HEART TRANSPLANTATION PROCEDURES

When a heart becomes available and is approved for a patient, it is packed in a sterile cold solution and rushed to the hospital where the recipient is waiting. The recipient will be contacted to return to the hospital if chronic care occurs outside of the hospital. A description of the procedure follows:
• General anesthesia is provided by an anesthesiologist experienced with cardiac patients.

• Intravenous antibiotics will prevent bacterial wound infections.

• The patient is put on a heart/lung machine, which performs the functions of the heart and lungs by pumpingthe blood to the rest of the body during surgery. This procedure is called cardiopulmonary bypass.

• Once the donor heart has arrived to the operating room, the patients diseased heart is removed.

• The donor heart is attached to the patients blood vessels, including the atrium(s), pulmonary artery, and aorta.

• After the blood vessels are connected, the new heart is perfused with the patients blood and begins beating. If the heart does not begin to beat immediately, the surgeon may use defibrillation to gain a productive rhythm.

• The patient is taken off the heart-lung machine.

• The new heart is stimulated to maintain a regular beat with medications and/or a pacemaker for two to five days after surgery, until the new heart functions normally on its own.

Heart transplant recipients are given immunosuppressive drugs to prevent the body from rejecting the new heart. These drugs are usually started before or during the heart transplant surgery. Immunosuppressive drugs keep the bodys immune system from recognizing and attacking the new heart as foreign tissue. Normally, immune system cells recognize and attack foreign or abnormal cells such as bacteria, cancer cells, and cells from a transplanted organ. The drugs suppress the immune cells and allow the new heart to function properly. However,they can also allow infections and other adverse effects to occur to the patient.

Because the chance of rejection is highest during the first few months after the transplantation, recipients are usually given a combination of three or four immunosuppressive drugs in high doses during this time. Afterwards, they must take maintenance doses of immunosuppressive drugs for the rest of their lives.

Cost and insurance coverage
The total cost for heart transplantation varies, depending on where it is performed, whether transportation and lodging are needed, and whether there are any complications. The costs for the surgery and first year of care are estimated to be about $250,000. The medical tests and medications after the first year cost about $21,000 per year. Insurance coverage for heart transplantation varies, depending on the policy. Most commercial insurance companies pay a certain percentage of heart transplant costs. Medicare pays for heart transplants if the surgery is performed at Medicare-approved centers. Medicaid pays for heart transplants in 33 states and in the District of Columbia.

Diagnosis/Preparation
Before patients are put on the transplant waiting list, their blood type is determined so a compatible donor heart can be found. The heart must come from a person with the same blood type as the patient, unless it is blood type O negative. A blood type O negative heart is a universal donor and is suitable for any patient regardless of blood type.

A panel reactive antibodies (PRA) test is also done before heart transplantation. This test tells doctors whether or not the patient is at high risk for having a hyperacute reaction against a donor heart. A hyperacute reaction is a strong immune response against the new heart that happens within minutes to hours after the new heart is transplanted. If the PRA shows that a patient has a high risk for this kind of reaction, then a crossmatch is done between a patient and a donor heart before transplant surgery. A crossmatch checks how close the match is between the patients tissue type and the tissue type of the donor heart. Most people are not high risk, and a crossmatch usually is not done before the transplant because the surgery must be done as quickly as possible after a donor heart is found.

While waiting for heart transplantation, patients are given treatment to keep the heart as healthy as possible. They are regularly checked to make sure the heart is pumping enough blood. Intravenous medications may be used to improve cardiac output. If these drugs are not effective, an intra-aortic balloon pump or ventricular-assist device can maintain cardiac output until a donor heart becomes available.

Aftercare
Immediately following surgery, patients are monitored closely in the intensive care unit (ICU) of the hospital for 24 - 72 hours. Most patients need to receive oxygen for four to 24 hours following surgery. Continuous cardiac monitoring is used to diagnose and treat donor heart function. Renal, liver, brain, and pulmonary functions are carefully monitored during this time. Heart transplant patients start taking immunosuppressive drugs before or during surgery to prevent immune rejection of the heart. High doses of immunosuppressive drugs are given at this time, because rejection is most likely to happen within the first few months after the surgery.

A few months after surgery, lower doses of immunosuppressive drugs usually are given, and then must be taken for the rest of the patients life.For six to eight weeks after the transplant surgery, patients usually come back to the transplant center twice a week for physical examinations and medical tests, which check for any signs of infection, rejection of the new heart, or other complications.

In addition to physical examination, the following tests may be done during these visits:
• laboratory tests to check for infection
• chest x ray to check for early signs of lung infection
• electrocardiogram (ECG) to check heart function
• echocardiogram to check the function of the ventricles in the heart
• blood tests to check liver and kidney function
• complete blood counts (CBC) to check the numbers of blood cells
• taking of a small tissue sample from the donor heart (endomyocardial biopsy) to check for signs of rejection.

During the physical examination, the blood pressure is checked and the heart sounds are listened to with a stethoscope to determine if the heart is beating properly and pumping enough blood. Kidney and liver functions are checked because these organs may lose function if the heart is being rejected.

An endomyocardial biopsy is the removal of a small sample of the heart muscle. This is done by cardiac catheterization. The heart muscle tissue is examined under a microscope for signs that the heart is being rejected. Endomyocardial biopsy is usually done weekly for the first four to eight weeks after transplant surgery, and then at longer intervals after that.