HEART TRANSPLANT

  • Heart failure: what it is and when is a transplant needed
  • Heart transplant: who can be placed on the waiting list?
  • When not transplanting
  • A new heart is available: the call from the transplant center
  • How is a heart transplant performed? The surgical procedure
  • The hospital stay after a heart transplant and the survival rate
  • Organ rejection and other complications
  • Rejection
  • Failure of the transplant
  • Infections
  • Kidney failure
  • Tumors
  • Thickening of the arterial vessels
  • Prevention is key

The heart transplant allows people with severe heart failure to receive a perfectly healthy heart from a deceased donor. First performed in 1967 by South African physician Christiaan Barnard, heart transplantation is a delicate and not uncomplicated surgery, but it allows the transplant patient to significantly improve their quality of life.

Let’s see what this operation consists of, when it is necessary and what are risks it entails.

HEART FAILURE: WHAT IT IS AND WHEN IS A TRANSPLANT NEEDED

In a state of heart failure, the heart loses its contractile function, that is, it is unable to pump blood around the body: this condition weakens the whole organism and causes suffering in other organs as well. 

People with this disorder are dyspnoic, that is, they are constantly short of breath, suffer from repeated coughing, and suffer from water retention, accumulating fluids in the lower limbs and abdomen, where edema and swelling are created.

Heart failure, therefore, causes a state of persistent breathlessness that can prevent you from carrying out even the simplest daily activities.

Diseases that can lead to severe heart failure are mainly:

  • Cardiomyopathy – a condition that prevents the heart from contracting and pumping blood.
  • Coronary artery disease – if their function fails, a heart attack occurs because the heart does not get enough blood.
  • Heart valve defects – there are four valves in the heart, and they regulate blood flow within the organ. If this is not done, the heart is unable to pump properly.
  • Congenital heart malformations.
  • Cardiac tumors.

A patient is considered eligible for heart transplantation when heart failure is so severe that no other treatment is possible, and life expectancy is no more than two years.

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HEART TRANSPLANT: WHO CAN BE PLACED ON THE WAITING LIST?

The assignment of a new heart to a sick patient takes place through the inclusion in the waiting list, according to a position assigned by the medical team of the Regional or Interregional Transplant Center based on a general assessment of the patient’s state of health.

According to data processed by the Association of Organ Donors, 233 heart transplants were performed in Italy in 2018, in 16 transplant centers located throughout the national territory. The average time to enter the waiting list is 3.4 years while you are called for surgery after just over 1 year. 7.6% of patients on the waiting list died before the call (data updated to 2017).

Each Transplant Center has its waiting list, while for pediatric patients (under 15 years old), the list is national.

Organ donation and transplantation are managed regionally by the National Health Service: heart transplantation is one of the health services defined by Lea (Essential Levels of Assistance) and for this reason, it is completely free for all citizens assisted by the NHS.

The specialist is responsible for assessing whether the patient needs a transplant is a cardiologist who is treating the patient. He will be the one to contact the competent Transplant Center: at this point, the team of specialists will start all the checks to understand if the patient can be included in the list.

It is important to underline that only patients who have a good chance of survival after surgery can be included, based on some tests to ascertain the general condition of the patient:

  • Complete cardiac control, through coronary angiography and electrocardiogram. From these tests, it is clear whether transplantation is the only possible way to ensure that the patient survives.
  • Chest radiological examinations. MRI, X-ray, and CT scan are necessary to ensure that the overall condition of the thoracic area and all the organs present is good.
  • A complete examination of blood and urine.
  • Cancer screening to exclude the presence of tumors
  • Blood pressure control.
  • Tests to rule out smoking, drug and alcohol addictions.
  • Psychological evaluation, to make sure that the patient is in a good state of mental and emotional stability.
  • Social evaluation, to verify that the patient can be cared for and supported by family members and contact persons.

If these checks are successful, the patient can be placed on the waiting list to receive a new heart.

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WHEN NOT TRANSPLANTING

Unfortunately, as this is a very delicate surgery, there are cases in which the patient is automatically excluded from heart transplantation. This occurs if one or more of these conditions occur:

  • Over 65 years of age.
  • Severe ongoing infections and the presence of serious infectious diseases such as AIDS.
  • Tumors in place.
  • Severe renal insufficiency.
  • Pulmonary hypertension, which is the considerable increase in blood pressure in the pulmonary arteries. This condition can be resolved with the implantation of a heart pump (VAD) that replaces the left ventricle and allows the pulmonary pressure to drop. In some cases, this procedure can make transplantation possible.
  • Addiction to alcohol, smoking, drugs.
  • Mental instability.
  • Absence of family members and people who can take care of the patient after the operation.

A NEW HEART IS AVAILABLE: THE CALL FROM THE TRANSPLANT CENTER

When a heart is available for transplantation, it is assigned to the competent Transplant Center, coordinated by the National Transplant Center, which must identify the most suitable recipient based on some elements:

  • Blood group compatibility
  • Organ size compatibility
  • Clinical urgency is based on the condition of the patient.

All parameters being equal, the one who has been on the list for the longest time has priority.

When a new heart is deemed available, a doctor from the Transplant Center will contact the patient on the waiting list, who is required to report to the hospital within 2 hours of the call.

It is useful to underline that a new heart, to be considered available, must meet the compatibility criteria and belong to a deceased donor who has given consent – or whose family has given consent – for organ transplantation.

The person who is about to receive the transplant must go to the hospital fasting from the moment of the call because the surgery takes place under general anesthesia.

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HOW IS A HEART TRANSPLANT PERFORMED? THE SURGICAL PROCEDURE

From the moment the donor has died, the heart can be taken within 6 hours, while no more than 4 hours should pass from the removal to the transplant.

An entire medical team is involved in a heart transplant: surgeon, anesthetist, nurses, cardiologist, physiotherapist, psychologist, to ensure the patient complete assistance from all points of view.

The intervention lasts from 3 to 5 hours. It is a delicate procedure and its success is compromised by the general conditions in which the recipient is at the time of the operation.

The surgeon, assisted by the medical team, first of all, proceeds with a sternotomy to open the chest and sternum and remove the damaged heart: it will then be necessary to connect the patient to the heart-lung machine, which allows extracorporeal circulation while awaiting implantation of the organ.

At this point the surgeon inserts the new heart: he connects all the blood vessels, first of all, the aorta, and closes the chest with a suture. If necessary, an electrical stimulus is used to make the new heartbeat, and the procedure is ended by inserting thoracic and bladder drains.

At the end of the transplant, the patient is transferred to intensive care.

THE HOSPITAL STAY AFTER A HEART TRANSPLANT AND THE SURVIVAL RATE

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Following the surgery, the transplant recipient will awaken from anesthesia after approximately 24 hours. If no complications arise, he will then be hospitalized in the hospital ward for about three weeks, immediately starting anti-rejection therapy based on immunosuppressants, drugs that keep the patient’s immune system under control thus reducing the possibility of rejection.

During the hospitalization period, the patient with the new heart will be placed in a room with a low microbial load, where the chances of coming into contact with microbes and infections are minimized. This phase is very delicate: the patient can receive very few visits and whoever comes into contact with him must avoid the transmission of bacteria by wearing a mask, shoes, cap, gown, and gloves. 

If the general conditions of the transplant patient remain good, when he is discharged he will immediately experience a significant improvement in the quality of his life and health: he will have the opportunity to start carrying out daily activities, work, and even recreational sports.

According to Aido data, one year after heart transplant survival is 80.9%, and 90.1% of transplant recipients work or can work.

Naturally, after the surgery, the patient will undergo numerous periodic checks: blood tests, echocardiogram, electrocardiogram, and heart biopsies. To this is added the therapy based on immunosuppressants.

It is very important for a person who has received a heart transplant to be able to count on the proximity of family members and qualified health workers, and given the delicacy of the intervention, psychological assistance is recommended.

ORGAN REJECTION AND OTHER COMPLICATIONS

The risks related to a heart transplant are varied, all of considerable magnitude: let’s see them together.

REJECTION

Organ rejection in heart transplantation is the main risk as the body rejects the new heart recognizing it as foreign to the body. We speak of hyperacute rejection when it occurs immediately after surgery, acute rejection if it appears after a few days or weeks, chronic rejection when it occurs months or years later.

To avoid rejection, the transplant patient takes immunosuppressants for life.

Symptoms of heart rejection are high fever, shortness of breath, swelling of the hands and feet, fatigue, palpitations.

FAILURE OF THE TRANSPLANT

The operation fails when the new heart does not start beating again after being transplanted.

INFECTIONS

Immunosuppressants lower the immune defenses of the whole organism: this is why transplant recipients are more exposed to bacterial and viral infections.

Antibiotics are given to prevent them.

KIDNEY FAILURE

This complication arises when the functionality of one or both kidneys fails and must be treated with dedicated therapy.

TUMORS

Also due to immunosuppressants, there is an increased risk of developing cancers of the skin and lymphoid tissues. To avoid this complication, it is advisable to expose yourself as little as possible to UV rays, both natural and artificial, and to always protect the skin very carefully.

THICKENING OF THE ARTERIAL VESSELS

Following the surgery, the arrangement of the arteries changes, and this can lead to a gradual thickening of the arterial walls, reducing the cavity in which blood can circulate and causing new blood circulation problems.

Other side effects of immunosuppressants must also be considered among the risks of heart transplantation. These include muscle weakness, nausea, vomiting, ulcers, blurred vision, insomnia, weight gain, shaking, acne, osteoporosis.

PREVENTION IS KEY

To prevent cardiovascular problems it is necessary to pay attention to a correct lifestyle: balanced diet, periodic checks, and physical movement. It is also important to carry out periodic heart tests, especially recommended for men after 40 and women after 50, especially if there are risk factors such as diabetes, hypertension, addictions, or strong stress factors.

  1. To allow you to better control the health of your heart, there are insurance policies that guarantee you can take advantage of the cardiological check-up and any additional investigations, such as the medicare  Family Protection policy, which provides complete protection against cardiovascular risks, with dedicated tests. , agreements with high-level structures, reimbursements for any hospitalizations, and other opportunities.

Evaluating this option can be very useful: have you ever thought about it?

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