Heart Transplant

• Risks of open-heart surgery include bleeding, infection and blood clots
• The donor heart may be rejected by your body
  • Your immune system may perceive the transplanted heart as a foreign entity. This could cause the immune system to reject the heart. Every patient who receives a heart transplant is also prescribed immunosuppressant medications to help prevent rejection.
  • To help avoid the transplanted heart from being rejected, it is crucial to always take your prescribed medications and attend all your follow-up appointments with your doctor.
• Often, the transplanted heart can be rejected without you experiencing any symptoms. Frequent heart biopsies will be performed for the first year after your heart transplant to check if your body is rejecting the donor heart. After the first year, you may no longer need frequent biopsies.
• During the biopsy procedure, a tube is passed through to the heart via the veins using a small incision in the neck or groin. A biopsy device is then run through this tube. The device obtains a small tissue sample from the heart, which is then studied in a lab.
• Primary graft failure: This occurs when the donor heart does not function as expected. Primary graft failure is a common cause for death in the first few months following a heart transplant.
• Problems relating to the arteries: It is possible that you may develop a condition called cardiac allograft vasculopathy after your transplant. In this condition, the walls of the arteries in the transplanted heart thicken and harden, making blood flow through the heart difficult. This can lead to heart attack, heart failure, arrythmias (abnormal heart beat), or sudden cardiac death.
• Side effects of medications: The life-long immunosuppressant medications that you will be prescribed after the heart transplant could contribute to severe damage to the kidneys or other problems.
• Cancer: People who take immunosuppressant medication are also at an increased risk of developing cancer, particularly skin and lip cancers, as well as non-Hodgkin’s lymphoma.
• Infection: Immunosuppressant medications reduce the ability to fight infections. It is common for people who have received heart transplants to develop infections that require hospital admission within the first year of transplantation.

Frequently, the preparations to receive a donor heart will begin weeks or months before the transplant operation.

The first step:

If your doctor has recommended that you undergo a heart transplant, then you will be referred for an evaluation to a heart transplant centre. You can also consult a transplant centre of your own choice. If you have health insurance, then your provider may have their own list of approved transplant centres.

The important criteria to consider for a heart transplant centre are the number of heart transplants performed at the centre each year and the survival rates of the patients who have undergone transplantation there. There are websites where transplant centre statistics can be compared, such as the National Organ and Tissue Transplant Organisation and the Indian Transplant Registry.

It is also worthwhile for you to check if a transplant centre offers other services, such as assistance with travel arrangements, coordination with support groups, local housing assistance for the duration of your recovery (if needed), or information on other organisations that can help you with these issues.

After you select a transplant centre, you will be evaluated to determine if you are eligible for a heart transplant and check if you:

• have a heart condition or disease that could improve after a transplant
• could see improvement by undergoing other, less aggressive treatments instead of a transplant
• are of adequate health to go through surgery and post-transplant treatments
• will give up smoking, if you are a smoker
• are ready to and capable of following the medical program that the transplant team will outline
• are emotionally prepared to undergo the waiting period for a donor heart
• have a suitable network of family and friends that can help and support you during this stressful period

• There is a four-hour window after the removal of a donor heart during which the heart transplant needs to take place. Due to the length of the window, hearts are typically offered first to a nearby transplant centre and then to centres that are within a specific distance of the donor hospital.
• The transplant centre will notify you when a potential heart is available. You must keep your mobile phone charged and turned on at all times.
• Once you are notified, you and your transplant team have limited time to accept the donation. You will have to go to the transplant centre immediately after being notified.
• As much as possible, make travel plans ahead of time. Some heart transplant centres provide private air transportation or other travel arrangements.
• Have a suitcase packed with everything you will need for your hospital stay, as well as an extra 24-hour supply of your medications.
• Once you arrive at the hospital, your doctors and transplant team will conduct a final evaluation to determine if the donor heart is suitable for you and if you are ready for surgery.
• If your doctors and transplant team decide that either the donor heart or surgery is not appropriate for you, you might not be able to have the transplant.

• Heart transplant surgery is an open-heart procedure that takes several hours. If you have had previous heart surgeries, the surgery is more complicated and will take longer.
• You will receive medication that causes you to sleep (general anaesthetic) before the procedure.
• Your surgeons will connect you to a heart-lung bypass machine to keep oxygen-rich blood flowing throughout your body.
• Your surgeon will make an incision in your chest. Your surgeon will separate your chest bone and open your rib cage to give access to your heart. After this, your surgeon will remove the diseased heart. They will then sew the donor heart into place and attach the major blood vessels to the donor heart.
• Your donor heart usually begins beating after restoration of blood flow. Occasionally, an electric shock may be required to ensure proper beating of the donor heart.
• You will be prescribed medication after the surgery to help you manage pain.
• A ventilator will be used to help you breathe after the surgery. You will also have tubes in your chest to help drain fluids from around the heart and lungs.
• You will also be given fluids and medications intravenously after the surgery.

• For the first few days after your transplant, you will have to remain in the intensive care unit (ICU). After this, you will be moved to a regular hospital room. Typically, you will stay in the hospital for one or two weeks. The length of ICU stay is different for each person.
• After discharge from the hospital, the transplant team will check your progress at an outpatient transplant centre. Many people choose to stay in proximity to the transplant centre for the first three months post-surgery, because of the frequency and intensity of monitoring. The follow-up appointments after this period are less frequent, making travel easier.
• Your transplant team will keep a careful eye out for any signs and symptoms that your body is rejecting the heart. These include shortness of breath, fever, fatigue, weight gain, or if you are not passing urine often enough. If you observe any of the signs and symptoms of rejection or infection, then you must let your transplant team know immediately.
• Frequent heart biopsies will be performed for the first year after your heart transplant to check if your body is rejecting the donor heart. Rejection is most common in the first year after transplantation. After the first year, you may no longer need frequent biopsies.

After your heart transplant, many long-term changes need to be incorporated into your lifestyle, including:

1. Taking immunosuppressants
   • Immunosuppressant medications reduce the activity of your immune system, thereby preventing it from targeting your donor heart and rejecting it. Some of these immunosuppressants will have to be taken life-long.
   • These medications increase your risk of getting an infection. As a result, your doctor might also prescribe antibacterial, antiviral, and antifungal medications to you.
   • Immunosuppressants can also worsen—or increase the risk of developing—certain conditions, including high blood pressure, high cholesterol, diabetes, or cancer.
   • The doses and number of immunosuppressants that you take can be reduced over time, as the risk of rejection decreases.
2. Managing your medications, treatments, and developing a lifelong care plan
   • After receiving a donor heart, it is crucial for you to adhere to all your doctor’s instructions, take all the medications, and stick to a lifelong care plan.
   • You may be given instructions about your lifestyle, such as ensuring to use a sunscreen, avoiding tobacco products, taking regular exercise, following a healthy diet, and taking precautions to reduce your infection risk.
   • Make sure to adhere to your doctor’s instructions, show up for your follow-up appointments, and get in touch with your transplant team immediately if you experience any signs of infection or rejection.
   • Establish a daily routine for your timely medications, to avoid forgetfulness in taking them.
   • Always carry a list of your medications, in case of emergency medical care. Make sure to tell each of your doctors about your current medications every time they prescribe you a new one.
3. Cardiac rehabilitation

Cardiac rehabilitation programs incorporate exercise and education to help you improve your health and recover after a heart transplant. These programs might start before you are discharged from the hospital and can help you regain your strength and improve your quality of life.

Most people who receive a heart transplant enjoy a good quality of life.

• Depending on your condition, you may be able to resume many of your daily life activities, such as returning to work, participating in hobbies and sports, and exercising. Discuss with your doctor what activities are appropriate for you.
• Women who have had heart transplants can become pregnant. Talk to your doctor if you are considering having children after your transplant. You will likely need medication adjustments before becoming pregnant, as some medications can cause pregnancy complications.
• Survival rates after heart transplantation vary based on several factors. Survival rates continue to improve despite an increase in older and higher risk heart transplant recipients. Worldwide, the overall survival rate for adults is more than 85% after one year and about 69% after five years.

Heart transplants are not successful for everyone. Your new heart can fail for a number of reasons.

• In such cases, your doctor might recommend adjusting your medications or, in more extreme cases, having another heart transplant.
• If additional treatment options are limited, you might choose to stop treatment.
• Discussions with your heart transplant team, doctor and family should address your expectations and preferences for treatment, emergency care and end-of-life care.

It is normal to feel anxious or overwhelmed while waiting for a transplant or to have fears about rejection, returning to work or other issues after a transplant. The support of friends and family members can help you cope during this stressful time.

• Joining a support group for transplant recipients: Talking with others who share your experience can ease fears and anxiety.
• Setting realistic goals and expectations: Recognise that life after transplant might not be the same as life before transplant.
• Having realistic expectations about results and recovery time can help reduce stress.
• Educating yourself: Read as much as you can about your procedure and ask questions about things you do not understand.

You may need to modify your diet after your heart transplant surgery to make sure that your new heart is healthy and functions well. A good diet and regular exercise to maintain a healthy weight can help you avoid complications like high blood pressure, diabetes, and heart disease.

A specialist in nutrition, such as a dietitian can help you understand your nutrition and dietary requirements after a transplant. They can also answer any questions you may have. A dietitian will also give you healthy food options and ideas that you can add to your diet plan. These may include:

• A daily intake of fresh fruits and vegetables
• Switching to whole-grain breads, multi-grain foods and cereals
• Consuming fat-free or low-fat dairy products, such as milk, to regulate the calcium levels in your body
• Eating lean meats, such as poultry or fish
• Keeping a low-sodium (low-salt) diet
• Staying away from unhealthy fats (saturated and trans fats)
• Staying away from grapefruit and grapefruit juice because it can affect specific immunosuppressant medications (calcineurin inhibitors)
• Limiting your alcohol intake
• Drinking enough water and other fluids every day to stay hydrated
• Adhering to food safety guidelines to decrease your chances of contracting an infection

• Your doctors and care team may suggest that you partake in regular exercise and physical activity after your transplant. This can help you improve your physical and mental health.
• Regular exercise can help regulate blood pressure, reduce stress, maintain weight, strengthen bones, and enhance overall physical function.
• A personalised exercise regimen will be developed by your doctors or care team.
• Your exercise regimen may include warm-up exercises such as slow-walking or stretching, as well as physical activities including cycling, walking, and strength training.
• Cool down exercises, such as slow walking, are also likely to be included in your exercise regimen.
• Make sure to have a conversation with your care team about what physical activities may be suitable for you.
• If you feel tired, then take a break from exercising. If you experience shortness of breath, nausea, irregular heartbeats, or dizziness, then stop exercising. Get in touch with your doctor immediately if your symptoms persist.