning properly.

    • Their immunosuppressant medications will be adjusted if needed. They’ll also be asked if one has experienced any of the possible signs of rejection, including:
    • fever
    • fatigue
    • shortness of breath
    • weight gain due to fluid retention
    • reduced urine output
    What’s the outlook post heart surgery?


    Ans: Receiving a new heart can improve their quality of life considerably, but they have to take good care of it. In addition to taking daily antirejection medications, they’ll need to follow a heart-healthy diet and lifestyle as prescribed by their doctor. This includes not smoking and exercising on a regular basis if they’re able.

    Survival rates for people who’ve had a heart transplant vary according to their overall health status, but averages remain high.


    Do heart transplant patients live long?


    Ans: How long one lives after a heart 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 five years after surgery. Nearly 85% return to work or other activities they previously enjoyed.


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