Background

Heart Transplantation is procedure of replacing failing heart with suitable donor’s heart through surgery. 

Orthotopic and heterotopic heart transplants are commonly used in medical procedures. Dr. Barnard conducted first human heart transplant successfully in 1967. 

Heart transplant is for patients with end-stage CHF and expected to live less than a year without it. This procedure used when other heart condition treatments unsuccessful or unavailable. 

Evaluation of the heart transplant candidate includes laboratory tests and imaging studies as follows: 

For laboratory tests: 

Fungus and tuberculosis 

Prostate-specific antigen 

Papanicolaou test 

Complete blood count 

For imaging studies: 

Coronary arteriography  

Echocardiography 

Posteroanterior and lateral chest radiographs 

For cardiac and pulmonary evaluation: 

Maximal venous oxygen consumption  

Right- and left-heart catheterization 

Indications

The general indication for cardiac transplantation as follows: 

Dilated cardiomyopathy 

Ischemic cardiomyopathy  

Congenital heart disease 

Valvular heart disease 

Refractory Heart Failure 

Ischemic Heart Disease 

Ventricular Arrhythmias 

Intractable Angina 

Severe chest pain  

Congenital Heart Disease 

Valvular Heart Disease 

Contraindications

Absolute Contraindications as follows: 

Active Infection 

Irreversible Pulmonary Hypertension 

Severe Peripheral Vascular Disease 

Recent Malignancy 

Severe Non-Cardiac End-Organ Damage 

Relative Contraindications as follows:  

Age and obesity 

Psychiatric Illness 

Active alcohol/tobacco abuse 

Poor Compliance 

Outcomes

Adult patients with congenital heart disease have 30-days mortality after transplantation but better late survival and excellent functional status post-procedure. 

The 1-year survival rate after biventricular assist device for severe heart failure was 89% is slightly lower than 92% without device. 

Postoperative mortality rates increase exponentially with hypertension, diabetes, and obesity. Heart transplant recipients with all three risk factors had 63% higher mortality than those without any risk. 

Cardiac transplantation future depends on donor organ shortage. Hearts from donors over 60 years old commonly used with outcomes slightly less than young donor hearts. 

Equipment

Anesthesia Equipment 

Surgical Instruments 

Cardiothoracic Instruments 

Electrocautery Device 

Donor Heart Transport Equipment 

Hemostasis and Blood Management 

Patient Preparation

Informed Consent:  

Educate patients and their family on procedure, risks, benefits, and post-transplant regimen importance. 

Patient Positioning

Recipient patient prepared for surgery with general anesthesia and baseline monitoring. Placed on cardiopulmonary bypass to assist heart and lung function during surgery. 

Technique

Step 1: Removal of Donor Heart 

Blood flow in the aorta is stopped with clamp, and the donor heart is cooled with cardioplegic solution during removal. Surrounding blood vessels are preserved. 

Step 2: Removal of Recipient Heart 

A vertical incision along the sternum gives access to the heart. Then tubes are connected to a bypass machine for pump and oxygenate blood during surgery. 

Now the recipient’s heart is stopped with cardioplegic solution and that excised with back of the left atrium, pulmonary veins, right atrium, and vena cavae. 

Step 3: Implantation of Donor Heart 

The donor heart is carefully connected to the recipient’s major blood vessels in a specific order: 

The left atrium to the recipient’s left atrial cuff, the right atrium to the right atrial cuff, the pulmonary artery to the recipient’s, and the aorta to the recipients. 

Step 4: Reperfusion and Weaning from Bypass 

Removal of aortic cross-clamp allows blood flow into donor heart, warms and restores contractions. 

The bypass machine slowly removed as heart resumes pumping again and then monitor hemodynamic stability. The sternum is wired together, and chest incision closed with sutures or staples. 

Fig. Heart transplantation          

Complications

Immediate hyperacute rejection possible up to 1-week post-allograft despite immunosuppression post-revascularization. 

Transplant patients need infection prevention to avoid bacterial infections during post-transplant period. 

Steroid therapy after transplant surgery can cause psychiatric issues, which can be prevented with evaluation. 

Allograft vascular disease leads to late graft failure and death, with concentric myointimal hyperplasia in coronary arteries as early as 3 months. 

Long-Term Complications as follows:  

Chronic Rejection and Cardiac Allograft Vasculopathy 

Chronic Kidney Disease 

Diabetes Mellitus 

Malignancies 

Hypertension 

References

Heart Transplantation – StatPearls – NCBI Bookshelf (nih.gov) 

References

Heart Transplantation – StatPearls – NCBI Bookshelf (nih.gov)