Heart transplant

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What is a heart transplant?

A heart transplant is a cardiothoracic surgical procedure that is done to replace a diseased and a failing heart with a heart obtained from a suitable donor. It is usually reserved for individuals with end-stage heart disease that is not responding to conservative medical therapy.

Alternate name

  • Cardiac transplant

Is heart transplant an elective or an emergency procedure?

A heart transplant is an elective procedure.

Indications for a heart transplant

Diseases and conditions that affect the heart that require a heart transplant may include the following:

  • Dilated Cardiomyopathy: A condition in which the heart muscle is stretched and thinned out to an extent where it is unable to properly pump blood that is required for the normal sustenance of body functions
  • Ischemic Cardiomyopathy: A condition in which the heart muscle is weakened after a heart attack or coronary artery disease due to reduced blood supply
  • Congenital Heart diseases or other diseases that cannot be managed by other surgical measures
  • Ejection fraction is less than 20% - ejection fraction is the ratio of the amount of blood that is pumped by the left lower chamber with each contraction of the heart versus the total amount of blood in the chamber
  • Intractable angina and severe cardiac arrhythmias which are not responding to conventional management

A heart transplant is generally preferred when the age of the individual is less than 65 years, pulmonary vascular resistance is low and the ability to comply with follow up medical care is good.

Contraindications and risk factors for a heart transplant

Some of the contraindications and risk factors for heart transplant include the following:

  • Age more than 65 years
  • High pulmonary vascular resistance: This is the presence of a high amount of resistance to the flow of blood from the pulmonary artery into the left atrium.
  • Active systemic infections especially HIV infection
  • Active systemic diseases such as connective tissue disease or sickle cell anemia
  • Chronic Lung disease with lung function less than 40%
  • Chronic liver or kidney disease
  • Severe and uncontrolled diabetes
  • Active cancer
  • History and continuance of smoking, alcohol, and drug abuse
  • Psychosocial instability
  • Inability to comply with follow up medical care

Investigations before the procedure

Some investigations that are done before a heart transplant include the following:

  • Laboratory Tests:
    • CBP & ESR
    • Viral, Bacterial, and Fungal serology tests
    • Testing for Tuberculosis
    • Coagulation profile and blood typing
    • Liver and renal function tests
    • Complete urine examination
    • Panel Reactive Antibody (PRA) testing
    • Tissue Typing (HLA typing)
    • Pap smear for women
  • Imaging tests:
    • Chest X-ray – PA and lateral views
    • Echocardiography
    • Bilateral Mammograms
  • Cardiopulmonary evaluation:
    • Pulmonary function tests
    • Maximal Venous Oxygen Consumption testing
  • Biopsy:
    • Endomyocardial biopsy: Only done if a systemic disease is suspected as a probable cause of cardiomyopathy

Preoperative advice

Before performing a heart transplant the following are done:

  • Individuals who are selected as candidates are put on an organ waitlist and a suitable donor heart is searched for availability
  • Risks and benefits of the procedure are explained
  • Hospital admission is done a day or two before the procedure
  • Nothing by mouth 8-12 hours before the procedure

Intraoperative details

Duration: A heart transplant is done as open-heart surgery and may last for a few hours.

Anesthesia: Heart transplant is performed under general anesthesia.

Description of the procedure:

With the individual lying on the back and after the general anesthetic has taken effect, a midline incision is made in the chest (sternotomy). The individual is connected to a heart-lung machine and the diseased heart is removed and the donor's heart is sewn in place and attached to all the important arteries and veins. The new heart that is attached may start beating on its own or it may need to be electrically stimulated to do so. The chest incision is sutured while leaving the draining tubes in place.

Postoperative details

After a heart transplant, the following is usually done:

  • The individual is shifted to a recovery room and then to a cardiac intensive care unit where they are placed under observation
  • Extubation is done once the individual regains consciousness or after 3-5 days
  • Drainage tubes are removed from the chest 1 -3 days after the procedure
  • Pacing wires are also removed 3-5 day after the procedure if there are no rhythm abnormalities

Common post-procedure complaints are:

  • Soreness and pain at the site of surgery
  • Signs of rejection of the heart transplant include
    • Shortness of breath
    • Fever
    • Tiredness
    • Weight gain and retention of fluid in the body
    • Decreased urine output

Discharge: Usually after 2 -3 weeks after the procedure.

Medication: Immunosuppressant and inotropic drugs are prescribed to reduce graft rejection and improve heart function respectively. Besides antibiotics, antiviral and antifungal medications may be prescribed as required.

Review: Usually on a very regular basis for the first month, and then a gradual decrease in the frequency over 1 year. Endomyocardial biopsies are taken every week for the first month to check for graft rejection.

Resumption of normal activities: Usually with some restriction after 4-6 weeks of the procedure.

Role of diet/exercise/lifestyle changes

Some measures that are essential after a heart transplant include:

  • Cardiac rehabilitation
  • Proper diet and healthy food habits
  • Maintaining ideal body weight and exercising as advised by the attending specialists
  • Reducing the risk of infections

Complications of heart transplant

Some complications that may be seen after a heart transplant include:

  • Bleeding
  • Infection at the surgical site
  • Rejection of the graft
  • Atrial arrhythmias
  • Serum sickness
  • Tricuspid valve regurgitation due to repeated biopsies
  • Highly increased risk of infections
  • Graft vascular disease

Prognosis

The prognosis for a heart transplant is generally good but is also dependent on the presence of other comorbidities such as hypertension, diabetes, and obesity which are linked to a higher mortality rate after a heart transplant.

Indications for hospitalization if required

Hospitalization will be required for a heart transplant.

Suggested clinical specialist/department to consult for the procedure

A heart transplant will be performed by specialists from the department of cardiothoracic surgery.

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