INTRODUCTION OF HEART TRANSPLANT
A heart transplant, or a cardiac transplant, is a surgical transplant procedure performed on patients with end-stage heart failure or severe coronary artery disease when other medical or surgical treatments have failed. As of 2016, the most common procedure is to take a functioning heart from a recently deceased organ donor (cadaveric allograft) and implant it into the patient. The patient’s own heart is either removed and replaced with the donor heart (orthotopic procedure) or, less commonly, left in place to support the donor heart (heterotopic procedure). Approximately 3500 heart transplants are performed every year in the world, more than half of which occur in the US.Post-operation survival periods average 15 years.Heart transplantation is not considered to be a cure for heart disease, but a life-saving treatment intended to improve the quality of life for recipients.
INDICATION OF HEART TRANSPLANT
Why the Procedure is Performed?
A heart transplant may be done to treat:
- Severe heart damage after a heart attack
- Severe heart failure, when medicines, other treatments, and surgery no longer help
- Severe heart defects that were present at birth and can’t be fixed with surgery
- Life-threatening abnormal heartbeats or rhythms that do not respond to other treatments
Heart transplant surgery may not be used in people who:
- Are malnourished
- Are older than age 65 to 70
- Have had a severe stroke or dementia
- Have had cancer less than 2 years ago
- Have HIV infection
- Have infections, such as hepatitis, that are active
- Have insulin-dependent diabetes and other organs, such as the kidneys, that aren’t working correctly
- Have kidney, lung, nerve, or liver disease
- Have no family support and do not follow their treatment
- Have other diseases that affect the blood vessels of the neck and leg
- Have pulmonary hypertension (thickening of blood vessels in the lung)
- Smoke or abuse alcohol or drugs, or have other lifestyle habits that may damage the new heart
- Are not reliable enough to take their medicines, or if the person is not able to keep up with the many hospital and medical office visits and tests
The first operation is harvesting the heart from the donor. The donor is usually an unfortunate person who has suffered irreversible brain injury, called “brain death”. Very often these are patients who have had major trauma to the head, for example, in an automobile accident. The victim’s organs, other than the brain, are working well with the help of medications and other “life support” that may include a respirator or other devices. A team of physicians, nurses, and technicians goes to the hospital of the donor to remove donated organs once brain death of the donor has been determined. The removed organs are transported on ice to keep them alive until they can be implanted. For the heart, this is optimally less than six hours. So, the organs are often flown by airplane or helicopter to the recipient’s hospital.
The second operation is removing the recipient’s damaged heart. Removing the damaged heart may be very easy or very difficult, depending on whether the recipient has had previous heart surgery (as is often the case). If there has been previous surgery, cutting through the scar tissue may prolong and complicate removal of the heart.
The third operation is probably the easiest; the implantation of the donor heart. Today, this operation basically involves the creation of only five lines of stitches, or “anastomoses”. These suture lines connect the large blood vessels entering and leaving the heart. Remarkably, if there are no complications, most patients who have had a heart transplant are home about one week after the surgery. The generosity of donors and their families makes organ transplant possible.
The surgery involves:
- A major incision down your chest. Your breastbone is split in half.
- Your main arteries are connected to a heart lung bypass machine to pump your blood and a ventilator will help you breathe.
- Most heart transplants are done with a method called orthotopic surgery, where most of your heart is removed but the back half of both upper chambers, called atria, are left in place. Then the front half of the donor heart is sewn to the back half of the old heart.
- The donor’s aorta and pulmonary arteries are connected to yours. The bypass machine is disconnected and your new heart begins the work of pumping blood.
- Your incisions are closed.
- This surgery is considered less complicated than most heart bypass surgeries, including coronary artery bypass graft (CABG).
ANESTHESIA FOR HEART TRANSPLANTATION
General anesthesia will be used. You will be asleep during the procedure.
Although several new surgical therapies hold promise for changing the surgical approach to heart failure, the most effective therapy currently for patients with end- stage congestive heart failure is heart transplantation. The challenges posed to the anesthesiologist caring for these patients are great, and are increasing as a result of a shift toward transplanting medically unstable pa tients. The anesthetic management of patients undergo ing heart transplantation requires a knowledge of the pathophysiology of heart failure, the altered pharmacody namics of anesthetics in the patient with heart failure, treatment of right heart failure, as well as the impact of new surgical therapies on cardiovascular function.
PREOPERATIVE PROCEDURE OF HEART TRANSPLANT
A typical heart transplantation begins when a suitable donor heart is identified. The heart comes from a recently deceased or brain dead donor, also called a beating heart cadaver. The patient is contacted by a nurse coordinator and instructed to come to the hospital for evaluation and pre-surgical medication. At the same time, the heart is removed from the donor and inspected by a team of surgeons to see if it is in suitable condition. Learning that a potential organ is unsuitable can induce distress in an already fragile patient, who usually requires emotional support before returning home.
The patient must also undergo emotional, psychological, and physical tests to verify mental health and ability to make good use of a new heart. The patient is also given immunosuppressant medication so that the patient’s immune system does not reject the new heart.
PROCEDURE OF HEART TRANSPLANT
What happens during a heart transplant?
A heart transplant is carried out with you unconscious under general anaesthetic, and normally takes between four and six hours.
You’ll be connected to a heart-lung bypass machine, which will take over the functions of the heart and lungs while the transplant is being carried out.
A thin, flexible tube called a catheter will also be inserted to drain your bladder during and after the operation.
During the procedure:
- a cut (incision) is made down your chest over your breastbone and the bone is separated, allowing the surgeon to access your heart
- your heart is removed, leaving behind a section of the right and left atria, the two upper chambers of the heart
- the new heart is connected to the aorta, the main artery from the heart, the pulmonary artery, and the remaining part of the atria
- You’ll be taken off the bypass machine when your new heart starts beating.
- Your breastbone will be closed with metal wires, and the tissues and skin will be closed with stitches.
POSTOPERATIVE PROCEDURE OF HEART TRANSPLANT
FOLLOW-UP AFTER THE SURGERY
Frequent follow-up appointments are crucial to the long-term recovery and management of a heart transplant. Your 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 your new heart is functioning properly. Your immunosuppressant medications will be adjusted if needed, and you’ll be asked if you’ve suffered from any of the possible signs of rejection, including:
- a fever
- shortness of breath
- weight gain due to fluid retention
- reduced urine output
Report any changes in your health to your cardiac team so that your heart function can be monitored if required. Once a year has passed after the transplant, your need for frequent monitoring will decline but you’ll still need yearly testing.
Women of childbearing age should consult their cardiologist before starting a family. Pregnancy is safe for people who’ve had a heart transplant. However, expectant mothers who have pre-existing heart disease or who’ve had a transplant are considered high risk and may experience a greater chance of pregnancy-related complications and a higher risk of organ rejection.
WHAT HAPPENS AFTER THE TRANSPLANT?
Most people leave hospital within about four weeks of the operation, but depending on your condition, you may need to stay in hospital for longer.
In the first few months after your surgery you will need to spend a lot of time visiting the hospital – you might even need to stay near the transplant centre. Your transplant team will talk to you about practical arrangements for after your surgery.
Although you will be weak after the operation, recovery can be very quick. It is important to build up your level of activity gradually. You should avoid activities involving lifting and pushing until your breastbone is fully healed, which can take up to three or four months.
Once you feel fit and able, you can start doing things like light vacuuming or light gardening.
WHAT IS LIFE LIKE AFTER A HEART TRANSPLANT?
Once you’ve recovered from surgery you should be able to return to a wide range of activities including driving, holidays and physical activity – some people are even able to go back to work.
You will need to take a number of medicines, including immunosuppressants, for the rest of your life. Without them your body would rapidly recognise your new heart as ‘foreign’ and try to reject it. This type of medicine can have side-effects which your doctor will discuss with you.
Many people who have had a successful heart transplant go on to live long and healthy lives. Over three-quarters of heart transplant patients live for over five years.
COMPLICATIONS OF HEART TRANSPLANT
WHAT ARE THE 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.
The risks of having a heart transplant include:
- Failure of the donor heart
- Complications from medicines
- 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).
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.
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.
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.
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).