Heart Transplant: What To Expect
What to Expect Before, During and After the Heart Transplant
The University of Maryland Medical Center's Heart Transplantation Program is committed to providing the best possible care to patients with end stage heart failure. In addition, we are uniquely positioned to contribute to scientific progress in the field, which will improve care for tomorrow's patients.
Entering the Transplant Program
Most candidates for transplantation are referred to the program by their primary physician or specialist. Others come to be evaluated at their own initiative. The process begins with a call to the Cardiothoracic Transplant Office (410-328-2864). The patient will be asked to provide some basic medical information by telephone, and to give us written permission to obtain medical records from other health care providers.
In general, patients with advanced heart failure who continue to have severe symptoms on maximal medical therapy should be considered for transplant evaluation. These symptoms might include breathlessness with little or no exercise, waking up at night short winded, and swelling in the feet and legs, among others. Patients with increasing medication requirements, frequent hospitalizations, or overall deterioration of clinical status should be considered relatively urgently.
The causes of congestive heart failure that result in cardiac transplantation are "ischemic" (not enough blood supply to the heart muscle) and primary (otherwise unexplained) cardiomyopathy. Together these two diagnoses account for about 9 of 10 heart transplant patients.
Ischemic cardiomyopathy is caused by coronary artery disease. Patients with coronary artery disease may suffer muscle damage from repeated or large heart attacks; if enough of the heart muscle is affected, the heart can no longer pump efficiently. Less often coronary artery narrowings which are associated with refractory chest discomfort or arrhythmias are found to be inoperable (not able to be treated by catheter techniques or open heart surgery).
A small percentage of patients who undergo cardiac transplantation have valvular heart disease, congenital heart disease, or inoperable hypertrophic cardiomyopathy as the underlying condition.
All candidates for transplantation begin the program with a comprehensive series of tests conducted by our multidisciplinary team of specialists. Some of these tests are required for any operative procedure (history and physical, chest X-ray, EKG, etc.) while others (such as special blood tests to learn about prior infection exposure) are required for transplantation surgery.
During the evaluation you will meet many members of the transplant team. Each member of the team will want to get to know you and will play different roles in your care. There are so many of us because a successful transplant program requires people with different expertise. While some aspects of transplantation have become routine, other aspects require innovation. This is where the experience of the team can make the difference between success and failure for an individual patient, particularly if the problem is unusual or serious.
Once the evaluation is complete, the transplant team will decide if heart transplantation is the best option. The risks and benefits will be discussed with each patient. If the patient and the transplant team agree that transplantation is the best available choice, the patient is then placed on the transplant waiting list at the University of Maryland.
This heart transplant waiting list is organized through the United Network for Organ Sharing (UNOS), which is the national list. Waiting time for a new heart varies by blood type, recipient size and weight, and by "status", which is a measure of severity of heart failure symptoms. Ranking candidates by status was instituted in hopes of assuring that the sickest patients, and particularly those most likely to die while awaiting a transplant, receive hearts first.
The average waiting time in Maryland is currently about 18 months for patients who are "healthy" enough to wait at home for their new heart. The wait is somewhat shorter for patients who require hospitalization, or intravenous medicines, or even insertion of a blood pump to reduce the risk of death while waiting.
What to Expect While Waiting
The time may be shorter or longer depending on the donor supply and the patient waiting list. While waiting, the patient is seen in clinic periodically to assist with any medical issues that may arise. Almost every patient will need to have a "right heart catheterization" and other tests every three to four months. These tests are important to help us know whether the candidate is developing problems that could complicate a transplant, or increase the risk of death while waiting.
Right heart "cath" involves passing a flexible catheter from a neck or groin vein through the right heart chambers and into a lung artery. This allows us to measure the flow of blood through the heart and the pressure in your lung arteries and heart chambers. In another test, the highest amount of oxygen your body can use during exercise (maximum peak oxygen consumption, or MVO2) is measured during a cardiopulmonary exercise test ("CPEX").
In addition to transplantation, patients with congestive heart failure can be treated with various innovative and investigational modalities at the University of Maryland. New investigational ("being studied") medications under study include a calcium sensitizing agent (levosimendan) and antagonists to the neurohormones ADH, endothelin and adenosine. We are also studying the effects of exercise and the antioxidant Co-enzyme Q10 in patients with heart failure.
The unique uses of pacemakers are being investigated for possible beneficial effects on heart function. The problem of sudden death in heart failure is also being studied.
The team is likely to recommend placement of a defibrillator, and may also prescribe blood thinners (coumadin). Please remember that it is VERY IMPORTANT for the patient and the physician to let us know promptly if there is any change in medications or in a waiting patient's medical condition. When in doubt, CALL.
It is very important that during the entire waiting period, the potential recipient is able to be reached 24 hours a day. If a donor is located, the transplant team needs to be able to find the potential recipient quickly and admit them to the hospital, or that heart may need to be given to another needy recipient. This means that if the candidate leaves home they must have their pager or cell phone with them and turned on at all times.
During the wait for transplant, the primary contacts will be the candidate's transplant cardiologist and one of the transplant nurse practitioners (Suzanne Lanks, Sharon Augustine, Carol Wade).
When a compatible organ becomes available, the transplant patient is immediately contacted by a nurse coordinator and admitted to the hospital. At this time, a history is taken of any medical events which may have occurred since the initial transplant evaluation. All appropriate testing is also done to ensure the patient's readiness for surgery.
One surgeon will lead the team which travels to the hospital where the donor is located, to remove the heart from the donor and to "put it to sleep" in a way that is likely to protect ("preserve") its function. This is done by interrupting blood flow to the donor heart while flushing a special cold "preservation" solution through the donor heart's arteries. The preservation solution halts the heart's electrical activity (and thus reduces its need for food and oxygen). The heart is then carefully but swiftly removed.
The organ is then protected by wrapping it in sterile plastic bags inside a picnic cooler (yes, really!) and brought to UMMC for implantation. Meanwhile, another team of surgeons will prepare the recipient to receive the new heart. Careful coordination is required between the donor and recipient surgical teams in order to minimize the amount of time that the new heart is "asleep".
As soon as we are confident that the donor heart is in good condition and is suitable, the recipient will be taken to the operatng room. The breast bone is opened (in case of prior surgery, this is one of the more difficult and dangerous parts of the procedure) and preparations made for supporting circulation with a heart-lung ("cardiopulmonary bypass") machine. Once the new heart has arrived safely, the recipient is placed on "bypass", the old heart removed, and the new heart stitched in place. This is done by sewing together the ends of the main vessels (superior and inferior vena cavae or right atrium; pulmonary artery; left atrium; and aorta) leading in and out of the heart.
The surgery lasts approximately six to eight hours. When the surgery is completed, the patient is taken to the intensive care unit. Over the subsequent days as the recipient recovers from surgery, the breathing tube and various drainage tubes and intravenous lines are gradually removed, and the process of rehabilitation is begun. Occasionally the new heart may have an abnormally slow rhythm, and a pacemaker may be required.
Careful, comprehensive post-surgical monitoring constantly evaluates whether the body is accepting the new organ. This includes regular heart echocardiograms, electrocardiograms, and biopsies.
Biopsies are performed by placing an IV line, usually from the right neck, and passing a delicate scissor device through the veins and into the right ventricle. There, under X-ray or echocardiogram guidance, several small pieces of the right ventricle are removed for microscopic examination. If we see evidence of immune injury to the heart (either infiltration of cells called "lymphocytes", or evidence that protein antibodies may be building up against the heart), then additional therapy may be prescribed to reverse this "acute rejection" process. In almost every instance this therapy is successful at reversing the rejection.
The average length of stay in the intensive care unit is 3-7 days, followed by 1-2 weeks in the hospital.
The Outpatient Clinic
Follow-up care initially involves returning to the Outpatient Clinic once a week for the first month after leaving the hospital. At this time a series of tests, including blood tests, are conducted to closely monitor the patient's progress. This is a period when medications are precisely adjusted. This process takes many factors into account to reach a point of stability. After this initial period, patients are seen periodically as determined by their condition.
The Patient's Responsibility
While transplantation can greatly improve the quality of life of the recipients, it also demands much of them. They must become active participants in preserving their health.
It is important and expected that each patient will learn the names of all medications, what they are being taken for, the dosages, and how often each is taken. The nurses and the transplant nurse practitioners will work with the recipient and their family to help them learn this information.
Transplantation has become so successful in recent years in large part through the development of new, more effective drugs which prevent donated organs. These drugs inhibit the body's immune system from identifying the new organ as foreign, or "non-self", and then from trying to destroy it. It is necessary for all patients to take immunosuppressive medication for the rest of their lives following transplant. A successful transplant can be undermined very quickly by the failure of patients to take their medications appropriately and responsibly.
||Prograf or Cyclosporine
- Increased risk of infection
- Numbness or tingling in hands, feet and mouth
- Hair growth
- Hot flashes
- Overgrowth & swelling of gums
- High blood pressure
- Kidney dysfunction
- Increased blood sugar
- Low white count and platelets
- Increases cholesterol
- Delayed healing
- Fluid retention
||Cellcept or Imuran
- Stomach cramps
- Increased blood sugar
- Low white blood counts
|Prevents or reverses acute rejection
- Flu-like symptoms
- Increased risk of infection
- Stomach irritation
- Swelling of face (chipmunk cheeks), hands or ankles
- Weight gain
- High blood sugar
- Skin changes
- Muscle weakness
- Mood changes
- Brittle bones
Typical Medicines to Prevent or Treat Infection:
- Bactrim or Dapsone - fights a specific pneumonia called pneumocystis
- Acyclovir - fights herpes simplex
- Gancyclovir - fights a specific virus called CMV
Typical Complications That may Occur After Transplantation:
- Bone loss
- Narrowing of heart arteries (coronary artery disease)
- High cholesterol or triglycerides
- Skin cancer
The transplant team has much experience in diagnosing these problems and in preventing and treating them.
The Heart Biopsy Regimen
Heart biopsies are a necessary part of careful, comprehensive monitoring to evaluate whether the body is accepting the new organ. Biopsies are performed by placing an IV line, usually from the right neck, and passing a delicate scissor device through the veins and into the right ventricle.
There, under X-ray or echocardiogram guidance, several small pieces of the right ventricle are removed for microscopic examination. If we see evidence of immune injury to the heart (either infiltration of cells called "lymphocytes", or evidence that protein antibodies may be building up against the heart), then additional therapy may be prescribed to reverse this "acute rejection" process. In almost every instance this therapy is successful at reversing the rejection.
This page was last updated: July 24, 2013