Heart Transplant

Common conditions for which a heart transplant is recommended include:

• Severe heart failure, wherein the pumping function is weakened.
• Coronary artery disease, wherein blocked arteries have led to irreversible damage.
• Cardiomyopathy, which is a disease of the heart muscle.
• Life-threatening arrhythmias (abnormal heart rhythms) that cannot be controlled with medicines or devices.

Heart transplants involve the following steps:

• Anaesthesia: You will receive medication (general anaesthetic) that puts you into a deep sleep before the procedure.
• Heart-lung bypass machine: You will be connected to a machine that takes over the work of your heart and lungs, ensuring that your body continues to receive oxygen-rich blood.
• Accessing the heart: The surgeon will make an incision in your chest and carefully open the rib cage and reach your heart.
• Removing the diseased heart: The surgeon will then remove the damaged or failing heart.
• Placing the donor heart: The new donor heart will be carefully stitched into place, and the major blood vessels will be attached to the donor heart.
• Restarting the heart: Once the blood flow is restored, the donor heart usually starts beating on its own. If needed, the surgical team may give it a mild electric shock to help it start.
• Immediate recovery measures:
  • You will be prescribed pain-relief medications after the surgery.
  • A ventilator (breathing machine) will be used to help you breathe initially after the surgery.
  • Drainage tubes will be placed in your chest to remove excess fluids around the heart and lungs.
  • IV fluids and medications will be provided to help your body recover and protect the new heart.

Heart transplant surgery is a major open-heart operation that usually takes several hours. If you have had previous heart surgeries, it may take longer because of added complexity.

• Frequently, the preparations to receive a donor heart begin weeks or months before the transplant operation. If your doctor recommends a heart transplant, you will be referred for an evaluation to a heart transplant centre (or you can choose one yourself).
• Important criteria to consider when choosing a heart transplant centre:
  • Experience: Number of heart transplants performed yearly and the survival rates of the patients.
  • Insurance: Check if your provider has approved centres.
  • Resources: Transplant centre statistics can be compared through the National Organ and Tissue Transplant Organisation or the Indian Transplant Registry websites.
  • Support services: Assistance with travel arrangements, support groups, local housing during recovery (if needed), or information on other organisations that can help.
• After selecting a transplant centre, an eligibility evaluation for a heart transplant will be done to check if you:
  • Have a heart condition or disease that could improve after a transplant
  • Have any better alternative treatments instead of a transplant
  • Are healthy enough to undergo surgery and post-transplant treatments
  • Are willing to quit smoking, if applicable
  • Can follow strict medical instructions
  • Are emotionally prepared for the waiting period
  • Are surrounded by family and friends to support you during recovery

When a donor heart becomes available, timing is critical. A donor heart must be transplanted within about 4 hours of removal.

• The transplant centre will notify you when a potential heart is available. You must keep your mobile phone charged and turned on at all times.
• You and your transplant team must quickly decide to accept the donation. You will have to go to the transplant centre immediately after being notified.
• Travel to the hospital right away. Some heart transplant centres provide private air transportation or other travel arrangements.
• Keep a packed hospital bag and an extra 24-hour supply of your medications ready.
• Once you arrive at the hospital, your doctors and transplant team will conduct a final evaluation to confirm the donor heart is suitable and that you are ready for surgery.
• If either condition is not met, the transplant may be postponed.
   

• Risks from the surgery:
  • Bleeding, infection, and blood clots: General risks of open-heart surgery.
• Risk of heart rejection:
  • The donor heart may be rejected by your body as the immune system may perceive it as a foreign entity, causing it to reject the heart.
  • Rejection without symptoms: Even with medication, rejection may happen silently.
• Other possible complications:
  • Primary graft failure: This occurs when the donor heart does not function as expected and is one of the most serious early risks.
  • Problems relating to the arteries (cardiac allograft vasculopathy): over time, the arteries in the transplanted heart may thicken and harden, reducing blood flow through the heart. This can cause a heart attack, heart failure, arrhythmias (abnormal heartbeat), or sudden cardiac death.
• Risks from long-term medications:
  • Severe kidney damage or other organ problems: Due to continuous intake of immunosuppressants.
  • Higher cancer risk: Particularly skin and lip cancers, as well as non-Hodgkin’s lymphoma.
  • Greater risk of infection: Due to a suppressed immune system, infections can happen more easily. Patients may require hospital admission, particularly within the first year of transplantation.

• In the hospital: 

  • After surgery, you will spend a few days in the intensive care unit (ICU), followed by 1–2 weeks in a regular hospital room.
  • After discharge, your recovery will be closely monitored at an outpatient transplant centre. Many patients stay in proximity to the transplant centre for the first three months for frequent follow-ups.

• Monitoring for rejection:

  • Your transplant team will watch for any warning signs like shortness of breath, fever, fatigue, weight gain, or reduced urine output. If you observe any of the signs and symptoms of rejection or infection, report these immediately.
  • Frequent heart biopsies will be performed during the first year to check for rejection. Rejection is most common in the first year after transplantation. After the first year, you may no longer need frequent biopsies.

• Long-term care:

  • Immunosuppressants
    • Immunosuppressant medications reduce the immune system activity, thereby preventing it from targeting your donor heart and rejecting it. Some of these immunosuppressants need to be taken lifelong.
    • These medications increase infection risk; thus, your doctor may prescribe antibacterials, antivirals, and antifungals.
    • Medication doses usually reduce over time as the risk of rejection decreases.
  • Managing health and lifestyle
    • Follow all medical advice, take all the medications routinely, and attend all follow-up appointments.
    • You may be given instructions about your lifestyle, such as using sunscreen, avoiding tobacco products, taking regular exercise, following a healthy diet, and taking precautions to reduce your infection risk.
    • Always carry a list of your medications in case of emergency medical care, and inform your doctors about them before starting new treatments.
  • Cardiac rehabilitation: These programs incorporate exercise and education to assist you with recovering your strength and improving your overall health after a heart transplant.

• Coping and support:
  • It is normal to feel anxious while waiting for a transplant or to have fears about rejection. Support from family, friends, and transplant support groups can help.
  • Set realistic expectations about recovery and learn as much as you can about your procedure.

• Diet and nutrition: A healthy diet supports your new heart and reduces complications. A dietitian can guide you. Key points include:
  • Eat fresh fruits, vegetables, whole grains, and lean meats.
  • Limit salt, unhealthy fats, alcohol, and grapefruit (can affect medicines).
  • Drink enough water and other fluids every day to stay hydrated.
  • Adhere to food safety guidelines to avoid contracting an infection.

• Exercise:
  • Your care team may suggest regular exercise and physical activity after your transplant to improve your physical and mental health.
  • Regular exercise can help regulate blood pressure, reduce stress, maintain weight, strengthen bones, and enhance overall physical function.
  • Your care team will design a personalised exercise plan that includes warm-ups, walking, cycling, strength training, and cool-down exercises such as slow walking.
  • Make sure to have a conversation with your care team about what physical activities may be suitable for you.
  • Stop and call your doctor if you have severe fatigue, breathlessness, dizziness, irregular heartbeats, or nausea. 

• Most people who receive a heart transplant enjoy a good quality of life and are able to efficiently perform daily activities again.
• Women can have children after transplant, but medication adjustments are needed—discuss with your doctor.
• Survival rates after heart transplantation are improving worldwide: the overall survival rate for adults is more than 85% after one year and about 69% after five years.

Heart transplants may fail in some individuals due to various factors. 

• In such cases, treatment may include adjusting your medications or, in more extreme cases, undergoing another heart transplant.
• If additional treatment options are limited, you might choose to stop treatment.
• Discussions with your heart transplant team, doctor, and family should address your expectations and preferences for treatment, emergency care, and end-of-life care.