Heart transplant: A treatment for end-stage heart failure

Find out what's involved in a heart transplant — from registering with a heart transplant center and waiting for a donor heart to the heart transplant surgery and post-transplant care.

If medications and other treatments are no longer enough to manage your heart failure, you and your doctor may have decided that it's time to consider a heart transplant. While this is a major operation, be comforted by the fact that medical technology has improved greatly since the first heart transplant in 1967 and your chances of survival are higher than ever.

When you have heart failure, your heart is still working but not as efficiently as it should. A weakened or damaged heart isn't able to pump enough blood to keep up with your body's needs. A heart transplant can be a lifesaving option when other treatments fail.

When faced with a decision about heart transplantation, know what to expect of the heart transplant process, the surgery itself, potential risks and follow-up care.

The transplant journey: Taking the first steps

If your doctor recommends that you consider a heart transplant, he or she will likely refer you to a heart transplant center for an evaluation. You're also free to select a transplant center on your own, but check with your health insurance provider to see which transplant centers are covered under your insurance plan.

When evaluating heart transplant centers, take into account the number of heart transplants a center performs each year and recipient survival rates. You can compare transplant center statistics on the Web through a database maintained by the Scientific Registry of Transplant Recipients.

Also consider additional services provided by a transplant center. Many centers coordinate support groups, assist you with travel arrangements, help you find local housing for your recovery period, or direct you to organizations that can help with these concerns.

Once you decide where you would like to have your heart transplant, you'll need to undergo an evaluation to determine whether you meet the eligibility requirements for a transplant. The evaluation will assess whether you:

Have a medical condition that would benefit from transplantation
Might benefit from other treatment options
Are healthy enough to undergo surgery and post-transplant treatments
Agree to quit smoking, if you smoke
Are willing and able to follow the medical program outlined by the transplant team
Have sufficient emotional stamina to undergo the wait for a donor organ and have a supportive network of family and friends to help you during this stressful time

Waiting for a donor organ

If the transplant center medical team determines that you're a good candidate for a heart transplant, the center will register you on a nationwide waiting list. On any given day, about 4,000 people are waiting for a heart transplant in the United States. Unfortunately, there aren't enough hearts for every person in need, and some people may die while waiting for a transplant. Over the course of a year, there are only enough donor hearts to provide about 2,000 transplants.

While you're on the waiting list, your medical team will monitor the condition of your heart and other organs and alter your treatment as necessary. Your transplant team may temporarily remove your name from the waiting list if you have a significant medical event, such as a severe infection or stroke, that makes you medically unstable.

If as you wait for a donor heart medical therapy is not satisfactory to support your vital organ function, your doctors may recommend that a mechanical device be implanted to support the work of your heart while you wait for a donor organ. These devices are known as ventricular assist devices (VADs) and have become increasingly used in people awaiting transplant. The devices are also referred to as a bridge to transplantation because they buy some time until a donor heart is available.

Research is under way to improve other options, too, such as the use of a total artificial heart. Currently, the use of such devices is limited.

When a donor heart becomes available, the donor-recipient matching system considers the following factors to make a match:

Medical urgency of potential recipients
Blood type (A, B, AB or O)
Antibodies the recipients may have developed
Size of the donor organ
Time spent on the waiting list

Preparing for the transplant

A heart transplant usually needs to occur within four hours of organ removal for the donor organ to remain viable. Because of this time restraint, hearts are offered first to a transplant center within the region, then to centers within certain distances of the donor hospital. The transplant center will provide you with a pager or cell phone to notify you when a potential donor organ is available. You must keep your cell phone charged and turned on at all times, and you should change your pager batteries monthly.

When you're notified, you and your transplant team have a limited amount of time to consider whether to accept the donation, and you'll be expected to arrive at the transplant hospital soon after being notified of the potential donation.

As much as possible, you should make travel plans ahead of time. Some heart transplant centers provide assistance with air transportation or other travel arrangements. Have a suitcase packed with everything you'll need for your hospital stay, as well as an extra 24-hour supply of your medications.

The surgery

Surgery usually takes about four hours — longer if you've had prior heart surgery or there are complications during the procedure. The surgeon will open your chest cavity and connect you to a heart-lung bypass machine to keep oxygenated blood flowing throughout your body. The diseased heart is removed, and the donor heart is sewn into place. The new heart often starts beating when blood flow is restored. Sometimes an electric shock is needed to make the muscle fibers contract in a coordinated manner.

You'll have some pain after the surgery, which will be treated with medications. You'll also have a ventilator to help you breathe and tubes in your chest to drain fluids from around your lungs and heart. Recovery often involves a one- to two-week hospital stay and about three months of frequent monitoring by the transplant team.

After the surgery

Key to understanding post-transplant treatment is the concept that a transplanted organ is foreign tissue to your body. Without specific treatments, your immune system will attack a new heart just as it would a viral infection.

To determine whether your body is rejecting the new heart, you'll have frequent heart biopsies. In this procedure, a tube is inserted into a vein in your neck or groin and directed to your heart. A biopsy device is run through the tube to extract a tiny sample of heart tissue, which is examined in a lab. Since rejection is most likely to occur in the early weeks and months after heart transplantation, the frequency of heart biopsies is highest during this early period.

Your new drug regimen after the transplant will include immunosuppressants — medications that suppress the activity of your immune system to prevent it from attacking your donated heart. Because your immune system will most likely never get used to the new organ, you'll take some of these medications for the rest of your life.

These medications may cause noticeable side effects. With some post-transplant drugs, such as corticosteroids, your face may become round and full, and you may gain weight, develop acne or facial hair, or experience stomach problems. Some of the effects are more pronounced when you first start the drug regimen but decrease in severity later on.

Because immunosuppressants make your body more vulnerable to infection, your doctor may also prescribe antibacterial, antiviral and antifungal medications. Some drugs could worsen — or raise your risk of developing — conditions such as high blood pressure, high cholesterol, cancer or diabetes.

Over time as the risk of rejection is reduced, the doses and number of anti-rejection drugs can be reduced, but you will need some level of immunosuppressive therapy indefinitely.

What can you expect of your new heart?

The majority of people who receive a heart transplant enjoy a high quality of life. Most people can return to work within three to six months of a heart transplant and have few if any restrictions.

Recipient survival rates vary based on a number of factors, but overall the one-year survival rate is nearly 90 percent after one year and 72 percent after five years.

What if your new heart fails?

Heart transplants aren't successful for everyone. Your new heart may fail because of organ rejection or because of the development of valvular heart disease or coronary artery disease. Should this happen, re-transplantation may be an option or modifications in your medical therapy may be a better alternative.

In some cases, subsequent treatment options are limited and you may choose to discontinue treatment. Discussions with your heart transplant team, physician and family should address your expectations and preferences for treatment, emergency care and end-of-life care.