Heart Transplant

What is a heart transplant?

A heart transplant is a surgery that replaces your heart with a donated heart from another person. To receive a heart transplant, you must be very ill despite medical therapy and need a new heart to survive. Because there’s a limited availability of donor hearts, you also must meet very strict requirements to qualify for this kind of transplant.

Like other organ transplant surgeries, heart transplants are difficult operations that have risks. After receiving a transplant, you’ll need medical care for the rest of your life to prevent rejection and complications.

Who needs a heart transplant?

A heart transplant is a last-resort treatment for people who have end-stage heart failure. That means your heart has permanent damage or weakness that keeps it from pumping enough blood to your body.

This kind of heart failure can happen for a wide variety of reasons. Most people who need a heart transplant have one of the following conditions:

• Cardiomyopathy. This refers to any disease that damages your heart muscle (cardio = heart, myo- = muscle, pathy = disease). Causes include infections and genetic diseases. Sometimes, the cause is unclear (idiopathic) even after extensive testing.
• Coronary artery disease. Blockages in the arteries in your heart can lead to heart attacks that cause irreversible damage to your heart.
• Congenital heart disease. Congenital heart disease is a defect in the heart’s structure that you’re born with. Some forms of congenital heart disease can lead to end-stage heart failure, which may require a heart transplant.
• Valvular heart disease. These are conditions that involve damage to your heart valves.

Heart transplants are possible for children and adults up to age 70 and in some circumstances up to age 75.

How common are heart transplants?

Heart transplants are rare. In 2020, just under 8,200 transplants were performed worldwide. The country with the highest number (3,658) was the United States. The countries with the next highest totals were Germany, France and Spain.

Heart transplants are uncommon for two reasons:

• Donor heart shortage. Transplanting a heart requires a donor, and donors are in short supply. Plus, the donor and recipient must be a “match.” That means both people must have a compatible blood type and similar body size. Without this matching, the recipient’s immune system is more likely to reject the donor’s heart.
• Transplant complexity. Heart transplants are very complicated surgeries. There are fewer than 150 hospitals in the U.S. (out of more than 6,000 hospitals) that perform this surgery.

What happens before a heart transplant?

The following steps happen before your heart transplant surgery:

1. Referral to a transplant program.
2. Transplant evaluation.
3. Addition to the waiting list.
4. Bridge treatment.
   • You receive ongoing medical treatment while awaiting transplantation.
   • You may need support with a mechanical device while awaiting transplantation.

These steps are described in greater detail below.

Referral to a transplant program

To begin the process, your healthcare provider must refer you to a heart transplant program. Then you can schedule your evaluation.

Transplant evaluation

There aren’t enough available heart donors to provide a heart to everyone who needs one. So, the evaluation ensures that you have the best chance to benefit from one long-term.

Your transplant evaluation includes several parts.

Medical evaluation

Your healthcare provider checks your overall health by running several different tests. Some, but not all, of the possible tests are listed below.

Lab testing includes blood and urine tests that examine your:

• Blood composition. Your provider checks the levels of red blood cells, platelets and other components in your blood. They also analyze your blood chemistry to look for signs of other conditions that might affect your ability to have a heart transplant.
• Immune system. Your provider uses the findings from an immune system analysis to predict how well your immune system can tolerate a donor organ.
• Kidney function. A urinalysis shows how well your kidneys are working.
• Use of alcohol, tobacco and drugs. Testing for alcohol, tobacco and drugs is an important part of your preparation. You must avoid alcohol, tobacco products (including vaping) and recreational drugs (including marijuana) for an extended time before your transplant.

Imaging tests you may need include:

• X-rays.
• Computed tomography (CT) scans.
• Magnetic resonance imaging (MRI).
• Echocardiogram.

Diagnostic tests check the function of your heart, respiratory and circulatory systems. These may include:

• Electrocardiogram (ECG or EKG).
• Exercise stress testing.
• Pulmonary (lung) function testing.
• Heart catheterization.
• Holter monitor.

Testing for specific diseases is also possible, especially the following:

• Tuberculosis.
• HIV.
• Hepatitis B.
• Hepatitis C.
• Toxoplasmosis.
• Herpes simplex virus.
• Varicella-zoster virus (the virus that causes chickenpox and shingles).

Transplant recipients need to be up-to-date on vaccines before transplantation. An infectious disease specialist helps with this process.

Psychological and neurological evaluation

Part of the selection process includes psychological and neurological testing and evaluation. That’s because maintaining a healthy heart transplant is stressful and at times challenging. People who receive a transplant also face an increased risk of depression. Neurological tests check for issues that might cause you additional problems.

Dental evaluation

Your oral health, especially the condition of your teeth, can play a big role in your heart health. It’s common for oral infections from cavities to spread to your heart and cause damage there.

Social and financial evaluation

Heart transplant is a difficult, intensive process. People with the best chance of success also have a good support system around them, including family and friends. The transplant team will talk with you about your situation and learn what resources you might need to get through the process.

Addition to the waiting list

If the screenings and evaluations find that you’re a good candidate, the next step is for transplant list coordinators to add you to the waiting list. The list prioritizes people based on their current health condition and how long they’ve been waiting. The more urgently you need a heart, the higher on the list you tend to be.

Bridge treatment

Bridge treatments are therapies, medications or other types of care that help you while you wait for a transplant. These therapies help you have fewer and milder symptoms.

Potential bridge treatments include:

• Medications. These medications affect your heart function in different ways, such as making your heart beat faster or pump harder.
• Mechanical support. Certain types of devices can help your heart pump. An example is an intra-aortic balloon pump. A doctor inserts this pump into a major blood vessel and threads it up to your heart until it’s just outside your heart’s aortic valve. The pump then inflates and deflates a small balloon in time with your heart. This makes it easier for your heart to pump.
• Left ventricular assist device. Your heart may be so weak that it pumps an inadequate amount of blood to your body. This can lead to organ damage. In this case, your team may recommend a left ventricular assist device to keep you safe while awaiting transplantation.

What happens during a heart transplant?

A heart transplant is a complicated surgery. Your care team will perform the following steps.

1. Give you general anesthesia. A heart transplant always involves general anesthesia, which puts you into a deep sleep.
2. Connect you to a ventilator. While you’re asleep, your provider inserts a tube down your throat, attaching the end of the tube outside your body to a machine called a ventilator. The ventilator keeps you breathing even though you’re under anesthesia.
3. Give you blood thinners. Your provider adds a blood thinner like heparin to your blood. This reduces the risk of blood clots as your blood flows through the heart-lung bypass machine.
4. Connect you to a heart-lung bypass machine. This is also called a cardiopulmonary bypass machine. This device takes over the work of your heart and lungs during your surgery. It adds oxygen to your blood and removes carbon dioxide. It also keeps your blood circulating to all your other organs and tissues.
5. Remove your heart. To make room for the donor heart, your surgeon removes your heart. This procedure involves clamping off the blood vessels that connect to your heart and disconnecting your heart from them.
6. Implant the donor heart. Your surgeon attaches the donor heart to your major blood vessels and starts to warm and restart your new heart. Your new heart may need help to start beating. If so, your care team may need to use an electrical pacing device. This device works like a pacemaker but doesn’t involve permanent implantation.

What happens after a heart transplant?

After your heart transplant, you can expect the following:

• Hospital recovery. You’ll recover in the hospital for one to three weeks, depending on your situation. You’ll spend the first part of your recovery in the intensive care unit (ICU). In the ICU, healthcare providers will monitor you around the clock. They’ll check your vital signs and also watch for any signs that your body is rejecting your new heart.
• Plan of care. Before you leave the hospital, your provider will give you a plan of care that you should follow while recovering at home. Make sure you understand the plan, and ask as many questions as needed.
• Cardiac rehab. Your provider will tell you how to join a cardiac rehabilitation program. This is a prescribed, monitored program that helps you improve your strength, endurance and heart function.

When you’re back home, it’s important to closely follow your plan of care. Your plan will include instructions for:

• Medications you need to take.
• What to eat and drink, and what to avoid.
• Exercise and physical activities that are safe vs. unsafe.
• Recognizing signs of infection or organ rejection.

It’s also essential to learn what’s normal during recovery, and what signals a problem. One example is knowing what your resting heart rate should be.

After your heart transplant, your resting heart rate usually stays at the high end of normal or slightly higher (90 to 110 beats per minute). This is because the donor heart doesn’t automatically connect with your body’s nervous system, which controls your heart rate. Talk with your provider about the resting heart rate you can expect and how it might change in the future.

Immune system suppression

After your surgery, your provider will start you on medications that suppress your immune system. These immunosuppressants are essential medications for transplant recipients.

That’s because your immune system’s normal reaction to a foreign object (like a donor heart) is to treat it like an infection or other harmful invader and attack it. The immunosuppressant medications protect your new heart from attack by your own immune system. You’ll need to take these medications for the rest of your life.

What are the advantages of heart transplantation?

The biggest advantage of heart transplantation is that it can save your life when you have no other options available. Heart transplantation may be the only option if other treatments:

• Haven’t helped you.
• Have a low chance of helping you.
• Are too risky for you.

What are the disadvantages of heart transplantation?

The biggest disadvantages of heart transplantation are:

• Donor hearts are scarce. There aren’t enough donor hearts available to help all the people who need a heart transplant.
• It’s an extremely complicated surgery. So it can only be done at the most well-equipped hospitals.
• Some people may be too ill to survive the procedure.
• The procedure has several potential risks and complications (see below).

What are the risks of heart transplantation?

The most common risks and complications of heart transplant surgery include:

• Organ rejection.
• Infections (because of immune system suppression).
• Graft failure (where part of the connection between your body and the donor heart fails for any reason).
• Cardiac allograft vasculopathy (CAV).
• Kidney disease and kidney failure.
• Osteoporosis.
• High blood pressure (hypertension).
• Nerve damage.
• Irregular heart rhythms (arrhythmias).

Other possible complications include:

• Stroke.
• Delirium.
• Pain.
• Depression.

How long does it take to recover from a heart transplant?

Heart transplant surgery is a complicated, extensive surgery. Recovery times are typically longer than most heart surgeries. You’ll need to stay in the hospital for at least 10 days, and possibly up to three weeks. How long you spend in the hospital depends on your specific situation and how the surgery went. Overall, you’ll need several months to fully recover.

What is the outlook for heart transplant recipients?

In the U.S., about 91% of adult heart transplant recipients live at least one year after the surgery. The risk of death is highest in the first year. The most common causes of death within the first year are:

• Graft failure.
• Organ rejection.
• Infection.

After the first year, graft failure remains one of the most common causes of death.

After five years, cancer becomes a common cause of death. A major reason is the immunosuppressant drugs you take to avoid organ rejection. These drugs reduce your body’s ability to stop malfunctioning cells, making you more vulnerable to cancer.

About half of all people who receive a heart transplant live more than 10 years after the procedure. Advances in medicine and transplant care mean more and more people live 20 to 30 years or more after their transplant.

Heart transplants in children

Pediatric heart transplant recipients (children ages 17 and under) also tend to have good outcomes. About 92% live at least one year after their transplant, and slightly more than 70% live at least 10 years.

Heart retransplantation

Some adults and children need a second transplant to replace the first. This is called a retransplantation. It may be necessary if your body rejects the first transplanted heart, or for other reasons.

Retransplantations account for 2% to 4% of heart transplant surgeries in adults, and about 5% of those in children.

When can I go back to my usual routine after a heart transplant?

Your healthcare provider is the best person to tell you when you can return to your usual activities. It depends on how your recovery is going and your overall health.

You likely won’t be able to drive for at least six to eight weeks after your surgery. You also shouldn’t lift anything heavier than 10 pounds for at least six weeks. Your provider will give you specific instructions that you should closely follow.

Can people with heart transplants drink alcohol?

You should limit or eliminate alcohol consumption after your heart transplant. Alcohol contains many calories but no nutritional value. Alcohol causes your triglyceride level to go up, which isn’t good for your blood vessels and heart. A heart transplant gives you the chance to be healthier and stronger than before. So, it’s important to do whatever you can to support your new heart and keep it working at its best.

If you do choose to drink alcohol, limit your consumption to one drink per day. This means no more than:

• One 6-ounce glass of wine.
• One 12-ounce beer.
• A drink with 1.5 ounces of distilled liquor (rum, whiskey, gin, vodka).

If you find it hard to drink less or quit, talk with your healthcare provider. Your provider will share resources to help you.

Can people with heart transplants get vaccines?

You can safely receive some vaccines if you’ve had a heart transplant. For example, the flu shot is safe and helps you stay healthy after your transplant. There’s no risk of catching the flu from the flu shot because the virus is dead. But there’s an exception: You shouldn’t have the nasal spray flu vaccine because it contains a live form of the virus.

Any vaccine that’s considered “live” can be dangerous for transplant recipients. These vaccines contain a weakened form of a virus that’s harmless for most people. But your immunosuppressant drugs make you more vulnerable to sickness. So, live vaccines may make you sick. It’s also risky for you to be in close contact with someone who recently received a live vaccine. If someone in your household needs a live vaccine, talk with your healthcare provider about any precautions you should take.

In general, talk with your healthcare provider before receiving any vaccine to make sure it’s safe for you.

When should I see my healthcare provider?

Your healthcare provider will set up a schedule of visits after your procedure, especially within the first three months. These visits are essential for a successful recovery.

As part of your follow-up appointments, your provider will order tests to check for signs of organ rejection. Your provider will also explain what symptoms to look out for and tell you when you should call your care team.

Your healthcare provider will also talk with you about the importance of:

• Preventive dental care. Cavities and infections in your mouth can easily spread to your heart.
• Vaccinations. Vaccines help you avoid deadly infections. Your provider will explain which ones are safe and necessary for you.
• Routine health screenings. These are essential for diagnosing conditions like high blood pressure and high cholesterol. Your provider will also check for signs of other health problems, like various forms of cancer.

When should I go to the emergency room?

Call 911 or your local emergency number if you have any of the following symptoms of complications as you recover at home:

• Fever.
• Drainage or oozing from the incision in your chest.
• Redness or warmth around the incision.
• The feeling that your breastbone (sternum) is moving or shifting.
• Any kind of cracking or popping sound/feeling in your breastbone when you move.

A note from Cleveland Clinic

A heart transplant can be a life-saving medical procedure. But there’s a limited supply of donor hearts. Healthcare providers can help determine if you’re a good candidate for a transplant, and if so, help you prepare for the next steps. Thanks to advances in medicine, most people enjoy a better quality of life after their transplant. In the long-term, it’s possible to live years or even decades after your heart transplant, giving you a chance to make new memories with your loved ones.