“Heart transplants have been successfully performed since 1967. Latest figures tell us that 85 percent of those who receive heart transplants survive for more than one year, and 70 percent live five years following the procedure,” I told John Plant, a 40 years old bank with a dilated and poorly pumping heart. He had been in and out of the hospital many times in the last six months. He was on maximal treatment but his effort tolerance remained severely impaired. We had proposed ‘heart transplant’ to him and his first knee jerk reaction was a big ‘no’. “A dream has been transformed into a reality and many patients are enjoying nearly normal life after heart transplant. Today’s heart transplant recipients live longer after surgery than those who received heart transplants just 10 years ago. Many transplant patients go back to work and many participate in moderately strenuous activities, such as walking, swimming and even running,” I added to convince him and eventually he agreed to go for it. Two years down the lane, he was active, playing golf and enjoying holidays in Paris.
Heart transplant has emerged as an established safe and effective theraphy for patients with severe heart problems. Technique of heart transplantation has made great strides of development over the years. Indeed it is a major surgery, in which a severely diseased or damaged heart is replaced with a healthy heart from a recently deceased person. Mortality during surgery is acceptable and the biggest problems are find a heart and prevention of rejection. Patients continue to face a lengthy waiting list to receive a donor heart. According to the recent figures approximately 3,800 patients were waiting for a heart transplant as of June 2007. Only 2,148 people received a donated heart in 2007. According to the American Heart Association, at the present time all over the world, the majority of heart transplant patients were while males. More than half are between the ages of 50 and 64, and about 20 percent are between the ages of 35 and 49. Researches are working to develop equipment to improve the health and comfort for patients waiting for a donor heart and, ideally, to develop a mechanical heart that could permanently solve the shortage problem.
Who needs heart transplant?
When a patient is diagnosed as having an end-stage heart disease, and all medical interventions have failed, and the patient is stable enough to sustain a major surgery then he or she is considered for transplant. End stage heart disease due to decrease in blood supply – coronary artery disease and disease of heart muscle called cardiomyopathy are the most common conditions that may lead to a heart transplant. Heart diseases due to inborn heart problems which are not amenable to surgery are the most common reasons for heart transplant in children. Patients with failure of a previous bypass and persistent angina and heart failure are considered for heart transplant.
Heart transplants are sometimes performed along with lung transplants for individuals with end-stage lung disease that also involves the heart. These conditions are elevated pressures in right sided circulation called pulmonary hypertension. High blood pressure in blood vessels of lungs arising from right side of heart is consequent to either primary – where the cause is not known or Eisenmenger syndrome where the cause is a congenital heart disease. The condition accounts for nearly half of all heart-lung transplants.
Who donates the heart?
Unlike most organs, the heart can only be obtained from donors who die a “brain death,” meaning that the brain dies while the body remains on life support. Organs are obtained from people who give their consent to have certain organs donated. They can also be obtained by permission of next of kin when a suitable donor is considered to be “brain dead.” Although almost 40 percent of donated kidneys are surgically removed from living donors, most major organ donations (e.g., the heart, lungs and liver) are pledged while living and removed when the donor dies. Because of the great demand for organ donors, generally healthy people are strongly encouraged to become donors.
How the heart is transplanted?
Patients waiting for a donor heart are required to report to the hospital immediately on finding a donor. If the donor heart is in the same hospital as the recipient, then the surgery is performed as soon as all preparations have been made. If the donor heart is being transported by ambulance or by air, then the surgical team responsible for the transfer keeps the hospital team informed of their progress.
When the time is right, the patient is given general anesthesia. An incision is made through the chest and sternum, and the ribs are separated. A heart-lung machine takes over the functions of heart and lungs, freeing heart from its normal function so that it can be removed. Some heart muscle is reserved during extraction to act as a support for the new heart as it is sewn into place. When the new heart is positioned and blood vessels are reattached, a heart incision is closed, heart is restarted and blood circulation and oxygen are stored. The warmth of blood should “wake up” the heart and stimulate it to start beating. If this does not occur, it may be necessary to start the heart using an electric shock (defibrillation). Once blood is flowing through the new heart normally and without any leaks, the heart-lung machine is disconnected and chest incision is closed.
After the heart transplant, patient is kept in ICU and monitored during this critical time by cardiac surgeon, cardiologist and other members of the hospital staff. They watch closely for any signs of heart rejection or infection. Medications that suppress the body’s natural immune system are administered to counter the body’s tendency to reject the new heart, and these medications have dramatically reduced the number of rejections.
Patients are unlikely to be very active in the next couple of days, but should be able to walk around in just three or four days. The total length of a hospital stay after a heart transplant is 10 to 14 days. Once a patient is discharged from the hospital, cardiologist and primary physician provide regular medical support, including biopsies and other diagnostic tests several times a year.
The improved life expectancy of patients after a heart transplant is largely due to a new drug called cyclosporine. It is an immunosuppressive drug that appeared in 1983. From its unique way of suppressing the immune system, cyclosporine has become a mainstay in minimizing the body’s tendency to reject a new heart. This is a major risk associated with transplant surgery. When rejection occurs, the immune system sends out antibodies to destroy the new heart, which is perceived as foreign or ‘invading’ tissue cells. Left unchecked, this rejection can result in extensive damage and failure of the transplanted heart.
Problems after the transplant:
Three main problems associated with transplant are rejection, infection and accelerated atherosclerosis.
a. Rejection: Certain tests are required on a regular basis to predict whether the heart is being rejected. These tests include regular biopsies and serial blood tests. Serial biopsies are done to monitor body’s response to the transplanted heart. This involves using a thin tube to remove a small piece of heart tissue. The tube is inserted through a vein either in the groin or side of the neck. Biopsies are outpatient procedures that can be done in under an hour. They are performed often in the first four months after transplantation and, less frequently, in months and years after that. The risk of transplant failure is three times greater among recipients with high levels of troponin I than those with normal levels of this enzyme.
Patients can monitor themselves, as some symptoms may signal rejection, including dizziness, nausea or vomiting, chest pain, shortness of breath, flu-like symptoms like chills, sore throat and fever. Rejection, however, is not necessarily an irreversible event. It can be controlled with different dosage regimen or timing of medications. Patients are encouraged to immediately contact their transplant centre or team, should any of the above symptoms occur.
b. Infection. Patients are urged to immediately report to their physician if any of the following signs of infection like fever, redness, swelling and drainage of fluid appear.
c. Accelerated atherosclerosis. When patients receive a new heart, they also receive new coronary arteries on the surface of that heart. Although these new coronary arteries may have less blockages than their original coronary arteries, heart transplant recipients are more like to develop coronary artery disease (CAD). This disease is thought to be part of the slow rejection process in the transplanted hearts. About 50 percent of heart transplant patients develop CAD. Therefore, patients must undergo cardiac tests periodically to check for the disease.
A longer-term goal for some researchers is the genetically engineered heart. The organ is composed of human tissues – perhaps one’s own – and is cultured or grown over a period of months to match detailed specifications. Currently, this “heart-in-a-box” project exists only in a university research facility, but researchers have a goal to have cryogenically (defined as ‘low-temperature”; in this case, very cold) stored organs available for transplant in less than a decade.
The dreams of yesterday have worn the attire of reality today. Heart transplant is a viable option in selected patients with heart failure, who do not respond to maximal therapy. Due to recent technological advances, the outlook has improved, survival being more than 83% at one year.
___________________________________________________
Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah
Heart transplant has emerged as an established safe and effective theraphy for patients with severe heart problems. Technique of heart transplantation has made great strides of development over the years. Indeed it is a major surgery, in which a severely diseased or damaged heart is replaced with a healthy heart from a recently deceased person. Mortality during surgery is acceptable and the biggest problems are find a heart and prevention of rejection. Patients continue to face a lengthy waiting list to receive a donor heart. According to the recent figures approximately 3,800 patients were waiting for a heart transplant as of June 2007. Only 2,148 people received a donated heart in 2007. According to the American Heart Association, at the present time all over the world, the majority of heart transplant patients were while males. More than half are between the ages of 50 and 64, and about 20 percent are between the ages of 35 and 49. Researches are working to develop equipment to improve the health and comfort for patients waiting for a donor heart and, ideally, to develop a mechanical heart that could permanently solve the shortage problem.
Who needs heart transplant?
When a patient is diagnosed as having an end-stage heart disease, and all medical interventions have failed, and the patient is stable enough to sustain a major surgery then he or she is considered for transplant. End stage heart disease due to decrease in blood supply – coronary artery disease and disease of heart muscle called cardiomyopathy are the most common conditions that may lead to a heart transplant. Heart diseases due to inborn heart problems which are not amenable to surgery are the most common reasons for heart transplant in children. Patients with failure of a previous bypass and persistent angina and heart failure are considered for heart transplant.
Heart transplants are sometimes performed along with lung transplants for individuals with end-stage lung disease that also involves the heart. These conditions are elevated pressures in right sided circulation called pulmonary hypertension. High blood pressure in blood vessels of lungs arising from right side of heart is consequent to either primary – where the cause is not known or Eisenmenger syndrome where the cause is a congenital heart disease. The condition accounts for nearly half of all heart-lung transplants.
Who donates the heart?
Unlike most organs, the heart can only be obtained from donors who die a “brain death,” meaning that the brain dies while the body remains on life support. Organs are obtained from people who give their consent to have certain organs donated. They can also be obtained by permission of next of kin when a suitable donor is considered to be “brain dead.” Although almost 40 percent of donated kidneys are surgically removed from living donors, most major organ donations (e.g., the heart, lungs and liver) are pledged while living and removed when the donor dies. Because of the great demand for organ donors, generally healthy people are strongly encouraged to become donors.
How the heart is transplanted?
Patients waiting for a donor heart are required to report to the hospital immediately on finding a donor. If the donor heart is in the same hospital as the recipient, then the surgery is performed as soon as all preparations have been made. If the donor heart is being transported by ambulance or by air, then the surgical team responsible for the transfer keeps the hospital team informed of their progress.
When the time is right, the patient is given general anesthesia. An incision is made through the chest and sternum, and the ribs are separated. A heart-lung machine takes over the functions of heart and lungs, freeing heart from its normal function so that it can be removed. Some heart muscle is reserved during extraction to act as a support for the new heart as it is sewn into place. When the new heart is positioned and blood vessels are reattached, a heart incision is closed, heart is restarted and blood circulation and oxygen are stored. The warmth of blood should “wake up” the heart and stimulate it to start beating. If this does not occur, it may be necessary to start the heart using an electric shock (defibrillation). Once blood is flowing through the new heart normally and without any leaks, the heart-lung machine is disconnected and chest incision is closed.
After the heart transplant, patient is kept in ICU and monitored during this critical time by cardiac surgeon, cardiologist and other members of the hospital staff. They watch closely for any signs of heart rejection or infection. Medications that suppress the body’s natural immune system are administered to counter the body’s tendency to reject the new heart, and these medications have dramatically reduced the number of rejections.
Patients are unlikely to be very active in the next couple of days, but should be able to walk around in just three or four days. The total length of a hospital stay after a heart transplant is 10 to 14 days. Once a patient is discharged from the hospital, cardiologist and primary physician provide regular medical support, including biopsies and other diagnostic tests several times a year.
The improved life expectancy of patients after a heart transplant is largely due to a new drug called cyclosporine. It is an immunosuppressive drug that appeared in 1983. From its unique way of suppressing the immune system, cyclosporine has become a mainstay in minimizing the body’s tendency to reject a new heart. This is a major risk associated with transplant surgery. When rejection occurs, the immune system sends out antibodies to destroy the new heart, which is perceived as foreign or ‘invading’ tissue cells. Left unchecked, this rejection can result in extensive damage and failure of the transplanted heart.
Problems after the transplant:
Three main problems associated with transplant are rejection, infection and accelerated atherosclerosis.
a. Rejection: Certain tests are required on a regular basis to predict whether the heart is being rejected. These tests include regular biopsies and serial blood tests. Serial biopsies are done to monitor body’s response to the transplanted heart. This involves using a thin tube to remove a small piece of heart tissue. The tube is inserted through a vein either in the groin or side of the neck. Biopsies are outpatient procedures that can be done in under an hour. They are performed often in the first four months after transplantation and, less frequently, in months and years after that. The risk of transplant failure is three times greater among recipients with high levels of troponin I than those with normal levels of this enzyme.
Patients can monitor themselves, as some symptoms may signal rejection, including dizziness, nausea or vomiting, chest pain, shortness of breath, flu-like symptoms like chills, sore throat and fever. Rejection, however, is not necessarily an irreversible event. It can be controlled with different dosage regimen or timing of medications. Patients are encouraged to immediately contact their transplant centre or team, should any of the above symptoms occur.
b. Infection. Patients are urged to immediately report to their physician if any of the following signs of infection like fever, redness, swelling and drainage of fluid appear.
c. Accelerated atherosclerosis. When patients receive a new heart, they also receive new coronary arteries on the surface of that heart. Although these new coronary arteries may have less blockages than their original coronary arteries, heart transplant recipients are more like to develop coronary artery disease (CAD). This disease is thought to be part of the slow rejection process in the transplanted hearts. About 50 percent of heart transplant patients develop CAD. Therefore, patients must undergo cardiac tests periodically to check for the disease.
A longer-term goal for some researchers is the genetically engineered heart. The organ is composed of human tissues – perhaps one’s own – and is cultured or grown over a period of months to match detailed specifications. Currently, this “heart-in-a-box” project exists only in a university research facility, but researchers have a goal to have cryogenically (defined as ‘low-temperature”; in this case, very cold) stored organs available for transplant in less than a decade.
The dreams of yesterday have worn the attire of reality today. Heart transplant is a viable option in selected patients with heart failure, who do not respond to maximal therapy. Due to recent technological advances, the outlook has improved, survival being more than 83% at one year.
___________________________________________________
Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah
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