Generality
Heart transplantation is a surgical procedure aimed at replacing the heart that is no more efficient than an individual with a healthy heart from a recently deceased donor.
If the operation and recovery proceed smoothly, thanks to the transplant the patient significantly improves his / her quality of life (compared to before the intervention) and can return to exercise different activities, from work to physical.
What is heart transplant?
Heart transplantation is the surgery that serves to replace a seriously damaged heart with another healthy one, coming from a recently dead donor.
The donor is not chosen at random, but must have in common, with the recipient, the blood group and the size of the heart. All this, as we will see later, reduces the availability of transplantable organs and lengthens waiting times.
The heart transplant operation is very delicate and not without possible complications. However, in those patients with severely ill hearts, it may represent the only real viable therapeutic solution.
HOW MUCH COMMON IS THE HEART TRANSPLANTATION?
Since it is difficult to find appropriate donors for all those who need a healthy heart, the requests for transplantation exceed, and by far, those that are available. In 2013, in Italy, 219 interventions were performed against 696 patients waiting to receive a new heart.
Usually, the transplant recipients are adults, but in some cases it is possible that the intervention is also carried out on children.
When you run
When an individual's heart is severely damaged and does not "work" as it should, it is called heart failure .
People with severe heart failure are ideal candidates for a heart transplant, as this is the only real effective therapeutic treatment.
But what are the causes of heart failure, which make heart transplantation vital?
CAUSES OF CARDIAC INSUFFICIENCY
Heart failure occurs for several reasons; the main ones are:
- Coronary artery disease . Coronary arteries are the blood vessels that nourish the heart muscle (myocardium). If their blood and oxygen supply fails, the myocardium dies.
- Cardiomyopathies . It is a generic term, which refers to myocardial diseases that can alter the anatomy and functional efficiency of the heart.
- Heart valve defects . The heart valves are four and regulate, in a precise way, the flow of blood between the compartments of the heart and between the afferent and efferent heart and blood vessels.
Figure: coronary artery disorders (coronary arteries) can be so profound that they require a heart transplant. Congenital defects of the heart . Present since birth, these anatomical defects represent the main reason for heart transplantation in young and very young patients.
Risks of the transaction
Heart transplantation is a very delicate operation and not without complications.
Several disorders, not all, arise due to the intake of immunosuppressive drugs ; these medicines are essential for a transplanted individual, because they weaken the immune system reducing the chances of rejection of the new implanted heart.
The following list reports the most common complications following a heart transplant:
- Rejection of the organ
- Transplant failure
- Infections
- Defects of arterial vessels connected to the heart
- tumors
- Kidney failure
REJECT OF THE ORGAN
Rejection occurs when a person's transplanted immune system attacks the implanted organ because it considers it foreign to the organism.
The danger of rejection is reduced over time, but, unfortunately, it never completely runs out. Therefore, the intake of immunosuppressants and periodic controls become, for those who have undergone a transplant (heart or any other organ), a normal routine.
There are two forms of rejection: acute, if it occurs shortly after surgery; chronic, if it is revealed months or years after the operation.
Symptoms of rejection of the heart:
- Shortness of breath
- High fever
- Water retention (swollen hands and feet)
- Sense of fatigue
- Palpitations
- Weight gain
TRANSPLANT FAILURE
Transplant failure means the situation in which the newly implanted heart interrupts the heartbeat suddenly or does not even begin its action. In such circumstances, the patient is in serious danger.
Transplant failure can occur or because the donor's heart, at the time of death, suffered not visible but critical damage, or because the blood vessels (afferent and efferent with respect to the heart) are not properly connected.
INFECTIONS
Transplanted individuals are exposed to bacterial, fungal and viral infections, as the immune defenses are weakened by the intake of immunosuppressants.
The most common bacterial infections among patients are those that affect the lungs, causing all the symptoms of pneumonia . Antibiotics are given to prevent them.
The most common fungal infections are invasive; they cause fever, chest pain, shortness of breath and dizziness; they are prevented with antifungal drugs .
Finally, the most frequent viral infections are those sustained by cytomegalovirus ; for their prevention, it is advisable to take antivirals, especially in the first months after surgery.
FAULTS OF ARTERIAL VASES
Arterial vessels connected to the transplanted heart can thicken (narrowing the inner lumen of the vessel) and harden. This modification process is gradual and takes a long time: according to an English source, one patient suffers from this disorder every 12, one year after the operation, and one patient every three after five years from the operation.
The reasons for this complication are different: at the beginning there could be a temporary rejection of the heart or a passing infection.
TUMORS
It appears that, again due to immunosuppressants, transplant patients are more exposed to skin tumors and lymphomas (ie lymphoid cell tumors). For this reason, it is recommended to avoid prolonged exposure to ultraviolet rays from the sun or artificial lamps.
KIDNEY FAILURE
By renal failure, we mean the drastic reduction in the functional capacity of one or both kidneys.
Symptoms of renal failure:
- Fatigue
- Water retention (ie, swollen hands and feet)
- Shortness of breath
- Nausea
- Blood in the urine
Preparation
How to prepare for the intervention
Since the availability of transplantable hearts does not satisfy all the requests, it is necessary to choose among the various patients with heart failure those most suitable for transplantation.
Transplant centers are in charge of establishing a waiting list, which carry out a long series of tests on candidates who require a new heart.
The controls are very rigorous and evaluate not only the severity of an individual's heart failure, but also his mental faculties, the environment in which he lives, possible addictions to drugs, alcohol or smoking, etc. Not surprisingly, these assessments are the responsibility of a team made up of different figures: surgeons, cardiologists, social workers and psychologists.
Once a patient is placed on a waiting list, he will have to wait his turn, taking care to be ready when he is called for the transplant.
HOW IS INSERTION IN THE WAITING LIST?
The first contact between patient and transplant center takes place through the attending physician, who, after a careful examination, assesses whether the conditions for a heart transplant can exist.
At this point, the team of experts from the transplant center will submit the patient to the following controls:
- Blood tests, urine tests and cancer screening . They are used to assess the health status of the possible candidate and to understand if he can withstand a heart transplant. They exclude from the waiting list serious infections, such as AIDS, or being (states) with cancer. A passing infection can only exclude the patient temporarily.
- Blood pressure control . Describes the patient's state of health. It is an additional datum, which serves to understand how the individual will react to the intervention.
- Radiological examination of the chest . X-rays, MRIs, and CT scans all show the appearance of the heart, lungs and chest organs. Once again, they clarify the patient's heart problems and highlight any other disorders or anomalies.
- Specific heart checks . These are exams such as coronary angiography and the electrocardiogram. These, describing in depth the state of heart health, definitively establish whether transplantation is the only real effective cure.
- Psychological and social evaluation . The first one assesses if the possible candidate is mentally stable, if he knows the implications of a heart transplant and if he can take care of his own person. The second scours the social environment in which the patient lives: the presence of family and close friends, willing to help the subject, is essential to return to the waiting list.
- Evaluation of any dependencies . They do not include alcohol, drug and smoking addictions on the waiting list. Quitting smoking can be included in the list of candidates.
If all these assessments are positive (ie in favor of the intervention), then the patient will be placed on the waiting list.
In what situations are you excluded from the waiting list?
- Age over 65 years
- Serious infectious diseases, such as AIDS
- Severe kidney failure associated with heart problems
- Tumor in any part of the body
- Addiction to drugs, alcohol and smoking
- Mental instability
- Absence of family or close friends able to follow the patient, should this need help
HOW LONG IS THE WAIT FOR A TRANSPLANT?
Waiting times can vary from a few weeks to months; even, in the most unfortunate cases, the patient can die before receiving the summons.
The main factors that affect waiting times are:
- The recipient's blood group, which must be compatible with that of the donor (blood compatibility). There are rarer blood groups than others and this has a decisive influence on availability.
- Hearts of similar size, between recipient and donor. A 190 cm tall individual does not have a heart suitable for a 170 cm person or a child.
- Number of patients on the waiting list and occupied position . The location depends on the severity of heart failure.
Some patients awaiting a transplant, if suffering from severe heart failure, may undergo temporary therapeutic intervention, known as a ventricular assist device (VAD).
THE CALL FROM THE TRANSPLANT CENTER
Once entered in the list, the call from the transplant center can take place at any time of the day. Therefore, it is good to always be ready to call and not to delay, because every minute that passes is important. In fact, a heart to be transplanted, even if well preserved, becomes unusable after 5-6 hours.
After the call, it is a good idea to follow the medical advice of not eating or drinking anything, as the operation is performed under general anesthesia.
Figure: a bag used for transporting organs.
Once in the hospital, the patient has to make rapid checks on the state of health (measurement of blood pressure, temperature, etc.), to be certain that there are all the prerequisites for the operation.
Procedure
Heart transplantation is a very delicate surgical procedure, which must be performed under general anesthesia within 4 hours of removal from the donor.
The team of doctors and experts, who take care of the transplant and follow the patient during the post-intervention stay, is made up of different figures, all equally important:
- Anesthesiologist
- Surgeon
- Nursing specialist in transplants
- Cardiologist doctor
- Physiotherapist
- Psychologist
- Social worker
GENERAL ANESTHESIA
The administration of these drugs, carried out intravenously and / or by inhalation, occurs before and throughout the duration of the surgery.
At the end of the operation, the pharmacological treatment is interrupted to allow the patient to regain consciousness.
HOW IT WORKS
First, the surgeon cuts into the chest and gently separates the sternum, to have free access to the heart.
Having done this, it interrupts the connections between blood vessels and heart, removes it very carefully and connects the patient to the so - called heart-lung machine . The heart-lung machine takes the place of a beating heart, guaranteeing oxygenation of the blood and its circulation.
Finally, he inserts the "new" heart, connects it to all the various blood vessels starting from the aorta, awaits the resumption of the beat and, only at that point, closes the chest with sutures.
Figure: opening of the chest
If the heart does not start up independently, the surgeon can infuse a small electric shock as a stimulus.
It is important to remember that small tubes are provided for drainage of the bladder and chest.
The heart transplant, except for complications, requires 3 to 5 hours for its execution.
Recovery
At the end of the operation, the patient is kept in intensive care for a few days, to see how he responds to the transplant. If no complications arise, he is moved to a hospital ward, where he will spend at least two weeks. During this time, the medical staff, in addition to constantly monitoring the health of the transplant recipient, will instruct the transplant on how to take care of themselves, once they have been discharged from the hospital.
Therefore, the patient will learn how to take medications, when to resume moderate exercise, what is good to avoid doing etc.
PERIODICAL CHECKS
Immuno-suppressor side effects:
- Vulnerability to infections
- Osteoporosis
- Muscle weakness
- Nausea
- He retched
- Ulcers
- Insomnia
- Blurred vision
- Weight gain
- Flickering at the hands
- Acne
For a heart transplant, especially in the first three months, blood tests, echocardiograms, electrocardiograms, heart biopsies and chest radiographs will become a normal routine. On the other hand, the delicacy of the intervention requires it.
DRUGS
The intake of immunosuppressive drugs begins after the operation and lasts for life, as the risk of organ rejection, as already mentioned, never completely vanishes.
At the beginning of the treatment, the patient is followed by the medical staff; after which, however, he must become independent and manage the pharmacological treatment himself. This explains why there is also a psychological evaluation of the candidates on the waiting list.
Doses are usually elevated only during the first few months; then, as soon as the doctor deems it appropriate, they will be gradually reduced.
RESULTS
Heart transplantation, if successful, significantly improves the patients' quality of life.
In fact, patients can even return to work and practice moderate physical activity.
On the contrary, if complications arise, the viable solutions are few and with little probability of success: if a heart defect has occurred, a corrective surgery or a second heart transplant can be attempted if another organ is available.
The numbers of heart transplant, in Italy (2013):
- 219 heart transplant recipients, out of 696 patients on the waiting list
- The average waiting time, before receiving a new heart, was 28 months
- The mortality rate of patients on the waiting list was 6.1%
- The survival rate, one year after surgery, is 88%; at three years, by 80%; at 5 years, by 73%
- Number of authorized heart transplant centers: 17
