What is a heart transplant?
A heart transplant is an organ transplant 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 number 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 procedures that do have risks. After receiving a transplant, you’ll also need medical care for the rest of your life to help prevent dangerous complications.
Who needs to have this treatment?
Heart transplants are possible for people of any age, but most heart transplant recipients are between 50 and 64 years old. This procedure is also possible in children, usually because of heart problems they develop or already have at birth.
Why is this treatment done/used?
A heart transplant is a last-resort treatment when you 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, ranging from infections that damage your heart muscle to abnormal heart rhythms (arrhythmias) that may cause a reversible weakening of the heart.
Diagnoses most likely to result in heart transplant
The following conditions make up the majority of reasons for heart transplant:
- Cardiomyopathy. This refers to any disease that damages your heart muscle (cardio = heart, myo- = muscle, pathy = disease). Diseases that cause this kind of damage include infections, genetic diseases and damage from medical treatments (such as chemotherapy or radiation therapy for cancer).
- Coronary artery disease. This is a condition that affects the arteries that supply your heart. It’s a common cause of heart attack.
- Congenital heart disease. This is any heart disease you have when you’re born.
- Valvular heart disease. These are conditions that involve damage to your heart valves.
- Retransplants. These are instances where a person needs a second transplant to replace the first. This can happen because the donor's body rejects the first transplanted heart or for other reasons.
How common are these procedures? How often are these procedures performed?
Heart transplants overall are uncommon. In 2020, there were just under 8,200 transplants worldwide. The overwhelming majority of those (3,658) were in the United States. Other countries with the highest numbers of transplants 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. Part of the reason it's hard to find a donor is because the donor and recipient must be a "match." 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, and there are fewer than 150 hospitals in the U.S. (out of more than 6,000 hospitals overall) that perform them.
What happens before this procedure?
Because there are far more people who need hearts than donors, there's a strict selection process that you have to undergo to receive a heart transplant. The goal of this process is to select recipients who have the best chance of long-term survival based on their overall health.
After a healthcare provider refers you to a transplant program, you’ll undergo the following.
To ensure that donor hearts go to people with the best chance of survival, healthcare providers will evaluate your overall health by running several different tests. Some, but not all, of the possible tests are listed below.
Lab tests will include tests on your blood, urine and other screenings. These tests will look for the following:
- Blood composition. This analyzes your blood’s levels of red blood cells, platelets, and more. These tests will also analyze your blood chemistry, looking for signs of other conditions that might affect your ability to undergo a heart transplant.
- Immune system analysis. These tests help providers anticipate how well your immune system can tolerate a donor organ.
- Kidney function. These tests analyze your urine to see how well your kidneys are working.
- Tests for alcohol, tobacco and drugs. These are often important tests if you have a history of using recreational drugs or drinking too much alcohol. Most transplant centers require that you’re sober and avoid using tobacco products (including vaping) and recreational drugs for an extended time before your transplant.
Imaging tests that are possible include:
- Computed tomography (CT) scans.
- Magnetic resonance imaging (MRI), ultrasound (echocardiogram) and more.
Diagnostic tests, which evaluate the function of your heart, respiratory and circulatory systems, 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:
- Hepatitis B.
- Hepatitis C.
- Herpes simplex virus.
- Varicella-zoster virus (the virus that causes chickenpox and shingles).
Psychological and neurological evaluation
Part of the selection process includes neurological and psychological testing and evaluation. That's because maintaining a healthy heart transplant is stressful and at times challenging. People who receive a transplant also have a higher rate of depression afterward for various reasons including the usage of steroids to prevent rejection. Neurological tests also ensure there aren’t any other problems that might cause the heart recipient additional problems.
Your oral health, especially the condition of your teeth, can play a big role in heart health. It’s common for oral infections from cavities, or upper respiratory infections like strep throat, 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.
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 list. The list prioritizes people based on their current health and condition and how long they've been waiting. The more urgently you need a heart, the higher on the list you tend to be.
Bridging treatments are therapies, medications or other types of care that help you while you wait for a transplant. These therapies are supposed to lessen how often you have certain symptoms or how severe the symptoms are.
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, which a doctor inserts into a major blood vessel and threads 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, making it easier for your heart to pump.
What happens during this procedure?
A heart transplant is a complicated surgery that usually involves the following steps.
Heart transplant always involves general anesthesia, which puts you into a deep sleep. While you’re asleep, providers will insert a tube down your throat, attaching the end of the tube outside your body to a machine called a ventilator. The ventilator will keep you breathing even though you’re under anesthesia.
After you’re under anesthesia, providers will lower your body temperature to around 82 degrees F (about 28 degrees C). Lowering your body temperature means the activity of your cells slows down. That prevents damage to your cells when blood flow stops during various steps of the surgery.
Removing your heart
At some point, providers will also add blood thinners like heparin to your blood to keep it from clotting at the wrong time. They’ll then reroute all the blood in your body through a device called a heart-lung bypass machine. That device adds oxygen and removes carbon dioxide from your blood, and also keeps your blood circulating.
To make room for the donor heart you'll receive, doctors have to perform a procedure called cardiectomy to remove your heart. This procedure involves clamping off all the major blood vessels that connect to your heart and disconnecting your heart from them.
Implanting the donor's heart
At the same time that providers are removing your heart, they’ll also prepare the donor heart so surgeons can hook it up to all the necessary blood vessels. In most situations, the donor's heart comes from another hospital facility, with a surgical team at that facility coordinating with the team that will perform the transplant procedure on you.
Once the donor heart is ready, the surgeon will attach it to the various blood vessels connected to your original heart and start to warm and restart your new heart. In some cases, your new heart may need help beating, so using an electrical pacing device (which works like a pacemaker but doesn't involve a permanently implanted device) may be necessary.
What happens after this procedure?
After your heart transplant, the following will need to happen.
Immune system suppression
After the procedure, providers will start you on medications that will suppress your immune system. They do that because your immune system’s normal reaction to a foreign object is to treat it like an infection or other harmful invader and attack it. That suppression protects the new heart from attack by your own immune system.
Providers will continue to monitor your condition and vital signs closely. They do that to watch for any signs that your body is rejecting the new heart (despite immune-suppressing medications). You’ll also need to take those medications for the rest of your life.
Nervous system reconnection
Providers will also monitor the new heart's electrical function. That's necessary because the donor's heart doesn't connect to your nervous system. Fortunately, your heart can still manage how fast it beats in other ways. Your resting heart rate will usually stay at the high end of normal or slightly higher (90 to 110 beats per minute).
In many people, the heart recipient's nervous system can form new connections with the donor's heart. The sympathetic nervous system connections, which control your fight-or-flight response and speed up your heart, form after about six months. The parasympathetic nervous system connections, which help your heart slow down and relax, form after about 18 months to two years. In some cases, this reconnection doesn’t happen, but this isn’t usually the case.
If you undergo a heart transplant, you’ll stay in the hospital intensive care unit for one to three weeks, depending on your situation. Before discharge, you’ll likely get additional information, resources and education on the following:
- Medications you need to take.
- Diet and nutrition concerns.
- Exercise (including do's and don’ts).
- How to recognize infections or organ rejection.
After release from the hospital, it’s common to participate in a cardiac rehabilitation program. These are prescribed, monitored programs where specially trained healthcare professionals help you exercise and improve your strength, endurance and heart function.
You’ll also need to regularly see your healthcare provider for follow-up care, lab tests, diagnostic tests, imaging, and additional follow-up care over the next several months. All of these tests are necessary to ensure your well-being and recovery after receiving a heart transplant.
Risks / Benefits
What are the advantages and disadvantages of this procedure?
The biggest advantage of heart transplantation is that it’s a life-saving option when other options didn’t work, were too risky to use, or were unlikely to help.
The biggest disadvantages of heart transplant are:
- More people need a heart transplant than there are available donor hearts.
- It’s an extremely complicated surgery, limiting it to only the most well-equipped and best-staffed 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 or complications of this procedure?
The most common risks and complications of heart transplant include the following:
- Organ rejection.
- Infections (because of immune system suppression).
- Graft failure (where part of the connection between your body and the donor's heart fails for any reason).
- Kidney disease and failure.
- High blood pressure (hypertension).
- Nerve damage.
- Irregular heart rhythms (arrhythmias).
Other possible complications include:
Recovery and Outlook
What is the recovery time?
Heart transplant surgery is a complicated, extensive surgery procedure and recovery times are typically longer than most heart surgeries. The expected hospital stay is at least seven to 10 days, and usually up to three weeks. The time you spend in the hospital depends on your specific situation, health and how the surgery went. Overall, recovery from this procedure usually takes several months.
What’s the outlook after this procedure?
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, and the most common causes of death within the first year are graft failure, rejection or infection.
After the first year, graft failure remains one of the most common causes of death, with cancer rising and becoming more common after five years. This is because cancer is a cell malfunction that makes those cells reproduce uncontrollably. Your immune system usually detects those malfunctioning cells and stops them before they become a big problem (cells that can avoid this detection become cancer). The immune-suppressing drugs you take to avoid organ rejection also reduce your body’s ability to stop malfunctioning cells.
About half of all people who receive a heart transplant will 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% will live at least one year after their transplant, and slightly more than 70% will live at least 10 years.
When can I go back to work, school and drive?
Your healthcare provider is the best person to tell you when you can resume your usual activities. This is because your circumstances and overall health are the biggest factors in activities you can resume and activities you should avoid.
When to Call the Doctor
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. Those visits are critical to making sure you are recovering and aren’t experiencing any complications or problems related to your new heart.
Your provider will also tell you what signs and symptoms to watch for that mean you need emergency medical attention. Most commonly, the signs and symptoms involve the rejection of your new heart or infections. These symptoms include:
- Drainage or oozing from the incision in your chest.
- Redness or warmth around the incision.
- If your breastbone (sternum) moves, shifts or causes any kind of cracking or popping sound/feeling when you move.
Your healthcare provider will also recommend and help you do the following:
- Make sure you get preventive dental care (cavities and infections in your mouth can easily spread to your heart).
- Stay current on all your vaccinations (this helps avoid deadly infections).
- Get routine health screenings as needed (these can help avoid certain types of cancer, which become more possible because of immune system suppression).
A note from Cleveland Clinic
A heart transplant can be a life-saving medical procedure. However, not everyone can receive a transplant because donor hearts are in limited supply. 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 feel better and have improved quality of life after their transplant. In the long term, it's possible to live years or even decades after you get a transplanted heart, giving you a chance to make new memories and experiences with your loved ones.
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