Evaluation

In some cases, the need for heart transplantation happens very quickly and patients don’t have much time to prepare. In other cases, the health of a patient’s heart has been failing for some time and transplantation is something he or she has had time to consider and plan for. All candidates for a heart transplant undergo a thorough physiologic and psychosocial evaluation that includes blood tests, medical imaging studies, a health assessment, and more. The goal is to ensure that transplantation is the best option given the patient’s circumstances.  Each case is reviewed in detail and discussed by the team. Following this process, patients are notified in writing of the team’s decision and a follow-up office visit will be scheduled.

Once accepted into the Heart Transplantation Program, the potential recipient’s name is entered into a national waiting list maintained by UNOS (United Network for Organ Sharing). Heart transplants use the hearts from deceased “brain dead” donors. In this situation, the brain dies and for medcal and legal purposes, the patient is declared officially dead.  However, through modern technology it is possible that the remaining organs in this person are still alive. When a donor organ becomes available, all patient information is compared to that particular donor. Generally donor organs are distributed within a given geographic region. Factors that effect “matching” with a given donor include how sick the particular recipient is compared to other recipients on the list, how long the candidate has been on the waiting list, and biological similarities between the candidate and the donor such as body size and blood type.

While listed and awaiting transplant, patients will be followed by the heart failure team at Yale-New Haven in addition to visits with their local referring cardiologist. As a patient becomes sicker, he or she may require more intensive forms of treatment such as infusion of continuous intravenous medications and/or placement of ventricular assist devices (VADS). VADS are mechanical devices that can provide an extended period of support for a failing heart.

Surgical Procedure

The surgery typically takes four to six hours not including preoperative preparation time or postoperative transport to and initial assessment in the recovery area. The surgery involves opening the chest cavity and connecting the patient to a heart-lung bypass machine to keep oxygenated blood flowing throughout the body. Once the diseased heart is removed, the donor heart is sewn into place. Sometimes and electric shock is needed to the make the muscle fibers contract in a coordinated manner.

Immediately following surgery, patients are brought to the cardiothoracic intensive care unit, remaining sedated and on a ventilator (breathing machine). Vital signs are closely monitored and multiple intravenous medications are adjusted. During the first twenty-four hours, many of the supportive medications and monitoring equipment may be discontinued as their use is no longer needed. In addition, discontinuation of ventilatory support is typical, and the patient may get out of bed and into a chair.

Heart transplant recipients are given immunosuppressive drugs to prevent the body from rejecting the new heart. These drugs are usually started shortly after the heart transplant surgery. Immunosuppressive drugs keep the body’s immune system from recognizing and attacking the new heart as foreign tissue. Because the chance of rejection is highest during the first year after the transplantation, recipients are usually given a combination of three or four immunosuppressive drugs in high doses during this time. The dosage of medication will gradually decrease over the first year, and many medications will be discontinued, however transplant recipients must take maintenance doses of immunosuppressive drugs for the rest of their lives.

The length of stay is frequently influenced by the level and longevity of a recipient’s incapacity prior to the time of transplant; however recipients typically transfer from the intensive care to the step-down unit approximately 4-5 days after surgery. Discharge from the hospital usually occurs 7 to 10 days after the transplant operation.

At discharge, transplant recipients are followed as outpatients in the cardiac transplant clinic every one to two weeks and progressively less frequently until, by three years post-transplant, recipients may be seen twice yearly.

For a personal take on heart transplant recovery read the the story of Kim Lane.