November 18, 2017

Heart Transplant

Patient consideration for heart transplantation

Heart transplantation is usually reserved to treat end-stage heart disease, when all other options have been searched. Patients considered good candidates are those with highest probability of success after receiving a transplant. Not only do patients have to qualify by physical ailment but also pass psychological evaluation. The psychological evaluation assesses how well a patient is prepared to live with post-management of looking after the donated organ. There are limited donor organs, so it is important that select patients have the greatest chance of postoperative survival and rehabilitation.

“Beating Heart” Donors

Typically, a suitable heart donor comes from a recently deceased or brain dead donor. The donor will be inspected by a team in order to be evaluate it to be in suitable condition to be transplanted. The heart is then placed over ice and transported to any hospital across the nation. A heart can be used 5-8 hours after being removed, but it is urgent that the transplant team work quickly to transport the organ to its destination.

Potential cardiac donors go through rigorous screening evaluation.

What heart qualifies as a good donor?

  • Age < 55 years
  • No pulmonary disease
  • Normal or clean angiogram, indicative of a healthy heart
  • Normal ventricular and valve function
  • Antibody crossmatch between donor and recipient
  • Negative testing for hepatitis B and HIV
  • Blood matching, ABO groups
  • Matching size

Factors that effect placement on the waiting list
There are different factors that decide where a patient is placed on a waiting list. By this point, patients are usually very sick and a heart transplant is the last and only option. Sicker patients are placed at the top and are more likely to be recipients of the next available organ donor. The waitlist is based on urgency on how badly a patient is in need of a lung transplant.

Some of these factors include:

  • Age
  • Diabetes
  • Heart function
  • Body mass index
  • Need for mechanical ventilation
  • Overall diagnosis
  • Highest accrued waiting time

Series of events that happen

  1. Donor is found
  2. Family is contacted
  3. Donor organs are checked and a transplant team sent to pick up organs
  4. Patient brought to PACU
  5. Transplant lasts 8-10 hours

Incisions that will be made to access, remove, and replace with donor
The patient will typically undergo a sternotomy to access the heart inside the chest. Using a ‘heart-lung’ machine pump, the surgical team is able to re-route blood going through the patient’s heart into the machine. This allows circulation to the rest of the body while the surgical team replaces the old heart. The diseased heart is removed by cutting through the major arteries that are attached to the heart. Once removed, the new donor heart is prepared and reattached to the existing arteries. The procedure is much like unplugging and re-plugging a pump with all of its respective attaching hoses and lines.

Post-management

Ventilation, the patient will remain “on vent”, or assisted breathing, until they are able to breath sufficiently on their own.

Catheters: are usually placed to assist and stabilize the patient’s new heart. These catheters may stay in place 48-72 hours, until the heart has a chance to adequately recover.

Chest tubes: may stay in place 48-72 hours

Immunosuppression
Corticosteroids
Calcineurin inhibitor
Cell-cycle inhibitor

Risks of rejection and infection
Fight bacterial infection, pneumonia can develop
Bleeding and hemorrhaging
Leakage or tears
Systemic arterial circulation failure (if organs not revascularized properly)
Airway complications – strictures or collapses of airways

Early signs of rejection:

  • Fever
  • Urinating less often
  • Change in heart rate
  • Flu-like symptoms
  • Pain at the site of the transplant