A heart transplant, or a cardiac transplant, is a surgical transplant procedure performed
on patients with end-stage heart failure or severe coronary artery disease. As of 2008
the most common procedure is to take a working heart from a recently deceased organ donor
and implant it into the patient. The patient's own heart is either removed or, less commonly,
left in place to support the donor heart. Post-operation survival periods average 15
years. Heart transplantation is not considered to be a cure for heart disease, but a life-saving
treatment intended to improve the quality of life for recipients.
History Norman Shumway is widely regarded as the father
of heart transplantation although the world's first adult human heart transplant was performed
by a South African cardiac surgeon, Christiaan Barnard, utilizing the techniques developed
and perfected by Shumway and Richard Lower. Barnard performed the first transplant on
Louis Washkansky on December 3, 1967 at the Groote Schuur Hospital in Cape Town, South
Africa. Adrian Kantrowitz performed the world's first pediatric heart transplant on December
6, 1967, at Maimonides Hospital in Brooklyn, New York, barely three days after Christiaan
Barnard's pioneering procedure. Norman Shumway performed the first adult heart transplant
in the United States on January 6, 1968, at the Stanford University Hospital.
Worldwide, about 3,500 heart transplants are performed annually. The vast majority of these
are performed in the United States. Cedars-Sinai Medical Center in Los Angeles, California,
currently is the largest heart transplant center in the world, having performed 119
adult transplants in 2013 alone. About 800,000 people have NYHA Class IV heart failure symptoms
indicating advanced heart failure. The great disparity between the number of patients needing
transplants and the number of procedures being performed spurred research into the transplantation
of non-human hearts into humans after 1993. Xenografts from other species and man-made
artificial hearts are two less successful alternatives to allografts.
Contraindications Some patients are less suitable for a heart
transplant, especially if they suffer from other circulatory conditions related to the
heart. The following conditions in a patient increase the chances of complications:
Kidney, lung, or liver disease Insulin-dependent diabetes with other organ
dysfunction Life-threatening diseases unrelated to heart
failure Vascular disease of the neck and leg arteries.
High pulmonary vascular resistance Recent thromboembolism
Age over 60 years Substance abuse, notably tobacco smoking
Procedures Pre-operative
A typical heart transplantation begins when a suitable donor heart is identified. The
heart comes from a recently deceased or brain dead donor, also called a beating heart cadaver.
The patient is contacted by a nurse coordinator and instructed to come to the hospital for
evaluation and pre-surgical medication. At the same time, the heart is removed from the
donor and inspected by a team of surgeons to see if it is in suitable condition. Learning
that a potential organ is unsuitable can induce distress in an already fragile patient, who
usually requires emotional support before returning home.
The patient must also undergo emotional, psychological, and physical tests to verify mental health
and ability to make good use of a new heart. The patient is also given immunosuppressant
medication so that the patient's immune system does not reject the new heart.
Operative
Once the donor heart passes inspection, the patient is taken into the operating room and
given a general anaesthetic. Either an orthotopic or a heterotopic procedure follows, depending
on the conditions of the patient and the donor heart.
Orthotopic procedure The orthotopic procedure begins with a median
sternotomy, opening the chest and exposing the mediastinum. The pericardium is opened,
the great vessels are dissected and the patient is attached to cardiopulmonary bypass. The
donor's heart is injected with potassium chloride. Potassium chloride stops the heart beating
before the heart is removed from the donor's body and packed in ice. Ice can usually keep
the heart usable for four to six hours depending on preservation and starting condition. The
failing heart is removed by transecting the great vessels and a portion of the left atrium.
The patient's pulmonary veins are not transected; rather a circular portion of the left atrium
containing the pulmonary veins is left in place. The donor heart is trimmed to fit onto
the patient's remaining left atrium and the great vessels are sutured in place. The new
heart is restarted, the patient is weaned from cardiopulmonary bypass and the chest
cavity is closed. The orthotopic procedure was developed by
Shumway and Lower at Stanford-Lane Hospital in San Francisco in 1958.
Heterotopic procedure In the heterotopic procedure, the patient's
own heart is not removed. The new heart is positioned so that the chambers and blood
vessels of both hearts can be connected to form what is effectively a 'double heart'.
The procedure can give the patient's original heart a chance to recover, and if the donor's
heart fails, it can later be removed, leaving the patient's original heart. Heterotopic
procedures are used only in cases where the donor heart is not strong enough to function
by itself. 'Living organ' transplant
In February 2006, at the Bad Oeynhausen Clinic for Thorax and Cardiovascular Surgery, Germany,
surgeons successfully transplanted a 'beating heart' into a patient. Rather than cooling
the heart, the living organ procedure keeps it at body temperature and connects it to
a special machine called an Organ Care System that allows it to continue pumping warm, oxygenated
blood. This technique can maintain the heart in a suitable condition for much longer than
the traditional method. Dead heart transplant
In October 2014, Australian surgeons have recently successfully transplanted dead hearts
into patients for the first time. According to Surgeon Kumud Dhital, the incredible development
of the preservation solution with this technology of being able to preserve heart, resuscitate
it and to assess the function of heart has made this possible. The patients to have the
surgery were Michelle Gribilas of 57-year-old, and Jan Damen, 43.
Post-operative
The patient is taken to the ICU to recover. When they wake up, they move to a special
recovery unit for rehabilitation. The duration of in-hospital, post-transplant care depends
on the patient's general health, how well the heart is working, and the patient's ability
to look after the new heart. Doctors typically prefer that patients leave the hospital 1
– 2 weeks after surgery, because of the risk of infection and presuming no complications.
After release, the patient returns for regular check-ups and rehabilitation. They may also
require emotional support. The frequency of hospital visits decreases as the patient adjusts
to the transplant. The patient remains on immunosuppressant medication to avoid the
possibility of rejection. Since the vagus nerve is severed during the operation, the
new heart beats at around 100 beats per minute unless nerve regrowth occurs.
Immunosuppressive agents are continued in the intensive care unit.
The patient is regularly monitored to detect rejection. This surveillance can be performed
via frequent biopsy or a gene expression blood test known as AlloMap Molecular Expression
Testing. Typically, biopsy is performed immediately post-transplant and then AlloMap replaces
it once the patient is stable. The transition from biopsy to AlloMap can occur as soon as
55 days after the transplant. Complications
Post-operative complications include infection, sepsis, organ rejection, as well as the side-effects
of the immunosuppressive medication. Since the transplanted heart originates from another
organism, the recipient's immune system typically attempts to reject it. The risk of rejection
never fully goes away, and the patient will be on immunosuppressive drugs for the rest
of his or her life, but these may cause unwanted side effects, such as increased likelihood
of infections, like fevers, unusual pains, or any new feelings. Recipients can get kidney
disease from a heart transplant. Many recent advances in reducing complications due to
tissue rejection stem from mouse heart transplant procedures. Surgery death rate is 5-10% in
2011. Hong Kong death rate is 5% for 16 patients from beginning to 2014.
Prognosis The prognosis for heart transplant patients
following the orthotopic procedure has increased over the past 20 years, and as of June 5,
2009, the survival rates were: 1 year: 88.0%, 86.2%
3 years: 79.3%, 77.2% 5 years: 73.2%, 69.0%
In a study spanning 1999 to 2007, conducted on behalf of the U.S. federal government by
Dr. Eric Weiss of the Johns Hopkins University School of Medicine, it was discovered that,
compared to men receiving male hearts, "men receiving female hearts had a 15% increase
in the risk of adjusted cumulative mortality" over five years. No significant differences
were noted with females receiving hearts from male or female donors.
Notable recipients Kenneth Claus, transplanted at Shands Hospital,Gainesville,
Florida, September 23, 1988 was rated 19th best professor in the U.S. for 2009 - 2010
by Rate My Professor. He still teaches 3 semesters a year.
At the time of his death on August 10, 2009, Tony Huesman was the world's longest living
heart transplant recipient, having survived for 30 years, 11 months and 10 days, before
dying of cancer. Huesman received a heart in 1978 at the age of 20 after viral pneumonia
severely weakened his heart. The operation was performed at Stanford University under
heart transplant pioneer Dr. Norman Shumway. As of December 2013, the record holder for
longest living heart recipient is Englishman John McCafferty, 71. He received his heart
on 20 October 1982. Kelly Perkins climbs mountains around the
world to promote positive awareness of organ donation. Perkins was the first recipient
to climb the peaks of Mt. Fuji, Mt. Kilimanjaro, the Matterhorn, Mt. Whitney, and Cajon de
Arenales in Argentina in 2007, 12 years after her surgery.
Twenty-two years after Dwight Kroening's heart transplant, he was the first recipient to
finish an Ironman competition. Fiona Coote was the fourth Australian to receive
a heart transplant in 1984 and the youngest Australian. In the 24 years after her transplant
she became involved in publicity and charity work for the Red Cross, and promoted organ
donation in Australia. Race car driver and manufacturer Carroll Shelby
received a heart transplant in 1990. Golfer Erik Compton qualified for the PGA
Tour at age 32, after his second heart transplant. Former Vice President of the United States
Dick Cheney received a heart transplant on March 24, 2012.
Former chairman and founder of MCI Communications William G. McGowan received a heart transplant
on April 25, 1987. After a six-month recovery, McGowan returned to his duties as MCI chairman
where he remained until his death on June 8, 1992 from another heart attack.
See also Biological pacemaker
Xenographic References
External links [1] - The real first heart transplant.
Official Heart Transplant Museum - Heart Of Cape Town
Photograph of first U.S. heart transplant Western Cape government, South Africa. "Chris
Barnard Performs World's First Heart Transplant". Cape Gateway. Retrieved 2007-01-10.
Department of Cardiothoracic Surgery. "Patient's Guide to Heart Transplant Surgery". University
of Southern California. Retrieved 2007-01-10. Nancy Reid. "Heart transplant: How is it performed?".
Healthwise. Retrieved 2007-01-10.
Jeffrey Everett. "Heart Transplant: Indications". AllRefer.com. Retrieved 2007-01-10.
The Adrian Kantrowitz Papers Profiles in Science from the National Library of Medicine for
Adrian Kantrowitz, the first to perform a pediatric heart transplant