What’s involved in a heart transplant?

Here’s what you need to know about this life-saving surgery.

When you’re experiencing end-stage heart failure — the final stage of heart failure — the heart muscle is failing severely in its attempt to pump blood through the body. If you’ve reached this stage, you’ve likely already tried treatments that have not worked. In this case, a heart transplant may be an option for you.

However, a heart transplant involves major heart surgery and can be very risky in some patients. For that reason, not everyone is the right candidate for heart transplant. Here, Dr. Kaushik Amancherla, a cardiologist with the Vanderbilt Heart Transplant program, answers some key questions you might have about the heart transplant procedure, step-by-step.

Who is a heart transplant right for?

“A heart transplant may not be the right choice for everyone,” said Amancherla. “A wide range of information is needed to determine if it is the right thing to do for the patient.”

A transplant team will evaluate the information. The team includes a transplant surgeon, a transplant cardiologist (doctor specializing in the treatment of the heart), nurse practitioners or physician assistants, one or more transplant nurses, a social worker, and a psychiatrist or psychologist. Other team members may include a dietitian, a chaplain, hospital administrator and an anesthesiologist (doctor who uses medicines to keep you asleep during surgery). By interacting with this large team, a holistic approach is taken to determine if heart transplantation is the right choice.

What happens once you are on the transplant list?

“Once you have been accepted as a transplant candidate, you will be placed on the United Network for Organ Sharing (UNOS) list,” Amancherla said. When a donor organ becomes available, candidates are selected from the heart transplant waiting list based on criteria like the severity of their condition, body size and blood type.

If the heart is to be yours, you will need to go to the hospital right away so you can get ready for the transplant. (Most hearts must be transplanted within a few hours after they’ve been removed from the donor.)

What happens during heart transplant surgery?

Generally, the heart transplant procedure follows this process:

• You will be given general anesthesia. Once you are asleep, a breathing tube will be put through your mouth into your windpipe. The tube will be attached to a machine (ventilator) that will breathe for you during the surgery.
• The anesthesiologist will watch your heart rate, blood pressure and blood oxygen level during the surgery.
• The surgeon will make an incision down the center of your chest from the top of the breastbone to just above the top part of the stomach.
• The surgeon will cut the sternum in half. Once cut, the surgeon will separate the two halves and spread them apart to reach your heart.
• The surgeon will put tubes into your chest so that your blood can be pumped through your body by a heart-lung machine, called a cardiopulmonary bypass.
• Once your blood has been completely diverted into the bypass machine and is being pumped by the machine, your surgeon will remove the diseased heart.
• The surgeon will sew the donor heart into place. Once your new heart is in place, they will connect the blood vessels carefully so there are no leaks.
• When your new heart is fully connected, the blood circulating through the bypass machine will be allowed back into the heart and the tubes to the machine are removed. Your surgeon will shock the heart with small paddles to restart the heartbeat.
• Once your new heart starts to beat, the team will watch the heart to see how it’s working and make sure there are no leaks.
• Wires for pacing will be put into the heart. Your surgeon can attach these wires to a pacemaker outside your body for a short time to pace your new heart, if needed, during the initial recovery period.
• The surgeon will rejoin the sternum and sew it together with small wires.
• The surgeon will sew the skin over the sternum back together using stitches or surgical staples to close the incision.
• Tubes will be put into your chest to drain blood and other fluids from around the heart. These tubes will be connected to a suction device to drain fluids away from the heart as it heals.

What are the risks of a heart transplant?

As with any surgery, complications may occur. Potential risks of a heart transplant may include:

• Infection
• Bleeding during or after the surgery
• Blood clots that can cause heart attack, stroke or lung problems
• Breathing problems
• Kidney failure
• Coronary allograft vasculopathy (CAV). This is a problem with the blood vessels that carry blood to the heart muscle itself. They become thick and hard. This can cause serious heart muscle damage.
• Rejection or failure of the donor heart
• Death

“Your body’s immune system may reject the new heart,” Amancherla explained. “Rejection is your body’s normal reaction to a foreign object or tissue. When you get a new heart, your immune system reacts to what it sees as a foreign threat and attacks the new organ.” To allow the transplanted organ to survive in a new body, you will need to take anti-rejection medicines, which will trick the immune system into accepting the transplanted heart. You’ll take these medicines for the rest of your life.

What happens after the heart transplant procedure?

After surgery, you’ll be monitored closely in the intensive care unit (ICU). When your health-care team decides you are safe enough to leave the ICU, you will be moved to a private room on a surgical unit or transplant unit.

“Your team will closely watch your anti-rejection medicines to make sure you are getting the right dose and the best combination of medicines,” Amancherla said. “Nurses, respiratory therapists and physical therapists will work with you as you start physical therapy and breathing exercises.” Heart transplant surgery requires a hospital stay of seven to 14 days, or even longer.

You will need frequent follow-up visits after the heart transplant procedure. These visits may include blood tests, chest X-rays and a biopsy. In a biopsy, a thin needle is used to remove tissue from the heart so it can be checked under a microscope. The transplant team will explain the schedule for these visits and tests. The rehab program will continue for many months.

To allow the transplanted heart to survive in your body, you will need to take medicines for the rest of your life to fight rejection. “Each person may react differently to medicines, and side effects can be serious,” Amancherla said. “Your health-care provider will tailor medicine plans to meet your needs.”