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Cardiac transplantation involves removal of the diseased heart and replacement by a healthy heart from a brain dead donor.
Some patients with severe heart disease may benefit from transplantation. Our transplant team will evaluate the patient , the purpose of which is two-fold:
(a)To determine the severity of the disease and whether there are any other conventional treatments available.
(b)To determine whether the recipient would have a good long-term result after transplant.
A successful transplant will dramatically improve the symptoms of heart failure. Many transplant recipients can perform the same physical activities and enjoy the same quality of life as any other healthy individuals. All transplant recipients, however, are committed to daily drug treatment and close medical supervision for the rest of their lives.
The main aim of a heart transplant is to replace the unhealthy heart with a healthy one, thus leading to the restoration of normal health of the patient. Heart transplant serves as a remedy / cure for many cardiac ailments.
Approximately half of recipients are alive at 10 years after transplant. It however depends on many factors like compliance to drugs including immunosupressants and regular follow up as advised by the transplant team.
Optimism is the need of the hour. Most heart transplant operations go well. About 90 percent of transplanted hearts function well at the end of first year. If there are complications – say, the new heart fails to function or the body rejects it, the transplant team will decide whether to replace the failing transplanted heart by a second (or even third) transplant operation . Currently there are certain devices ( LVAD, RVAD , BiVADS , ECMO) to keep patients with failing heart alive while awaiting a new heart.
Yes. ABO blood typing has to be compatible strictly.
It is important that the recipient understands the benefits and risks involved in heart transplant. Our transplant coordinators advice them on the procedures that are to be followed during the process.
Approximately 3,700 to 3,800 heart transplants are performed worldwide. The number of heart transplants in our country is on the rise. In 2013, sixteen (16) transplants were performed, whereas in 2015, sixty four (64) transplants were performed.
When an organ becomes available for donation, it is checked to make sure that it is healthy. The blood and tissue type of both the donor and recipient are also checked to ensure that they are compatible. People from the same ethnic group are more likely to be a close match. Better matching of the donor organ to the recipient will improve transplant outcomes and benefit the overall waiting list by minimizing graft failure and need for re-transplantation.
If heart transplantation is the best option for you and if you accept to undergo the transplant , your name will be placed on a national waiting list based on your blood group, body size (height and weight) and medical urgency.
The waiting time for heart transplant is highly variable. Being accepted for a transplant carries with it the implication that your heart failure is severe and life-threatening. The waiting time can be a period of great anxiety with the possible risk of death during the waiting period. Approximately, about 15 in every 100 waitlisted patients die awaiting a donor heart. During the waiting period, you would be screened / treated for infections / any other medical problems which you might be suffering . The transplant team will also ask you to visit a dentist, to make sure you do not have any infection in the mouth which could possibly spread to your new heart.
The transplant team will continue to see you and treat your heart condition during the waiting period. It is also possible that the recipient might be contacted at short notice in the event of a donor heart being available at any point of time.
About one in three patients on the transplant list will be too ill to be discharged from hospital and will have to remain in hospital until the transplant is performed. Some priority is often given to these patients, who are clearly in much more urgent need of a transplant. Some patients may have to spend some of their waiting time in an intensive care unit, especially if they are on certain drugs used to support and stimulate the heart. However, despite the severity of their illness, these patients can be expected to do just as well after a transplant as other patients whose condition is more stable.
When an appropriate donor heart is found , our institute will get in touch with the recipient at the earliest (usually through phone). Once the recipient reaches the hospital , he / she will be reassessed rapidly to make sure that there are no new medical problems . Some investigations you had at your earlier assessment will be repeated, the aim of which is to make sure that no new medical issue has occured which might make the transplant less likely to be successful.
All the usual preparations for major surgery will be carried out, including shaving and bathing.
In the meantime, a separate surgical team will be examining the donor heart. Donor hearts may come from anywhere within the country. A period of four to five hours between removal from the donor and restoration of the blood supply in the recipient is acceptable, but usually efforts are made to reduce this time as much as possible. Hearts coming from far off are often brought by flight .
In some cases the donor organ is found to be unsuitable when examined by the surgical team. If this happens, the procedure will be abandoned and you will unfortunately have had a wasted journey to the hospital. This can be distressing but is unavoidable given the logistical problems involved in organising a transplant.
The recipient’s heart is not usually removed until the donor heart is physically within the hospital.
Most transplant operation takes about three and five hours.
The heart is placed in preservative solution in a sterile bag, which is surrounded with ice cubes.
Approximately, four to six hours.
The transplant evaluation tests includes specific cardiac assessment, tests are performed to determine the function of all the other major organ systems, screening for infectious diseases and cancer, and try and predict how well the recipient and his family will cope with the rigors of the transplant regimen. Many of the tests, even the complex ones, are fairly standardized and can be performed on a day care basis .However, some tests may require you to be briefly admitted to the hospital .Every potential candidate must make at least one outpatient visit to the institute to meet the transplant team. Typically, most of the evaluation can be completed within a couple of days. Patients deserved to be be good candidates for transplantation are then put on a national waiting list.
The waiting time for heart transplantation is quite variable and sometimes long - often more than a couple of weeks to months. Patients on our waiting list returns for an outpatient visit to our transplant clinic every two to three months, or more frequently if necessary .While many patients can wait at home, sometimes it is necessary for patients to be admitted to the hospital in order to remain in satisfactory condition until transplantation.
To qualify for placement on the heart transplant waiting list, a potential recipient must be relatively healthy and not have active / incureable cancer / infection. The patient also must be able to comply with treatment and medication requirements post transplantation.
The following situations disqualifies a brain dead person from being a potential cardiac donor:
The donor should ideally be younger than 55 years although there are exceptions.
The oral cavity is a potential source of infection because of the presence of plenty of bacterial and fungal commensals.. This is why a dental evaluation prior to cardiac transplantation is advisable. After cardiac transplantation , it is important that you have regular checkup and maintain good dental hygiene. The routine dental care provided by the dentist will help to prevent infections and decrease the amount of gum overgrowth caused by cyclosporine .When you plan to have a dental procedure, you must notify your dentist in advance that you have had a heart transplant and will require antibiotics prior to the dental procedure. The reason for this is that bacteria may get into your bloodstream during the dental procedure and promote infection. This prescription can be obtained from your dentist or the transplant team.
This varies from patient to patient . During the evaluation , the transplant surgeon will review the details of the surgical procedure, the risks of the procedure and the expected recovery after surgery .This will be discussed with the potential recipient in detail.
If you experience complications in the post operative period , the ICU stay and ventilator support might be prolonged. This is a truly critical period. Unfortunately, a proportion of these patients do not survive this period. The worldwide mortality rates are in the range of 5-10%.
Many heart transplant patients can be discharged from hospital two or three weeks after the operation. For the first month or two after the operation, you will preferably have to stay close to the transplant centre , in a hospital flat or similar accommodation, unless you live fairly locally. After this, you will need to attend weekly appointments at the outpatients’ clinic. Even years after a transplant, many patients have two or more outpatient appointments a year at the transplant centre.
Recovery from the operation is as rapid as for any other cardiac surgery, except that transplant patients were obviously weaker before the operation.
You will be encouraged to take part in rehabilitation programme / supervised physiotherapy. The rehabilitation programme also offers advice about how to have a healthier lifestyle and psychological support to the recipient and his / her family.
About six to eight weeks after the operation your life will return to near normal. However, as with other types of heart surgery, you will be advised to take certain medications.
It is important to take take a healthy, balanced diet. There is a tendency to gain weight, especially if you are taking steroids. You will be encouraged to do regular exercise, always starting with a slow warm-up . Your new heart will be without nerve supply, and therefore responds much more slowly than normal to the demand of exercise. Most recipients are eventually able to take part in full range of activities / sports.
Most transplant patients cope remarkably well with the psychological stress associated with a transplant. It is important to remember that the heart is no more than a pump and that a transplant does not change your personality or behaviour. Some patients do suffer mood swings with the high doses of steroids used in the early days after a transplant. Women who have a heart transplant may feel distressed by the hair growth and skin changes associated with immunosuppressant drugs.
The risks in general would be the following. A detailed explanation and counselling would be done by the transplant team
(a) In the immediate postop period - Bleeding, hemodynamic disturbances (hypotension, low cardiac output , hypoperfusion), rhythm disturbances, renal damage.
(b) In the weeks and months after the transplant
Attempts to reject the new heart
Soon after the transplant, the body tries to reject the new heart. The recipient is required to take immunosuppressants to reduce the risk of rejection. Regular check-up is required to monitor how well the transplanted heart is performing .For this, under local anesthesia, a catheter (a fine, hollow tube) with a little cup-shaped biopsy device at the end, is introduced through a vein in the neck and specimen of the heart tissue (biopsy) is retrieved and examined under a microscope
Echocardiogram provides a good guide to monitor the cardiac function.
Infection
Infection is always a cause of concern after transplantation, especially in the first few months. You will have to report to the transplant team any signs of infection and this might require antibiotics . Some antibiotics interact with immunosupressants and in general they should be prescribed by the transplant centre.
(c) In the years after the transplant
As years go by, the risk of acute rejection becomes much less and the doseage of immunosuppressants can be reduced. Your immune system will gradually become more effective again, but you will tend to run a small extra risk of infection. However, one potential complication of long-term immunosuppression is higher risk of certain forms of cancer. About one in ten transplant recipients develops one or the other form of cancer after heart transplant ,most common being skin and lymph gland tumours.
Skin cancer is more common in people with sun-damaged skin and accounts for four out of every ten cancers seen after heart transplantation. As these are superficial it is relatively easy to detect and treat them..
Lymph gland tumors (lymphomas) occur at any stage after a transplant. Some of these tumors shrink when the dose of immunosuppressant drugs is reduced, while others require further treatment like chemotherapy.
Other malignancies like cancer of the lung , bowel, or breast are no more common in heart transplant patients than they are in the general population.
Another long-term side effects of immunosupressants include damage to the kidneys (cyclosporine) or thinning of the bones (osteoporosis) caused by steroids.
Although acute rejection of the new heart is rare after the first three to six months, the body may continue to ‘attack’ the new heart. This is known as ‘chronic rejection’ . The site of the attack is the lining of the coronary arteries carrying blood around the new heart, as this is the ‘frontier’ between the donor and the recipient. The lining of these arteries gradually thickens and eventually the arteries may become blocked. This is rarely seen in the first few years after transplantation but can become a serious problem after five years. The situation is monitored by regular angiography (a test which shows the caliber of the coronary arteries ).
Most patients are treated with aspirin or anticoagulants to reduce the risk of blood clotting. The thickening of the arteries occurs much faster in patients who have high cholesterol levels, so it is important to control your blood cholesterol level .
In general, two weeks after the heart transplant, the recipient should start to feel much better, However, you need to take certain drugs to prevent rejection for the rest of your life. We recommend that you stay active, avoid smoking and alcohol, and stick to a healthy diet. It generally takes three to six months to fully recover from heart transplant surgery and resume normal life style. However, age and previous medical problems may cause a longer recovery period.
It is advisable for patients to be close to the transplant center for the first six weeks post discharge. The frequency of follow-up visits and laboratory tests during this interval can be a problem for patients who stay far away from the hospital. Our social worker can help you locate a suitable guest house near the hospital.
Generally, most patients experience tolerable pain or discomfort after heart transplantation at the incision site especially when they cough. Patients experiencing severe pain is rare . In either case , patients are provided with drugs and specific instructions by the transplant team and physiotherapists to reduce pain.
When the recipient is in the intensive care unit after the transplant , family members are not allowed to stay in your room. If you need assistance in finding a guest house, our social worker will help you . Once, the recipient is shifted to ward, your family members are encouraged to spend time with you. However, in order to protect you from infection, anyone who is ill / harbouring infection should not visit you . The lesser the number of visitors , the better , keeping in mind the possibility of cross infections.
The scar extends from top of the sternum / breast bone (suprasternal noch) just under your neck and ends just past the end of the sternal bone. Initially the scar is prominent. It tends to fade with the passage of time.
After the operation, the recipient will be shifted to the intensive care unit and will be on ventilatory support for a few hours until his condition becomes stable. Many patients regains consciousness after a few hours ; others take a little longer. If the hemodynamic parameters are in the acceptable range ,the patient will be shifted out from the intensive care unit within a few days to the high dependency or ‘step down’ ward.
It is usual for transplant patients to be kept in a separate room / bay to restrict the number of visitors to control infection. Visitors will be asked to wear gloves, masks and gowns to control risk of infection
After a successful heart transplant, most people are able to go back to their normal daily activities over a variable period of time depending on how sick they were before the transplant. Your doctor will be able to tell you how long your recovery period is likely to be.
Studies have shown that women who undergo heart transplantation can conceive and give birth normally, although they have to be monitored carefully because of a higher incidence of premature births. Advice to mothers regarding nursing of babies will be provided based on individual cases because of the possibility of immunosuppressive drugs being transmitted to the infants through breast milk.
During the working days, your call will be attended by our office staff. If you want to contact the transplant team with a routine, non-emergency question , we suggest you to place these calls during the routine working hours (Monday through Friday; from 8:00 am to 4:00 pm).Emergency calls can be made at anytime to F6 ICU.A prompt reply will be obtained.
It is likely that, following transplantation, you will be making some important dietary changes. These will be discussed with the patient / their family members in detail by the transplant team and the nutritionist .The following section outlines many of these recommended dietary restrictions
When the recipient reports for review , he / she will undergo a detailed physical examination by the cardiac surgeon, apart from which the recipient will undergo a chest X-ray, electrocardiogram and certain blood tests(for example – serum Tacrolimus level). You may also have to undergo an endomyocardial biopsy.
Alcohol consumption should be eliminated after the transplant. Alcoholic beverages are high in calories, low in nutrients and can increase the level of triglycerides in the blood. Even more important is the fact that alcohol can impair the liver function . Certain immunosuppressant drugs are broken down in the liver. So, for the medications to act effectively and safeguard the new heart from rejection , it is essential that the liver be healthy and this prohibits alcohol consumption.
Because it commonly takes eight weeks for the bones and tissues of the chest to heal after transplant surgery, it is advisable not to attempt any undue stress inducing activities with arms and upper body. You should not lift heavy weights or perform pulling or pushing activities with your arms. It is advised not to drive until the wound has sufficiently healed to resume driving which is generally three months post surgery.
For those people who are fortunate enough to receive a transplant, the long-term outlook is now very good indeed. Between 85% and 90% of transplant patients live for at least a year after the transplant; 75% are alive after five years; and between 50% and 60% are alive after ten years.The quality of life is usually good, especially if the side effects of the immunosuppressants can be kept to a minimum.
You will be able to return to work / go back to further education or school . Many transplant patients can even take part in sporting activities.
The appropriate time to return to work will depend on the type of work performed. As soon as the incision heals and you are feeling well, you can discuss with the transplant surgeon when to return to work. Some patients will be able to return to work relatively quickly. After transplantation, we expect recipients to participate fully in their normal routine activities. This means enjoying family activities, returning to work, leading a normal social life and contributing back to society. Generally, most recipients can return to work within three to six months following surgery.
DO take all the drugs as directed by the transplant team strictly and on time. Never stop your medications or change dosages without the doctor’s approval.
Antibodies are proteins which our immune system makes when it comes into contact with something foreign to our body. When we contract an infection such as cold , our body synthesizes certain antibodies to fight that infection.
When the heart is transplanted from (the donor) into the recipient, the immune system of the recipient triggers the same response by producing antibodies against the new organ that it would have against any foreign material, setting off a chain of events that can damage the transplanted organ. This process is called rejection. It can occur rapidly (acute rejection), or over a long period of time (chronic rejection). Rejection can occur despite close matching of the donated organ and the recipient .
If you feel ill and experience the following symptoms any time after discharge from the hospital , you should immediately contact the F6 ICU(SRMC)
After transplantation, it is important to take care of yourself by eating right, exercising daily, taking your medications as prescribed and on time, taking care of your skin and dental hygiene, washing your hands frequently, and using the infection-avoidance precautions we teach. Report any changes or feelings of discomfort to the transplant team immediately. The timely diagnosis of infection or rejection is crucial for life. Remember, call us even if in slightest doubt; it is better to be safe than sorry. None of these symptoms are specific for rejection; but they are important enough that when they occur, they should prompt a call to the doctor who will decide whether the situation warrants further investigation or should be observed for the time being.
It is very important to realize that rejection of transplanted heart is quite variable. Some patients will feel perfectly well, only to discover that their heart is being attacked by their immune system. In fact, it is more likely than not that there will be minimal or no symptoms of rejection.
After heart transplant, the recipient will receive certain medications called immunosuppressants. These drugs weaken the ability of the immune system to reject the new heart thus protecting the new organ and preserving its function. These drugs act by blocking the recipient's immune system so that it is less likely to react against the transplanted organ. A wide variety of drugs are available to achieve immunosupression. These include steroids , cyclosporine, tacrolimus, sirolimus, mycophenolate mofetil etc.
(a)Immunosupressants (anti-rejection medications)
Without these drugs, the recipient’s body would rapidly recognise the new heart as ‘foreign’ organ and mount an attack, or an attempt to ‘reject’ it. The immunosuppressant drugs control this rejection by reducing the strength of your body’s immune system. (The ‘immune system’ means the cells and proteins in the blood and tissues that help protect the body against attack from bacteria and viruses.) However, these immunosuppressant drugs also reduce your body’s defences against infection.
Rejection is most likely to happen within the first few months after a transplant and during this period you will be given quite a high dose of immunosuppressant drugs. It is during this period that the risk of infection is at its greatest .The following includes a few examples of immunosupressants
Cyclosporine
This drug is responsible for the huge improvement in the success rate of heart transplants since the early 1980s. Cyclosporine has risk of renal damage in most patients which necessitates close monitoring. Apart from nephrotoxicity , it may cause increased growth of facial and body hair, and it tends to make the gums thick and sore
Azathioprine
This drug reduces the production of white cells by the bone marrow and this increases the risk of infection. Its effect is monitored by measuring the white blood cell count and adjusting the dose accordingly.
Prednisolone
Patients who take prednisolone tend to gain weight , develop puffiness of the face ,weakness of bones and poor healing of the tissues.Some patients tend to develop high blood pressure. In most patients, the dose can be reduced within the first few weeks . However , in some patients it is possible to stop taking this drug after six or twelve months.
(b)Antibiotics
Antibiotics are given during and after the transplant and may be given from time to time if there is a threat of infection.
(c)Blood pressure lowering drugs
The combination of cyclosporine and steroids often causes high blood pressure and many patients need to take blood pressure lowering drugs.
(d)Diuretics
These drugs reduce the tendency of body to retain fluids by promoting excretion of excess body water through urine..
(e)Vitamins, minerals and nutritional supplements -
These aid your body in its efforts to heal and maintain proper functioning.
(f)Coronary artery disease prevention and antihypertensive drugs to prevent coronary artery disease and regulate blood pressure respectively . Most of the above medications are required immediately after the operation. Over the first year, dosages of some drugs can be lowered and possibly discontinued .
Endomyocardial biopsy is a diagnostic test to detect rejection after heart ransplantation. Having an episode of rejection is not uncommon and does not mean that the recipient will lose his or her new heart. Rejection will present itself if medications need adjusting and very often the patient may have no symptoms. This is why cardiac biopsies are an important part of routine care after transplantation.
Typical Cardiac Biopsy Schedule (Additional appointments are added as needed) includes:
First month following transplant: Every visit
The most important way to prevent heart rejection is strict drug compliance and regular follow up .Never alter or skip a dose unless instructed to do so by a member of your transplant team
Cytomegalovirus (CMV) is a type of herpes virus. It is the single most common type of infection which is seen after heart transplant. Peak incidence is from 2-5 months post transplant. CMV infection can occur in the blood, gastrointestinal system, or lungs.
The following is a list of do’s / don’t’s to be followed to prevent infections
While gardening, wear a mask and gloves to avoid contact with fungus spores which can promote infection.
