Your Heart Transplant: An Overview
The Heart Failure and Transplantation Program is part of CPMC's Heart and Vascular Center.
Heart transplant surgery is the replacement of a patient's diseased heart with a donor heart after all other treatments have failed. Approximately 2,300 heart transplants are performed each year in the United States.
Transplantation is considered when the heart is failing and does not respond to other therapies, but health is otherwise good. The leading causes for heart transplants at California Pacific Medical Center are:
- Cardiomyopathy--a weakening of the heart muscle; and
- Severe coronary artery disease--when the heart's blood vessels become blocked and the heart muscle is damaged.
How Long Will I Have to Wait? | Who are the Donors? | The Call You've Been Waiting For | Getting the Donor Heart to the Hospital | Once You Get to the Hospital | What Happens During Surgery? | What Happens After Surgery? | Why All These Medications? | When Can I Return Home? | What Will My Life Be Like After Transplant?
How Long Will I Have to Wait?
After the decision for transplantation is made, your name will be added to the United Network for Organ Sharing (UNOS) and California Transplant Donor Network (CTDN) waiting lists and you will receive a beeper for emergency contact when a heart becomes available. We cannot predict exactly how long you will have to remain on the UNOS waiting list, but an average wait is between six months to three years because of the shortage of donor organs.
If you are classified as a "Status One" on the waiting list, your situation is relatively grave. One of the following must be true:
- You are already in the hospital;
- You are receiving intravenous drugs to make your heart pump with more force;
- You are on a mechanical heart-assist device.
When a suitable heart is available in your region, it will be offered to the first person on the Status One list who matches the blood type of the donor and meets other criteria. If there is no match on the Status One list, the heart will be offered to the first person on the Status Two list. The average wait on the Status One list varies from region to region, depending on the number of patients on the waiting list.
If you are classified as a "Status Two," your condition is relatively stable. You may have to wait for months or years to have your transplant. If your condition worsens, you may be placed on the Status One list.
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Who are the Donors?
Donors are individuals-usually young to middle-aged people-who are brain dead, meaning that the brain shows no signs of life while the person's body is being kept alive by a machine. Usually donors have died from a bleed into the brain or an automobile accident involving injury to the brain. Whatever the case, donors are tested for underlying illnesses such as HIV, hepatitis B and C and drug use.
Donor hearts are given to patients based on the donor's blood type and body weight, and the potential recipient's blood type, body weight, severity of illness and geographic location. Priority is given to seriously ill patients at a nearby transplant center. The donor's identity is always kept confidential.
Donor organs are located through the United Network for Organ Sharing (UNOS). Because not enough organs are available for transplant, about 5,000 patients are waiting for a heart transplant at any given time.
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The Call You've Been Waiting For
Once your name has been activated on the waiting list for a donor heart, you will need to be prepared and ready to respond should a suitable donor organ be found. We must move quickly to minimize the time between the removal of the donor heart and the transplant itself.
When you receive a page or telephone call notifying you of a donor heart, it is imperative that you arrive at California Pacific Medical Center within two hours. If you live outside of the Bay Area, transportation is arranged by air ambulance. After receiving the transplant call, you should not eat or drink anything. Additionally, if any of the following conditions apply to you, tell the transplant coordinator when you receive your transplant call:
- Experienced a cold or illness within one month prior to call;
- Taken antibiotics within one month prior to call;
- Had a blood transfusion within one year prior to call;
- Taking aspirin or Coumadin daily.
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Getting the Donor Heart to the Hospital
The donor heart needs to be implanted within six hours of removal. Members of your surgical team will be present at the donor's site to remove the heart. The organ is cooled and kept in a special solution while being taken to California Pacific Medical Center for transplantation.
Throughout the organ retrieval process, the surgical team is in constant contact with the Medical Center to coordinate the transplantation with the heart removal. The surgeons will expose, inspect and perform tests on the donor heart, including an electrocardiogram, echocardiogram, inspection and palpation.
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Once You Get to the Hospital
When you arrive at California Pacific Medical Center, you will be admitted to the hospital's cardiopulmonary unit (CPU) where catheters are placed prior to surgery to measure heart and blood pressures. Initial blood work is also drawn to check electrolytes, CBC, PT and PTT, and a chest X-ray and EKG are performed.
Your operation will not begin until the donor heart has been completely inspected and evaluated. You will be taken to the operating room one to two hours before the anticipated arrival of the heart.
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What Happens During Surgery?
After the necessary pre-surgical testing, a general anesthesia is administered. Once you are asleep, the surgical team will shave your chest, wash it with antiseptic soap and drape you to prepare a sterile environment. You will receive steroids and immunosuppressive medications intravenously during the surgery to prevent rejection of the heart.
The transplant surgeon will make an incision in your chest and divide and separate your breastbone. You will be placed on a heart-lung machine, which will temporarily take over the functions of your heart and lungs.
The heart-lung machine pumps blood throughout the rest of the body, removing carbon dioxide (a waste product) and replacing it with oxygen needed by body tissues. The surgical team will remove your heart except for the back walls of the atria (the heart's upper chambers). The backs of the atria on the new heart are opened and the heart is sewn into place by joining the two atria and two large vessels that carry blood out of the heart. Flow is reestablished through the heart and lungs.
Surgeons then connect the blood vessels and allow blood to flow through the heart and lungs. As the heart warms up, it begins beating. Sometimes, surgeons must start the heart with an electrical shock. All the connected blood vessels and heart chambers are checked for leaks before you are removed from the heart-lung machine.
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What Happens After Surgery?
You will recover in the medical-surgical intensive care unit (MSICU), a specialized area of the hospital where close monitoring will be in effect for 24 hours. Once your vital signs and the function of the transplanted heart have stabilized, you will be transferred to the regular nursing floor to continue your postoperative care.
When you awake from surgery, you will have IV lines and possibly a tube that runs down your throat and into your stomach to deliver medication and nourishment until you can take them by mouth. You may also have a catheter in your bladder to help you pass urine for a few days following surgery. Tubes will be placed under the incision to remove fluids from your chest and a tube may be inserted in your throat to help you get enough oxygen. You will be asked to cough periodically to keep your lungs clear.
Usually, you can expect to be up and around the second day after surgery and if there are no signs of the body immediately rejecting the organ, you will be discharged in seven to 10 days.
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Why All These Medications?
Immunosuppressive drugs--medications that suppress the body's immune system so it will accept the transplanted organ--are administered the day before the transplant and thereafter for the rest of your life. To avoid complications, you must strictly adhere to your drug regimen.
The immunosuppressives currently being used include cyclosporine, azathioprine, cellcept and prednisone. These medications have significantly improved the survival of transplant patients, but there are some side effects you may experience. Side effects may include hypertension (high blood pressure), fluid retention, tremors, excessive hair growth, and possible kidney damage. To combat these problems, additional drugs are often prescribed. Read more about transplant medications.
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When Can I Return Home?
If there are no signs of the body immediately rejecting the organ, you will be discharged from the hospital in seven to 10 days. For six weeks following your transplant date, you will need weekly tests performed, so if you live more than 60 miles from California Pacific Medical Center, you will be required to stay in a patient apartment near the hospital.
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What Will My Life Be Like After Transplant?
Your prognosis depends on many factors, including age, general health and response to the transplant. It will be up to you to determine the pace of your recovery and rehabilitation. Figures show that nearly 20 percent of patients return to work and about 85% enjoy other activities they like. Many patients enjoy swimming, cycling, running, or other sports.
A transplanted heart functions differently from the old one. Because the nerves leading to the heart are cut during the operation, the transplanted heart beats slower than the normal heart. The new heart also responds more slowly to exercise and doesn't increase its rate as quickly as before.
The body's immune system protects the body from infection. Cells of the immune system move throughout the body, checking for anything that looks foreign or different from the body's own cells. Immune cells recognize the transplanted organ as different from the rest of the body and attempt to destroy it--this is called rejection.
To carefully monitor transplant patients for signs of heart rejection, small pieces of the transplanted organ are removed for inspection under a microscope. Called a biopsy, this procedure involves advancing a thin tube called a catheter through a vein to the heart. At the end of the catheter is a bioptome, a tiny instrument used to snip off a crumb-size piece of tissue. If the biopsy shows damaged cells, the dose and kind of immunosuppressive drug may be changed. Biopsies of the heart muscle are usually performed weekly for the first six weeks after surgery, then every three months for the first year, and then yearly thereafter.
A biopsy takes about 30 minutes and is performed using local anesthesia in the skin where the thin tube catheter is placed. It is usually an outpatient procedure.
In addition to biopsies, we need to perform other tests on a regular basis to monitor your new heart and overall health. It is important for you to keep in touch with your coordinator who will schedule these appointments and alert us of any side effects.
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