Heart Transplantation Process
When symptoms of heart failure worsen, despite lifestyle changes and medication, a patient may be diagnosed with advanced heart failure. About 10 percent of the over 6 million Americans living with heart failure have advanced heart failure – stage D according to the American Heart Association and American College of Cardiology’s A-to-D staging system. Advanced heart failure treatment is more complex, involving the implantation of devices or, when all other treatments are no longer effective, heart transplantation.
Heart Failure Treatment Options
- Transcatheter Aortic Valve Replacement (TAVR) – TAVR is an innovative, minimally invasive treatment for patients with severe aortic stenosis (narrowing of the valve in the aorta) who are not candidates for open heart surgery. TAVR uses catheters in blood vessels to replace the aortic valve with a specially designed artificial valve. The new heart valve is inserted via a small incision in a major artery. Once in place, the new valve expands, pushing the diseased valve aside to increase blood flow through the heart. Physicians affiliated with Memorial Hermann Heart & Vascular Institute were the first in Houston to implant a commercial transcatheter heart valve, and to date, have performed nearly 2,000 TAVR implants.
- Ventricular Assist Devices – Life-saving and therapeutic, ventricular assist devices (VADs) are implantable mechanical circulatory devices that help pump blood from the left ventricle of the heart to the body. VADs are designed to partially or completely replace the functions of a failing heart in patients with severe heart failure, either as a bridge to heart transplantation or as a long-term destination treatment for those who cannot receive a transplant. Most often, VADs are designed to assist the left ventricle of the heart (LVAD), but devices may also be used to assist the right ventricle (RVAD) or both ventricles (BiVAD). VADs significantly ease the burden on the heart and other organs, providing a higher survival rate and better quality of life. Memorial Hermann-Texas Medical Center has earned The Joint Commission’s Gold Seal of Approval™ for its ventricular assist device destination therapy program by demonstrating compliance with The Joint Commission’s national standards for health care quality and safety in disease-specific care.
- Total Artificial Heart – Despite growing demand, only approximately 3,200 donor hearts become available each year in the U.S. When a donor heart is unavailable and both cardiac ventricles fail, a temporary SynCardia Total Artificial Heart is used as a bridge to transplantation and can eliminate the symptoms and source of end-stage biventricular failure. As soon as patients are stabilized following surgery, they are returned to the active transplant list.
- Heart Transplantation – When all other treatments for heart failure have been unsuccessful, physicians may refer a patient for heart transplant. Advanced heart failure is staged on a four-point scale, A-D. As severity increases, patients enter stage D (end-stage heart failure), making them eligible for transplantation.
Pathway to Transplantation
Patients who have severe functional impairment with no medical or surgical therapeutic options and are referred for transplantation undergo a rigorous medical, psychological and social evaluation. On the basis of this evaluation, previous medical records and psychosocial information, a decision is made by the Medical Review Board regarding the advisability of cardiac transplantation.
Patients who are considered for transplantation:
- Suffer from
- Advanced heart failure (defined as NYHA Class IIIB or IV), refractory to optimized medical therapy
- Severe coronary artery disease with intractable angina, despite optimized medical therapy, that is not amenable to bypass surgery or angioplasty OR
- Malignant ventricular arrhythmias that do not respond to all other accepted therapeutic modalities
- Are generally less than 70 years old
- Do not have multi-organ dysfunction
- Exhibit psychosocial stability and have a supportive social environment
- Demonstrate financial responsibility for maintenance of post-transplant medications and testing
Not all patients with advanced heart failure are eligible for a heart transplant. Generally, those who meet one or more of these criteria are not recommended:
- 70 years of age or older
- Suffer from another medical condition that could shorten life, regardless of receiving a donor heart
- Have serious blockages in the arteries in arms or legs (peripheral artery disease)
- Have a personal medical history of cancer
- Are unwilling or unable to make lifestyle changes that are necessary to keep a donor heart healthy, including not drinking alcohol or smoking
Once transplant candidates have undergone a thorough screening process, they are placed on the national transplant list and monitored while awaiting a donor heart. If the transplant candidate’s condition begins to decline, intravenous medications, total artificial heart or ventricle assist device implantation may be recommended until a donor heart becomes available.
Heart Transplant Procedure
Once a donor heart has been identified, the patient is called to the hospital immediately, where a thorough evaluation is conducted on the donor organ and the patient.
Heart transplant is performed under general anesthesia with the patent on a bypass machine, which keeps oxygen-rich blood flowing throughout the procedure. It generally lasts four to six hours, longer if the patient has had previous coronary surgery or if there are complications. The surgeon exposes the chest cavity and opens the pericardium. The diseased heart is removed, leaving the back part of the left atrium in place. The donor heart is implanted, and the chest is closed. In some patients both heart and lungs may be transplanted during the same procedure.
Immediately after surgery, patients receive pain control medication. A ventilator is used to help a post-operative patient breathe and tubes are inserted in the chest to drain fluids from around the lungs and heart.
The post-surgery hospital stay will last one to two weeks. For about three months afterward, transplant recipients are closely monitored on an outpatient basis, including blood work, echocardiograms and electrocardiograms.
Heart Transplant Recovery
A patient’s post-op care is part of the individualized treatment plan that was created for him or at her at the beginning of his or her transplant journey. Following a patient’s transplant surgery, he or she will be cared for by the same multidisciplinary team that has cared from them from the start, to ensure continuity and quality of care.
After a heart transplant, patients must make some permanent long-term adjustments, including:
- Taking immunosuppressants, medications that reduce the activity of the immune system, to prevent the immune system from rejecting the new heart
- Undergoing cardiac rehabilitation and making lifestyle changes, such as regular exercise and diet, that keep a transplanted heart healthy
- Taking advantage of the emotional support services made available to them, to help them deal with the inevitable stress and changes that follow a transplant
Possible Transplant Risks
Although receiving a donor heart can save a person’s life, transplantation is an open-heart surgical procedure accompanied by serious risks, the most significant of which is rejection. All heart transplant recipients receive immunosuppressants, but about one in four have some signs of rejection during the first year after surgery. Usually the rejection has no symptoms and requires only an adjustment of medications.
Short-term risks can include arrhythmia, bleeding, stroke, donor organ dysfunction, hyperacute or acute rejection, infection and kidney failure. Long-term risks can include cancer, coronary disease, chronic rejection, hypertension and infection.
To refer a patient or for additional information regarding the heart transplant program at Memorial Hermann Heart & Vascular Institute, please use our Contact Us page here.