Dr. MJ Bazos MD,
In the three decades since the performance of
the first human heart transplant in December 1967, the procedure has changed
from an experimental operation to an established treatment for advanced heart
disease. Approximately 2,300 heart transplants are performed each year in the
In 1981, combined heart
and lung transplants began to be used to treat patients with conditions that
severely damage both these organs. As of 1995, about 500 people in the United
States and 2,000 worldwide have received heart-lung transplants.
There have been two main barriers to
increasing the number of successful operations. In 1983, the first barrier to
successful transplantations—rejection of the donor organ by the
patient—was overcome. The drug cyclosporine was introduced to suppress
rejection of a donor heart or heart-lung by the patient's body. Cyclosporine and
other medications to control rejection have significantly improved the survival
of transplant patients. About 80% of heart transplant patients survive 1 year or
more. About 60% of heart-lung transplants live at least 1 year after surgery.
Research is under way to develop even better ways to control transplant
rejection and improve survival.
availability is the second barrier to increasing the number of successful
transplantations. Hospitals and organizations nationwide are trying to increase
public awareness of this problem and improve organ distribution.
What Happens During a Heart or
A transplant is
the replacement of a patient's diseased heart or heart and lungs with a normal
organ(s) from someone—called a donor—who has died. The donor's
organ(s) is completely removed and quickly transported to the patient, who may
be located across the country. Organs are cooled and kept in a special solution
while being taken to the patient.
the operation, the patient is placed on a heart-lung machine. This machine
allows surgeons to bypass the blood flow to the heart and lungs. The machine
pumps the blood throughout the rest of the body, removing carbon dioxide (a
waste product) and replacing it with oxygen needed by body tissues. Doctors
remove the patient's heart except for the back walls of the atria, the heart's
upper chambers. The backs of the atria on the new heart are opened and the heart
is sewn into place. A similar process is followed in heart-lung transplants,
except doctors remove the heart and lungs as a unit from the donor; the new
lungs are attached first, followed by the heart.
Surgeons then connect the blood vessels
and allow blood to flow through the heart and lungs. As the heart warms up, it
begins beating. Sometimes, surgeons must start the heart with an electrical
shock. Surgeons check all the connected blood vessels and heart chambers for
leaks before removing the patient from the heart-lung machine.
Patients are usually up and around a
few days after surgery, and if there are no signs of the body immediately
rejecting the organ(s), patients are allowed to go home within 2 weeks.
Why Are Transplants Done?
A transplant is considered when the
heart is failing and does not respond to all other therapies, but health is
otherwise good. The leading reasons why people receive heart transplants are:
•Cardiomyopathy—a weakening of the
•Severe coronary artery disease—in
which the heart's blood vessels become blocked and the heart muscle is damaged.
•Birth defects of the heart.
Heart-lung transplants are performed on patients
who will die from end-stage lung disease that also involves the heart.
Alternative therapies for these patients have been tried or considered. Leading
reasons people receive heart-lung transplants are:
•Severe pulmonary hypertension—a
large increase in blood pressure in the vessels of the lungs that limits blood
flow and delivery of oxygen to the rest of the body.
•A birth defect of the heart that results
in Eisenmenger's complex—another name for acquired pulmonary hypertension.
Who Can Have a Transplant?
Patients under age 60 are the most
likely heart transplant candidates. Patients under age 45 are generally accepted
for heart-lung transplants. In both cases, patients must be suffering from
end-stage disease and be in good health otherwise. The doctor, patient, and
family must address the following four basic questions to determine whether a
transplant should be considered:
•Have all other therapies been tried or
•Is the patient likely to die without the
•Is the person in generally good health
other than the heart or heart and lung disease?
•Can the patient adhere to the lifestyle
changes—including complex drug treatments and frequent
examinations—required after a transplant?
Patients who do not meet the above
considerations or who have additional problems–other severe diseases,
active infections, or severe obesity–are not good candidates for a
transplant. How Are Donors Found?
Donors are individuals who are brain
dead, meaning that the brain shows no signs of life while the person's body is
being kept alive by a machine. Donors have often died as a result of an
automobile accident, a stroke, a gunshot wound, suicide, or a severe head
injury. Most hearts come from those who die before age 45. Donor organs are
located through the United Network for Organ Sharing (UNOS).
Not enough organs are available for
transplant. At any given time, almost 3,500 to 4,000 patients are waiting for a
heart or heart-lung transplant. A patient may wait months for a transplant. More
than 25% do not live long enough. Yet, only a fraction of those who could donate
organs actually do. Does a Person
Lead a Normal Life After a Transplant?
After a heart or heart-lung
transplant, patients must take several medications. The most important are those
to keep the body from rejecting the transplant. These medications, which must be
taken for life, can cause significant side effects, including hypertension,
fluid retention, tremors, excessive hair growth, and possible kidney damage. To
combat these problems, additional drugs are often prescribed.
A transplanted heart functions
differently from the old one. Because the nerves leading to the heart are cut
during the operation, the transplanted heart beats faster (about 100 to 110
beats per minute) than the normal heart (70 beats per minute). The new heart
also responds more slowly to exercise and doesn't increase its rate as quickly
as before. A patient's prognosis
depends on many factors, including age, general health, and response to the
transplant. Recent figures show that 73% of heart transplant patients live at
least 3 years after surgery. Nearly 85% of patients return to work or other
activities they like. Many patients enjoy swimming, cycling, running, or other
sports. As noted, 60% of patients who
receive combined heart-lung transplants survive at least 1 year. Fifty% live at
least 3 years. What Are the Risks
From Transplants? The most common
causes of death following a transplant are infection or rejection of the heart.
Patients on drugs to prevent transplant rejection are at risk for developing
kidney damage, high blood pressure, osteoporosis (a severe thinning of the
bones, which can cause fractures), and lymphoma (a type of cancer that affects
cells of the immune system). Coronary
artery disease (atherosclerosis) is a problem that develops in almost half the
patients who receive transplants. Normally, patients with this disease
experience chest pain and/or other symptoms when their hearts are under stress.
This is called angina and is an early warning sign of a blocked heart artery.
However, transplant patients may have no early pain symptoms of a blockage
building up because they have no sensations in their new hearts.
Thirty to fifty% of patients who
receive a heart-lung transplant develop bronchiolitis obliterans, in which there
are obstructive changes in the airways of the lungs.
What Does Rejection Mean?
The body's immune system protects the
body from infection. Cells of the immune system move throughout the body,
checking for anything that looks foreign or different from the body's own cells.
Immune cells recognize the transplanted organ(s) as different from the rest of
the body and attempt to destroy it—this is called rejection. If left
alone, the immune system would damage the cells of a new heart and eventually
destroy it. In a heart-lung transplant, immune cells may also destroy healthy
lung tissue. To prevent rejection,
patients receive immunosuppressants, drugs that suppress the immune system so
that the new organ(s) is not damaged. Because rejection can occur anytime after
a transplant, immunosuppressive drugs are given to patients the day before their
transplant and thereafter for the rest of their lives. To avoid complications,
patients must strictly adhere to their drug regimen. The three main drugs now
being used are cyclosporine, azathioprine, and prednisone. Researchers are
working on safer, more effective immunosuppressants for future testing. Some of
the more promising drugs are FK-506 and mycophenolate mofetil.
Doctors must balance the dose of
immunosuppressive drugs so that a patient's transplanted organ(s) is protected,
but his or her immune system is not completely shut down. Without an active
enough immune system, a patient can easily develop severe infections. For this
reason, medications are also prescribed to fight any infections.
To carefully monitor transplant
patients for signs of heart rejection, small pieces of the transplanted organ
are removed for inspection under a microscope. Called a biopsy, this procedure
involves advancing a thin tube called a catheter through a vein to the heart. At
the end of the catheter is a bioptome, a tiny instrument used to snip off a
piece of tissue. If the biopsy shows damaged cells, the dose and kind of
immunosuppressive drug may be changed. Biopsies of the heart muscle are usually
performed weekly for the first 3 to 6 weeks after surgery, then every 3 months
for the first year, and then yearly thereafter.
How Much Do Transplants Cost?
According to the UNOS, the estimated
first year charges for a heart transplant is $209,100, and annual followup
charges are $15,000. In most cases these costs are paid by private insurance
companies. More than 80% of commercial insurers and 97% of Blue Cross/Blue
Shield plans offer coverage for heart transplants. Medicaid programs in 33
states and the District of Columbia also reimburse for transplants. Heart
transplants are covered by Medicare for Medicare-eligible patients if the
operation is performed at an approved center.
Approximately 70% of commercial
insurance companies and 92% of Blue Cross/Blue Shield plans cover heart-lung
transplants. Medicaid coverage for heart-lung transplants is available in 20
states. According to the UNOS, estimated first year charges for a heart-lung
transplant is $246,000, and annual followup charges are $18,400.
What Will Transplants Be Like in 5
to 10 Years? Hospitals nationwide are
trying to set up a better system for distributing organs to patients in need.
Researchers are looking for easier methods to monitor rejection to replace the
regular biopsies that are needed now. Work is progressing to make
immunosuppressive drugs with fewer long-term side effects so that coronary
artery disease development and lung destruction may by prevented.