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Heart Transplantation

by Martin Hertl, MD, PhD, Paul S. Russell, MD

Heart transplantation is reserved for people who have severe heart failure, coronary artery disease, or other severe heart disorders and who cannot be treated effectively with drugs or other forms of surgery. In some medical centers, heart machines can keep people alive for weeks or months until a compatible heart can be found. Also, newly developed, implantable artificial hearts are being used to tide people over until a heart is available or, in some experimental situations, to be used as a long-term replacement. Nonetheless, about one fourth of people die while waiting. Donated hearts must be transplanted within 4 to 6 hours.

About 95% of people who have had a heart transplant are substantially better able to exercise and do daily activities than they were before the transplantation. Over 70% return to full-time employment. About 85 to 90% of heart transplant recipients survive for at least 1 year.

Through an incision in the chest, most of the damaged heart is removed, but the back wall of one of the upper heart chambers (atria) is left. The donated heart is then attached to what remains of the recipient’s heart. The procedure takes about 3 to 5 hours. The hospital stay after this operation is usually 7 to 14 days.

Complications

Immunosuppressants must be taken to prevent rejection of a transplanted heart. Rejection, if it occurs, may cause weakness and a rapid or other abnormal heart rhythm. When rejection occurs, the transplanted heart may not function well, causing low blood pressure and accumulation of fluid in the legs and sometimes the abdomen, resulting in swelling—a condition called edema. Fluid may also accumulate in the lungs, causing difficulty breathing. However, rejection is often mild. In such cases, no symptoms may occur, but electrocardiography (ECG) may detect changes in the heart’s electrical activity.

If doctors suspect rejection, they usually do a biopsy. A catheter is inserted through an incision in the neck into a vein and is threaded to the heart. A device at the end of the catheter is used to remove a small piece of heart tissue, which is examined under a microscope. Because effects of rejection can be serious, doctors also routinely do a biopsy once a year to look for rejection that has not yet caused symptoms.

Most deaths that occur after heart transplantation are due to rejection soon after the operation or to infections. About one fourth of people who have a heart transplant develop atherosclerosis in the coronary arteries.