Heart transplantation is a surgical procedure whereby a working heart is taken from a recently deceased donor and implanted into the recipient (Figure). It is a procedure performed for patients with truly end-stage heart disease when all other options for treatment have been exhausted. It may be considered for patients with advanced heart failure due to a virus, severe coronary artery disease, heart valve abnormalities, or congenital heart disease (abnormal heart at birth). There are ≈5 million patients with heart failure in the United States, a condition characterized by a decreased ability of the heart to pump sufficient blood to satisfy the needs of the body. Patients may experience a variety of symptoms, including fatigue, decreased exercise tolerance, shortness of breath, or swelling. Fortunately, with advances in medical therapy, the vast majority of patients with heart failure do well without the need for transplantation. However, despite this, a large number of patients have disease severe enough that they are considered for transplantation. Unfortunately, the need for heart transplants for such patients continues to outstrip the available organ supply. In 2008, 2100 heart transplantations were performed in the United States, with 3300 patients listed as awaiting heart transplantation.
Who Needs a New Heart?
The decision for the need to list a patient for a heart transplant is a complex one involving the patient, his or her physicians, and a multidisciplinary team at a transplant center. The initial evaluation is usually made by the patient's local cardiologist. Severity of symptoms and prognosis from the condition are the most important factors. Because of the shortage of organs, candidates are rigorously screened so that patients with the best chance of success are listed for transplantation.2 Many factors regarding the patient's general condition are reviewed by a number of specialists (Table).
How Long Do I Wait for a Transplant?
The wait for a heart transplant depends on a number of factors. The most critically ill patients who require hospitalization, treatment with intravenous medications, or a mechanical pump (ventricular assist device) to support their failing heart will be priority-listed (status 1). More stable patients may be at home awaiting a transplant (status 2). Other factors that determine length of wait include patient size, blood type, preformed antibodies that determine the risk of rejection after transplantation, and geographic region. Status 1 patients may wait a few days or weeks. Status 2 patients may wait a few months or even years for a heart transplant.
What Happens After a Heart Transplantation?
Outcomes after heart transplantation have improved significantly because of advances in immunosuppressive medications that have reduced the risk of rejection and minimized complications such as infection at the same time. One-year survival after transplantation is now 90%, and >75% of patients are alive at 5 years. The vast majority of patients report excellent quality of life, and most are able to return to work. These excellent outcomes, however, have only been achievable by meticulous management after transplantation by specialized personnel teams that include physicians, transplant coordinators, and nurses. The risk of rejection is the highest early after transplantation, particularly in the first year. Immunosuppression medications are generally prescribed at the highest level during this period and slowly tapered under close supervision over the subsequent year. The higher level of immunosuppression also increases the risk of infections during this period, which necessitates the use of prophylactic antibiotics to minimize this risk. Because rejection may not be associated with significant symptoms, especially early after onset, patients are typically required to undergo surveillance monitoring for rejection with a variety of techniques, including echocardiograms, blood tests, and heart biopsies. In this latter test, the heart is accessed through a vein in the neck or groin. With the use of a small sampling tool (bioptome), several small pieces of the heart are obtained and examined under the microscope for signs of rejection. The procedure is performed with the patient under local anesthesia and is associated with limited discomfort. It is generally performed in the outpatient setting. The frequency with which biopsies are performed is greatest in the earliest period after transplantation and is gradually tapered, so that many centers do not perform biopsies after the first year following transplantation when the risk of rejection is very low. Blood tests are performed in the clinic to check for adequate levels of the immunosuppressive drugs.
After the first year, continued monitoring is required to assess for a more chronic form of rejection that affects the arteries of the heart, known as cardiac allograft vasculopathy or transplant coronary artery disease. In this case, progressive narrowing of the donor heart's coronary arteries occurs in a process similar to that seen in nontransplant patients with coronary heart disease. Transplant patients, however, may not experience any significant symptoms, such as angina, from this because the transplanted heart is devoid of nerve connections. This therefore necessitates regular monitoring with coronary angiograms at yearly or 2-year intervals.
Patients also need monitoring for long-term side effects of immunosuppressive medications. These agents may be associated with kidney disease, high blood pressure, higher cholesterol levels, diabetes mellitus, osteoporosis, and an increased risk of certain cancers. Regular follow-up in conjunction with a primary care physician who works closely with the transplant team is therefore essential.
The outlook for patients after heart transplantation has improved dramatically over the last 25 years, with ongoing advances in posttransplant management and improvements in immunosuppressive and antibiotic drugs. Most patients report an excellent quality of life and are able to return to work, often many years after having been disabled from the crippling effects of heart failure before transplantation. With improved understanding of the rejection process, many new, exciting, and potentially better drugs are currently under investigation. For optimal outcomes, heart transplantation mandates a continuing relationship between the patient, personal physicians, and the transplant team, with the goal of achieving the most fulfilling life possible for the patient.
For further information, see the following:
Drs Patel and Kobashigawa received research grants from Novartis.
We acknowledge the National Heart, Lung, and Blood Institute, National Institutes of Health, for use of the figure.
- © 2011 American Heart Association, Inc.
NHLBI Diseases and Conditions Index: heart transplant. National Heart, Lung, and Blood Institute Web site. http://www.nhlbi.nih.gov/health/dci/Diseases/ht/ht_during.html. Published October 2009. Accessed April 11, 2011.
- Mehra MR,
- Kobashigawa J,
- Starling R,
- Russell S,
- Uber PA,
- Parameshwar J,
- Mohacsi P,
- Augustine S,
- Aaronson K,
- Barr M