HEART TRANSPLANTATION

What is it?

What is the procedure?

Complications and contraindications

What is heart transplantation?

A heart transplant, or a cardiac transplantation, is a surgical transplant procedure performed on patients with end-stage heart failure or severe coronary artery disease. As of 2008 the most common procedure was to take a working heart from a recently deceased organ donor (cadaveric allograft) and implant it into the patient. The patient's own heart is either removed (orthotopic procedure) or, less commonly, left in place to support the donor heart (heterotopic procedure); both were controversial solutions to an enduring human ailment. Post-operation survival periods averaged 15 years. Norman Shumway, is widely regarded as the father of heart transplantation although the world's first adult human heart transplant was performed by Christian Barnard in South Africa utilizing the techniques developed and perfected by Norman Shumway and Richard Lower.

Heart transplantation procedure

A typical heart transplantation begins when a suitable donor heart is identified. The heart comes from a recently deceased or brain dead donor, also called a beating heart cardaver. The patient is contacted by a nurse coordinator and instructed to come to the hospital for evaluation and pre-surgical medication. At the same time, the heart is removed from the donor and inspected by a team of surgeons to see if it is in suitable condition.

The patient must also undergo emotional, psychological, and physical tests to verify mental health and ability to make good use of a new heart. The patient is also given immunosuppressant medication so that the patient's immune system does not reject the new heart. Once the donor heart passes inspection, the patient is taken into the operating room and given a general anasthetic. Either an orthotopic or a heterotopic procedure follows, depending on the conditions of the patient and the donor heart.

Orthotopic procedure
The orthotopic procedure begins with a median sternotomy, opening the chest and exposing the mediastinum. The pericardium is opened, the great vessels are dissected and the patient is attached to cardiopulmonary bypass. The donor's heart is injected with potassium cholride (KCl). Potassium chloride stops the heartbeat before the heart is removed from the donor's body and packed in ice. Ice can usually keep the heart usable four. to six hours depending on preservation and starting condition. The failing heart is removed by transecting the great vessels and a portion of the left atrium. The patient's pulmonary veinsare not transected; rather a circular portion of the left atrium containing the pulmonary veins is left in place. The donor heart is trimmed to fit onto the patient's remaining left atrium and the great vessels are sutured in place. The new heart is restarted, the patient is weaned from cardiopulmonary bypass and the chest cavity is closed.

Heterotopic procedure
In the heterotopic procedure, the patient's own heart is not removed. The new heart is positioned so that the chambers and blood vessels of both hearts can be connected to form what is effectively a 'double heart'. The procedure can give the patient's original heart a chance to recover, and if the donor's heart fails (e.g., through rejection), it can later be removed, leaving the patient's original heart. Heterotopic procedures are used only in cases where the donor heart is not strong enough to function by itself (because either the patient's body is considerably larger than the donor's, the donor's heart is itself weak, or the patient suffers from pulmonary hypertention).

Schematic of a transplanted heart with native lungs and the great vessel.

Transplanted heart in the thorax of recipient.

Complications and contraindications

Complications Post-operative complications include infection, sepsis, organ rejection, as well as the sideeffects of the immunosuppressive medication. Since the transplanted heart originates from another organism, the recipient's immune system typically attempts to reject it. Immunosuppressive drugs reduce that risk, but may cause unwanted side effects, such as increased likelihood of infections or nephrotoxic effects. Many recent advances in reducing complications due to tissue rejection stem from mouse heart transplant procedures.

Contraindications Some patients are less suitable for a heart transplant, especially if they suffer from other circulatory conditions unrelated to the heart. The following conditions in a patient increase the chances of complications: Kidney, lung, or liver disease Insulin-dependent diabetes with other organ dysfunction Life-threatening diseases unrelated to heart failure. Vascular disease of the neck and leg arteries. High pulmonary vascular resistance Recent thromboembolism Age over 60 years (some variation between centers) Substance abuse (which increases the chance of lung disease)