Heart Transplant

Preparation

Your heart specialist may ask that you be evaluated for a heart transplant if he or she believes that your heart disease is so advanced that there are no other treatment options and that you would be a good candidate for this surgery.

A number of different conditions can damage your heart to the point where other treatments are unsuccessful and a transplant is the best chance for cure. These include:

• Congenital heart disease
• Coronary artery disease
• Heart Failure
• Pulmonary hypertension
• Valvular heart disease

Other conditions may exclude a patient from consideration for a transplant, such as irreversible pulmonary hypertension, cancer, HIV, active drug or alcohol addiction, acute mental incompetence and severe muscle loss due to malnutrition, called cardiac cachexia. A number of other conditions are evaluated on an individual basis to determine transplant suitability.

Once it is determined that you would benefit from transplant surgery, your name will be placed on a waiting list to receive a donor heart. There currently are not enough donor hearts available for the people who need them. Under national regulations, hearts must go to the sickest patients first in a given area.

Research currently is being done to evaluate devices that potentially could act as a "bridge" to transplantation by replacing heart function with a machine until a donor heart is available.

Evaluation

Our staff will determine your general suitability for transplantation using preliminary information from your referring doctor. After this initial assessment, a very comprehensive evaluation is conducted. Our approach to this is flexible although we do insist that every potential candidate and their family visit UCSF Medical Center at least once before the transplant.

All candidates are seen by UCSF's transplant team that includes a cardiologist, surgeon, transplant coordinator and social worker. If the patient lives far away from San Francisco, the team works with the referring doctor to complete portions of the pre-transplant selection protocol in your local community.

The pre-transplant evaluation includes assessment of both the cardiac and extra-cardiac systems. Stable patients usually are able to complete the standard pre-transplant selection protocol on an outpatient basis.

One of the most important components of the cardiac evaluation is an assessment of pulmonary vascular health. If the patient has pulmonary hypertension, it is essential to determine its severity and potential for cure. These trials are conducted in the hospital with right heart catheterization and continuous hemodynamic monitoring often for periods of six to 12 hours. Because the outcome of these trials is pivotal in determining the patient's suitability for transplant, we prefer to perform this part of the assessment at UCSF Medical Center.

Additional routine components of the cardiac assessment include:

• Non-invasive studies the evaluate the function of the heart muscle, including echocardiography and radionuclide scans.
• Perfusion tests, which measure the amount of blood flow to tissue, including resting and stress radionuclide scans or echocardiography.
• The measurement of maximal oxygen uptake during standard exercise studies.

Some patients also may need formal cardiac catheterization, including coronary angiography and ventriculography, myocardial biopsy and electrophysiologic studies.

In addition, there are a number of non-heart-related tests and other components that are part of the pre-transplant evaluation, including:

• Pulmonary function testing including spirometry and arterial blood gases.
• Lab tests for kidney and liver function.
• Interviews with the social worker, transplant coordinator and psychiatrist.
• Interviews with the hospital administration about financial security.
• Infectious disease screening including serology and skin testing.
• Immunogenetics including blood and tissue typing as well as checking your human leukocyte antigens (HLA) level.
• Cancer screening that includes chest X-rays and stools samples for everyone; mammograms, breast and pelvic exams for women; and prostate-specific antigen (PSA) and prostate exams for men.

Depending on your specific situation, additional tests may be run during the initial screening.

While the main focus of the evaluation is to determine whether the patient is a suitable candidate for transplantation, the team also works with the patient and family to resolve any potentially reversible conditions such as smoking, drug addition, obesity, mental distress, financial problems and so on.

The selection of patients for heart transplantation is based on a recommendation from the multidisciplinary heart transplant team that is comprised of representatives from various departments including surgery, internal medicine, nursing, psychiatry, social work, pathology and hospital administration. The potential heart transplant candidate's case is presented at the weekly transplant meeting after the members of the team complete the interviewing process and the patient completes all pre-transplant testing.

After this discussion, the team will decide to do one of the following:

• Accept the patient for transplantation.
• Provisionally accept the patient pending resolution of one or more minor issues.
• Not accept the patient at the present time but recommend that he or she be followed with possible reconsideration at a future date.
• Categorically not accept the patient.

All decisions of the committee are based upon group consensus. In difficult cases, the medical center's ethics committee is available to offer their expertise.

Waiting for a donor heart

Patients deemed to be acceptable candidates for transplantation are listed nationally with the California Transplant Donor Network. The listing is made according to the organ(s) required, heart or both heart and lung, blood group and acceptable donor height range. Allocation of donor hearts is done at the local and regional level strictly according to national policy. The two main features of this policy include the following:

• Patients who require combined heart and lung transplantation are given priority over those requiring isolated heart transplantation.
• Heart transplant recipients are prioritized according to the duration of time that they have been "actively" on the waiting list.

Most patients continue to receive all of their medical care from doctors in their local community. A few choose to transfer their care to UCSF Medical Center. In either case we maintain close contact with the patient's referring doctor.

All patients on the waiting list are seen by the transplant cardiologist and transplant coordinator in the outpatient clinic every three months or as dictated by his or her medical condition. During these visits the patient's continued candidacy for transplantation is reassessed and, if necessary, further medical consultations or studies are performed. These visits usually coincide with the monthly meetings of the Transplant Program's support group, which patients on the waiting list are encouraged to attend.

Local doctors immediately inform the transplant team if a medical condition arises that could affect the patient's transplantation eligibility. If the patient's clinical condition warrants, they may be temporarily or permanently removed from the "active" waiting list. Patients whose clinical condition deteriorates while on the waiting list are either admitted directly or transferred to UCSF Medical Center from the community hospital once his or her condition has stabilized.

The Transplant Program has access to a variety of medications and devices, including pacemakers, defibrillators and ventricular assistance devices, to support patients with severe heart disease until they can be transplanted.

UCSF Medical Center is a member of the United Network for Organ Sharing (UNOS) and a founding member of the California Transplant Donor Network (CTDN), an independent regional organ procurement organization supported by regional transplant centers. The network has developed and maintains working relationships with more than 150 hospitals in Northern and Central California as well as Northern Nevada where it assists in the identification of potential donors, provides donor management, procurement, preservation, transportation and distribution of donor organs as well as formal and informal education concerning organ donation and transplantation.

Procedure

Heart transplant surgery involves removing most of your diseased heart and inserting one from a person who has died. You will be called to come to the hospital immediately once you have been assigned a donor heart. Upon arrival, you will go the Coronary Care Unit for a physical exam and more tests, including blood and urine samples.

You will be prepared for surgery, which includes the insertion of intravenous lines and a catheter in your neck to measure the pressure in your heart.

You will be given anesthesia so that you will sleep through the surgery. You also will receive immunosuppressive drugs before and during the procedure to prevent your body from rejecting the new heart.

The surgery involves:

• A major incision down your chest. Your breastbone is split in half.
• Your main arteries are connected to a heart lung bypass machine to pump your blood and a ventilator will help you breathe.
• Most heart transplants are done with a method called orthotopic surgery, where most of your heart is removed but the back half of both upper chambers, called atria, are left in place. Then the front half of the donor heart is sewn to the back half of the old heart.
• The donor's aorta and pulmonary arteries are connected to yours. The bypass machine is disconnected and your new heart begins the work of pumping blood.
• Your incisions are closed.

This surgery is considered less complicated than most heart bypass surgeries, including coronary artery bypass graft (CABG).

Recovery

After your surgery, you will wake up in a special sterile room to ensure that you aren't exposed to infection. Staff and visitors must take measures to make sure that they do not bring in bacteria and infections by scrubbing their hands and wearing protective masks and gowns.

Once you are able to breathe on your own, the ventilator will be removed. However, you will continue to be hooked up to various monitors and catheters for a while. When you are stronger, you may be moved to a more general hospital room.

You will have to take precautions to prevent your exposure to infection for the rest of your life. Much of the rest of your hospital recovery will include education and training about taking care of yourself. This includes learning about the anti-rejection medications you will need to take, how to follow a heart-healthy low-fat diet and other changes.

If you don't have any complications, you will be in the hospital about 10 days.

After the hospital

Once you leave the hospital, you will need regular follow-up visits to monitor your progress. For the first two months after the transplant, you will need to see your doctor every one to two weeks.

If everything goes well, after six months the visits will cut back to one- or two-month intervals. After a year, these visits may be cut back to three- to six-month intervals. Follow-up care is tracked by computer on a quarterly basis; both routine and crisis visits are monitored for all patients.

You will be able to return to your normal activities gradually. You resume driving a car when your sternum, or breastbone, is fully healed, which takes approximately six weeks. You may return to work after two to three months after the transplant surgery. It generally takes three to six months to fully recover from heart transplant surgery. However, age and previous medical history problems may cause the recovery period to take longer.