Heart Transplant
A heart transplant is a major surgical procedure that replaces a failing heart with a healthy donor heart, offering hope to people whose hearts can no longer pump blood effectively despite other treatments.
Table of contents
- What is a Heart Transplant?
- When is a Heart Transplant Needed?
- Who Can Receive a Heart Transplant?
- Getting on the Waiting List and Finding a Donor
- Types of Heart Transplant Procedures
- The Transplant Surgery
- Recovery in the Hospital
- Life After a Heart Transplant
- Medications After Transplant
- Risks and Complications
- Long-Term Outlook
What is a Heart Transplant?
A heart transplant is a surgery that replaces your heart with a donated heart from another person[1][6]. This operation is performed when a failing heart is replaced with a healthier donor heart[1]. The procedure is reserved for people whose condition has not improved enough with medications or other surgeries[1].
A heart transplant is not considered to be a cure for heart disease. Rather, it is a life-saving treatment intended to improve the quality and duration of life for a recipient[3]. While a heart transplant is a major operation, your chance of survival is good with appropriate follow-up care[1].
The first successful human-to-human heart transplant was performed in 1967 by South African cardiac surgeon Christiaan Barnard[3]. Since then, doctors have learned much more about transplants, and advancements in technology and anti-rejection drugs have dramatically improved survival[5]. Today, around 3,700 heart transplants are performed each year in the United States[5]. Approximately 5,000 heart transplants are performed each year worldwide, more than half of which are in the US[3].
When is a Heart Transplant Needed?
Heart transplants are performed when other treatments for heart problems have not worked, leading to heart failure[1]. Heart failure is a condition where the heart is unable to pump enough blood to meet the needs of the body[5]. When heart failure occurs, the heart has permanent damage or weakness that keeps it from pumping enough blood to your body[6].
Heart failure does not mean that the heart has stopped working. It is a serious condition that progresses over time[5]. People with severe heart failure have a hard time doing even routine physical tasks and a poor prognosis[5].
In adults, heart failure can be caused by[1]:
- A weakening of the heart muscle (cardiomyopathy)
- Coronary artery disease – blockages in the arteries in your heart that can lead to heart attacks causing irreversible damage[6]
- Heart valve disease
- A heart problem you’re born with (congenital heart defect)
- Dangerous recurring abnormal heart rhythms (ventricular arrhythmias) not controlled by other treatments
- Failure of a previous heart transplant
In children, heart failure is most often caused by either a congenital heart defect or cardiomyopathy[1].
Main indications for transplant in chronic heart failure include patients who have disabling symptoms despite optimal medical management or refractory arrhythmias despite medical and electrophysiological procedures[2]. For acute heart failure refractory to inotropes (drugs that help the heart pump) and mechanical circulatory devices, a heart transplant is indicated[2].
Who Can Receive a Heart Transplant?
A heart transplant is a last-resort treatment for people who have end-stage heart failure[6]. To receive a heart transplant, you must be very ill despite medical therapy and need a new heart to survive[6]. Doctors perform a thorough examination of patients with advanced heart disease to determine whether they are eligible to receive a new heart and are healthy enough to undergo heart transplant surgery[5].
Heart transplants are possible for children and adults up to age 70 and in some circumstances up to age 75[6].
A heart transplant is not right for everyone. You might not be a good candidate if you have certain conditions. People may not be eligible for a heart transplant if they have one or more of the following conditions[5]:
- Current or recent history of cancer
- Severe pulmonary hypertension
- Severe cerebrovascular disease
- Advanced kidney, liver, or lung disease
- Use of tobacco, alcohol, and/or drugs within previous 6 months
- History of not taking medications as prescribed by doctors
- Aged 70 or over
- Current infection such as HIV or hepatitis C
- Obesity (having a body mass index [BMI] of 35 or higher)
- Poorly controlled diabetes
People with advanced kidney, liver, or lung disease may be candidates for multi-organ transplantation surgery, such as a heart-kidney, heart-liver, or heart-lung transplant[5]. Another organ transplant may be performed at the same time as a heart transplant in people with certain conditions at select medical centers[1].
Getting on the Waiting List and Finding a Donor
People deemed eligible for a heart transplant will be added to a waiting list for a donor heart[5]. Unfortunately, the demand for heart transplants exceeds the supply of available hearts[5]. There are currently about 3,800 people in the United States on the waiting list for a donor heart, and many will wait more than six months[5].
Because there is a limited availability of donor hearts, you must meet very strict requirements to qualify for this kind of transplant[6]. Transplanting a heart requires a donor, and donors are in short supply. Plus, the donor and recipient must be a “match.” That means both people must have a compatible blood type and similar body size[6].
Because the people on the heart transplant waiting list have severe heart problems, many of them need to be treated until a donor heart becomes available[5]. In some cases, this involves implantation of mechanical devices such as a ventricular assist device (VAD) or a total artificial heart (TAH) that help pump blood throughout the body while patients wait for a donor heart[5].
Most heart transplant recipients are adults, though children and adolescents may also need them. In 2020, for instance, there were 465 pediatric heart transplants in the U.S.[5]
Types of Heart Transplant Procedures
Historically, two types of transplant procedures have been described[2]:
Orthotopic heart transplant is the most commonly utilized technique. This involves excision (removal) of the recipient’s heart and implantation of a donor’s heart in the chest of the recipient[2]. The patient’s own heart is removed and replaced with the donor heart[3].
Heterotopic heart transplant is much less common. In this procedure, the recipient’s heart is not excised and the donor’s heart is implanted into the recipient’s chest[2]. The recipient’s diseased heart is left in place to support the donor heart (also called a “piggyback” transplant procedure)[3].
The Transplant Surgery
A heart transplant requires general anesthesia and usually takes 4 to 5 hours, though it may take longer, especially if a patient has a left ventricular assist device (LVAD) that needs to be removed[7].
During transplantation, surgeons place the patient on a heart-lung machine to maintain blood circulation and deliver oxygen to the body[7]. The surgeons then remove the damaged heart and connect the donor heart. The new heart starts beating once blood flow is restored, which often requires support with medications[7].
Your doctor did the surgery through a cut (incision) in your chest[18]. Once the surgery is done, the patient is transferred to the intensive care unit[7].
Recovery in the Hospital
The first few hours to weeks after your heart transplant are a critical time for you, as your body adapts to its new healthy heart[19]. Just after your surgery, you will be admitted to the ICU for an average of 5 days and then transferred to a recovery room for a 7- to 10-day stay[19].
Patients are placed on a breathing tube for 1 to 3 days and recovery is carefully monitored[7]. During this time, you can expect to[19]:
- Be on a ventilator until you can breathe and cough on your own
- Perform coughing and breathing exercises under the guidance of a nurse every 2 hours
- Be on a heart monitor throughout your admission
- Receive educational support from members of the transplant team
You will feel tired and sore for several weeks after surgery. You may have some brief, sharp pains on either side of your chest. Your chest, shoulders, and upper back may ache. The incision in your chest may be sore or swollen. These symptoms usually get better after 4 to 6 weeks[18].
Life After a Heart Transplant
Once you leave the hospital, you and your caregivers will take a more active role in the care of your new donor heart[19]. After a heart transplant, you must follow a strict lifestyle involving daily medicines and regular medical care[7]. This includes regular sampling (biopsies) of the transplanted heart tissue to check for rejection[7].
You will probably be able to do many of your usual activities after about 3 months. But for 3 to 4 months, you will not be able to lift heavy objects or do activities that strain your chest or upper arm muscles[18]. At first you may notice that you get tired easily and need to rest often. It may take several months to get your energy back[18].
You probably started a cardiac rehabilitation (rehab) program in the hospital. You will continue with this rehab program after you go home to help you recover and prevent problems with your heart[18].
During this time, you will[19]:
- Conduct calls with your heart transplant coordinator to manage your medication
- Attend virtual and in-office appointments with your physicians
- Have tests and procedures, including heart biopsies to check for signs of rejection
- Perform cardiac rehabilitation activities, such as caring for your incision, moving around and breathing exercises
Once you are discharged from the hospital you will be seen in the out-patient clinic twice a week for about two weeks, then once per week, then once every 2 weeks for about 3 weeks, then once a month until you are out six months, then once every two months until you are a year out from transplant[17].
Having an organ transplant can bring up many emotions. You may feel grateful and happy. But you also may feel guilty or depressed. Seek out family, friends, and counsellors for support. If you think you are depressed, ask your doctor for help. Treatment can help you feel better[18].
Life after heart transplantation can look very different, especially in the months following your surgery. Symptoms from heart diseases such as end-stage heart failure should improve dramatically. And many can perform the same level of physical activity and have the same quality of life as those who have not had a heart transplant[19].
Many heart transplant patients are runners, swimmers, dancers, soccer players, baseball players, artists and musicians. They attend school regularly and achieve life and career goals[22].
Medications After Transplant
You must take anti-rejection medicine every day for the rest of your life to prevent the rejection of your new heart[19]. After receiving a transplant, you will need medical care for the rest of your life to prevent rejection and complications[6].
Blood work must also be performed to monitor the side effects of anti-rejection medicine. You should refill your medications on time to avoid missing a dose. You should not be taking any over-the-counter medications or herbal supplements unless cleared by the transplant team[19].
To prevent rejection, all transplant recipients receive immunosuppressive medications[7]. The transplant team may prescribe additional medications to help manage other medical problems, such as[19]:
- Pain
- Infection
- High blood pressure
- Diabetes
Risks and Complications
Like other organ transplant surgeries, heart transplants are difficult operations that have risks[6]. Heart transplant surgery carries the general risks associated with open chest surgery, including bleeding, stroke, and damage to organs such as the kidneys and liver—although these risks are generally low[7].
There are specific potential complications early after heart transplant, including[7]:
Primary Graft Dysfunction: This means that the new heart does not start beating and pumping right away. When this occurs, the patient may need to be placed back on the heart-lung machine until the heart recovers. Though it is rare that the heart does not recover, when this happens, a second heart transplant may be needed.
Acute Rejection: One of most significant risks after heart transplant. The patient’s body (immune system) can reject the donor heart. To prevent this, all transplant recipients receive immunosuppressive medications. Heart biopsies and blood tests are used to monitor for rejection.
After your heart transplant, watch for side effects and signs of complications or organ rejection, including[19]:
- Redness, swelling, bleeding, drainage or pain at the incision site
- Trouble breathing
- Excessive fatigue
- Low blood pressure
Contact your doctor immediately if you experience any of these symptoms. Staying in close contact with your medical team and attending all appointments and procedures can help reduce your risk of side effects and complications[19].
Long-Term Outlook
Post-operative survival periods average 15 years[3]. Thanks to advances in medicine, heart transplantations have a high success rate. People live for years or even decades after receiving their new heart[6].
Heart transplants are uncommon. In 2020, just under 8,200 transplants were performed worldwide. The country with the highest number (3,658) was the United States[6].
Heart transplants are rare for two reasons[6]:
- Donor heart shortage: Transplanting a heart requires a donor, and donors are in short supply. Plus, the donor and recipient must be a “match.”
- Transplant complexity: Heart transplants are very complicated surgeries. There are fewer than 150 hospitals in the U.S. (out of more than 6,000 hospitals) that perform this surgery.
