Adult Heart Transplantation

Overview

A heart transplant is an operation in which a medical transplant team, led by a cardiothoracic surgeon, will replace your failing heart with a new donor heart. Transplantation is usually considered a last option for patients with end-stage heart failure who cannot be treated with medication or other types of surgery.

The International Society for Heart and Lung Transplantation reports that more than 3,800 patients, including more than 500 children, receive new hearts each year. More than 3,500 lung transplants occur annually. Some patients require both a heart and lung transplant at the same time. Visit our page on lung transplantation for more information.

Survival rates for people receiving heart transplants continue to improve, especially in the first year after the transplant. About 88% of heart transplant patients survive the first year after surgery, and 75% survive for 5 years following transplant, according to the National Heart, Lung, and Blood Institute. The 10-year survival rate is about 56%.

Preparing for Heart Transplantation

Preparing for Heart Transplantation

Most patients undergoing heart transplantation in the United States have one of two problems—either they have a virus that damages the muscles in the heart (cardiomyopathy), or they have a major heart attack that damages the heart and causes scarring over time.

Other conditions that can lead to a heart transplant include: 

  • Coronary artery disease
  • Diseases of the heart valves that can’t be managed through valve surgery
  • A heart problem you're born with (congenital heart defect)
  • Failure of a previous heart transplant

For more information on transplant for congenital heart disease, visit our page on pediatric heart transplants

In adults, heart transplantation is considered when your heart failure has progressed to the point that no other treatment options are available. Visit our page on heart failure for more information 

If your heart disease has progressed to the point where it can’t be fixed with medications alone, then you may be evaluated by a transplant team to determine if transplant will be a safe and effective treatment for your heart condition. The transplant team will consist of a cardiothoracic surgeon, cardiologist, nurses and others, who all have expertise in the entire process of heart transplantation.

Your evaluation likely will include:

  • A physical examination
  • X-rays 
  • Blood tests
  • Studies to check your heart / lung pressure and function
  • Studies to evaluate other serious medical conditions
  • Tests and questions to ensure you're not using recreational drugs, alcohol or tobacco
  • A psychological evaluation
  • Tissue typing (this helps doctors know which donor heart will match, making sure your body will not reject the donated organ)

Once the transplant team has finished its evaluation and you have been accepted as a transplant candidate, you will be placed on a nationwide transplant waiting list. Generally, people listed for heart transplantation have significant limitations in their activity and lifestyle prior to transplantation.

A number of factors determine your initial place on the donor heart waiting list including:

  • Blood type
  • Heart size (your heart must be a similar size to the donor heart)
  • Your overall medical condition
  • How long you are able to wait for a new heart 

The order of the waiting list fluctuates over time. Some patients may experience enough improvement in heart function from other treatments to be taken off the list, while other patients may become sicker so they move up the list more quickly.

If you currently are on the heart transplant waiting list but no donor heart is available, your doctor may consider using a ventricular assist device (VAD) until the time of transplantation. A VAD is a miniature pump that is implanted in your chest to help your heart pump blood through your body. Essentially the pump assists the function of your heart when it is too weak to function normally on its own. 

While you are on the list, your transplant center will provide you with a pager or cellphone, which they will use to notify you when a potential donor organ is available. You must keep this cellphone or pager charged and turned on at all times.

When you are notified that a donor heart is available, you and your transplant team have a limited amount of time to decide to accept the donation, and you will be expected to travel to the transplant hospital immediately.

Other Considerations for Transplant

Other Considerations for Transplant

Some patients who are evaluated for a heart transplant are considered ineligible for transplantation for various reasons, but the decision is always individualized for every potential candidate. You may be considered ineligible for transplant if: 

  • You are over the age of 65 
  • You have another medical condition that could shorten your life 
  • You have peripheral artery disease (blockages in the arteries in your arms or legs)
  • You have had or currently have: 
    • Cancer  
    • A severe stroke or dementia
    • HIV infections 
    • Other active infections, such as hepatitis
    • Kidney, lung, nerve, or liver disease
  • Your doctors conclude that you are unwilling or unable to make lifestyle changes necessary to keeping your donor heart healthy, such as not drinking alcohol or not smoking

The Operation

The Operation

In order to ensure that a donor heart is usable, a heart transplant usually takes place within several hours of organ removal. For this reason, donor hearts typically are offered first to a transplant center close by, then to centers within certain distances of the donor hospital. A transplant team likely will be dispatched to secure the donor heart and bring it back to the transplant hospital for the procedure.  

Before the operation can begin, you must undergo a final evaluation and blood work at the hospital. Once all of your final tests have been completed, you will be taken into the operating room (OR). 

The procedure itself usually takes about 3 to 4 hours but can take longer for a number of reasons, especially if you have undergone previous heart surgery. If you have undergone previous heart surgeries or if there are any complications during the surgery, it may take longer. During a heart transplant, a cardiothoracic surgeon who specializes in heart transplantation will open your chest to remove your diseased heart. Once the diseased heart is removed, the new heart will be placed into your chest and sewn into place. 

You will be placed under general anesthesia during the procedure, and you also will be placed on a heart-lung machine (sometimes called “the pump”) during the operation. The machine temporarily takes over the function of your heart and lungs during surgery to maintain blood circulation and oxygen flow through your body. After the surgery is completed, you will be taken off the pump, and your heart and lungs will resume full function. Once this happens, your new heart will start beating on its own.  Several medicines are usually temporarily required to assist the heart and sometimes an electric shock is needed to make the new heart beat properly.

Recovery

Recovery

You should expect to stay in the hospital for 7 to 21 days after your heart transplant, and most patients spend at least a few days in the intensive care unit (ICU) so doctors and nurses can monitor heart function carefully. Some patients require the breathing machine for a portion or for most of this time to allow the heart and lungs to recover from the stress of a big operation. Close monitoring is critical during the early postoperative period after a transplant to ensure that you do not get an infection and that your heart is working well.

After your initial recovery, you should expect to have regular checkups with your heart specialist and you will be required to take medications called immunosuppressants (or anti-rejection medications) for the rest of your life. These medications help your body accept the new heart and reduce the risk of transplant rejection, but because there can be side effects, your doctor will run blood tests routinely to check the levels of these medicines. One side effect of the anti-rejection medications is immunodeficiency, in which your body has a difficult time fighting off infection. It is important to meet with your heart specialist regularly to ensure that your immune system is working properly. 

For monitoring, you will also have regular heart examinations which can include an EKG (electrocardiogram), echo (echocardiogram), Holter monitoring, evaluation of the coronary arteries and others to allow your doctor to see your new heart's rhythm and function. An endomyocardial biopsy (taking a tissue sample from the endocardium or myocardium, which are layers of the heart) can also help your doctor monitor your therapy and status.  You should also have routine medical checkups to maintain overall health.

After full recovery from a heart transplant, you can live a normal, healthy life with no restrictions on activity; however, before starting any exercise program or before engaging in any strenuous activities, be sure to speak with your heart specialist to ensure it is safe. You likely will be asked to initially avoid vigorous activity, so your doctor may limit your participation on sports teams, even in recreational leagues.   

Heart transplants are not always successful; it is possible for your new heart to fail because of organ rejection. If this happens, your doctor may recommend adjusting your medications or, in severe cases, may recommend another heart transplant. You also can develop valvular heart disease or coronary artery disease, which may require additional surgery later in life.  

Women who have received a heart transplant can sometimes encounter problems becoming pregnant and may have complications during pregnancy. Certain types of immunosuppressant medications can negatively affect a fetus, so be sure to discuss different medications with your doctor. You also may have a greater risk of rejection once the baby is born, so if you are considering pregnancy keep an open discussion with both your transplant specialist and obstetrician to be sure that all of your concerns are addressed. 

 

Reviewed by: Robbin G. Cohen, MD
July 2016 

Previously reviewed by Emily Farkas, MD