Heart and Lung Transplant

The most common indication for heart transplantation is severe end-stage heart failure, which means the heart cannot pump blood well enough to reach all tissues in the body.

A pioneering heart surgeon, Dr. Christiaan Barnard, performed the first successful human-to-human heart transplant operation in 1967 in Cape Town, South Africa. Unfortunately, early operations resulted in problems such as infection and rejection, and heart recipients did not survive very long.

With advances in surgical technique and the development of new drugs to suppress the immune system, a majority of transplant recipients currently survive more than 3 years.

• A "bridge" device (assisted device) has been developed that lets certain people live longer while they wait for transplantation. A balloon pump is inserted into the aorta and is attached to a battery generator device, that can help the heart to provide blood flow to the body. This “bridge” cannot be used for long and is used only in critically ill people and is very close to getting a new heart.
• A newer procedure involves implanting a mechanical pump into your body to help pump the blood. This pump called a left ventricular assist device (LVAD) can be used for months or even years. Some devices can be utilized indefinitely.
• Total artificial hearts are now available and have been implanted in a few patients. Besides costs, complications are still present as a significant problem.

Successful lung transplantation has been performed since the early 1980s. The first surgeries involved transplanting both lungs and the heart together. Since then, operations have been developed to transplant both lungs, a single lung, and even partial lung (lobes).

Combined heart and lung transplants are rare.

• With improved surgical techniques and powerful medicines to prevent rejection, life expectancy after transplantation has increased over the last 2 decades.
• In the United States, people may wait 18 months or longer for a donor's lung.

Because of such demand, systems have been developed to make sure that the sickest people are the first to receive donor organs. Donors are carefully screened to make sure that only healthy lungs are transplanted. Because of the severe shortage, bilateral lung transplants are rare. Most patients receive a single lung.

The most common indication for heart transplantation is severe end-stage heart failure, which means the heart cannot pump blood well enough to reach all tissues in the body. People who receive heart transplants get them only when their failing hearts do not respond to medicines or other surgical treatments. Several conditions lead to heart failure, including the following:

• Ischemia, or lack of oxygenated blood to the heart (coronary heart disease), leading to heart attack and permanently damaged heart muscle
• Heart valve disease, such as damage from rheumatic fever
• Infections of heart tissue, especially heart valves or heart muscle
• Untreated, uncontrolled high blood pressure
• Heart muscle disease, secondary to multiple causes
• Congenital heart defects (certain heart defects that an individual is born with)
• Certain drugs

The most common reason people get lung transplants is chronic obstructive lung diseases such as emphysema. Other people are born with conditions that cause their lungs to fail, such as the following:

• Cystic fibrosis
• Eisenmenger syndrome, which is due to inoperable congenital heart defects
• Idiopathic pulmonary fibrosis
• Primary pulmonary hypertension - High pressure in the arteries (of unknown cause) that supply blood to the lungs
• Alpha1 antitrypsin deficiency

Heart failure occurs when your heart is not able to pump enough blood to the tissues of your body.

One of the first symptoms you will notice is shortness of breath.

• Initially, shortness of breath occurs only with vigorous exertion or strenuous exercise. As the disease progresses, shortness of breath will occur with less and less effort, and finally at rest.
• You may find that you need to use more pillows at night because you get short of breath when lying flat (orthopnea).
• You may wake in the middle of the night very short of breath, needing to sit or stand upright (paroxysmal nocturnal dyspnea).

Other symptoms include the following:

• Nausea and vomiting
• Weight gain
• Confusion
• Swelling of your arms and legs (edema)
• Severe fatigue and tiredness
• Decreased urine

The main symptom for lung disease is shortness of breath.

• You may have coughing or wheezing.
• The shortness of breath becomes so severe that it limits your exercise and daily activities.
• If you have severe lung disease, you may need medicines, such as inhalers or steroids, or even oxygen to be able to function.
• In cystic fibrosis, recurrent pneumonias and excessive sputum production is common.
• Fatigue and tiredness is common.
• Cyanosis or bluish discoloration of the skin and lips is common.

If your physical condition worsens in any way, or you develop new symptoms, you need to be evaluated immediately at a hospital emergency department.

A number of factors help your health care provider determine whether you need a heart transplant and whether you are a candidate for the operation.

• A careful review of your medical and surgical history, other medical problems, medications, and lifestyle, followed by a thorough physical examination will help your health care provider determine how other medical conditions will affect the survival of a new heart or lung.
• Laboratory tests, X-rays, and heart function tests, such as echocardiography and cardiac catheterization, will be done to determine the overall function of your heart and lungs and whether the abnormalities are permanent or reversible/correctible.
• You may not be a suitable candidate if you have had other significant cardiovascular diseases, such as a stroke, blocked arteries to your legs and/or bowel, or kidney failure.
• Individuals who cannot comprehend or have a mental illness are not transplanted, candidates.

Before a transplant operation, attempts will be made to improve your medical condition with lifestyle changes and medical treatment.

• You will be given medications to improve your heart or lung condition.
• Any harmful medicines will be eliminated.
• Those who can walk are enrolled in exercise and weight-loss programs to improve their overall condition. Even if these efforts do not improve your function, losing weight and improving your exercise tolerance will help you survive and recover from the operation.
• Once selected for a transplant, every effort is made to prepare the individual for surgery and to fully maximize both the physical and the psychological health of the patient, in terms of function and behavior. Once selected for a transplant, you will be placed on the national waiting list managed by UNOS (United National Organ Service), which is a national agency that places patients on a list based on priority, location, and type of organ required.

Blood types, as well as heart/lung size, will be matched with the donor heart or lung, that is a larger person must have a larger heart, not a small heart from a small person. Almost every organ system in the body will be evaluated to ensure that it will not affect the transplant.

Generally, you are eligible for transplantation only if your daily functioning is severely impaired by your heart or lung condition, and medical treatment and lifestyle changes have not helped in improving your condition.

Heart and lung transplantations are very complicated procedures with many possible complications after you leave the hospital. Both you and your family must keep close contact with your primary care provider and your transplant team to increase your likelihood of recovery.

You can return to work or school when your transplant team clears you for these activities, but you should resume normal activities gradually. The majority of patients who receive a heart or lung transplant unfortunately can never resume their previous work on a full-time basis due to the rigorous demands of postoperative monitoring.

You must make lifestyle changes to ensure that your new heart stays healthy. An organized rehabilitation program will help you make these changes.

• You will be enrolled in an exercise program.
• You will learn to choose foods that are healthy for your heart.
• If you smoke, you will be given help to quit.
• Routine evaluation of the kidney, liver, and other organs will be made to ensure that no side effects from drugs occur.

Proper dental care is essential, because you can get infections from oral bacteria and become very ill. You must take antibiotics before undergoing any dental procedures to prevent infection.

Rejection of a transplant is the most serious complication of a transplant. For this reason, you must keep a log of the following:

• Temperature
• Weight
• Blood pressure
• Heart rate and rhythm
• Urine check for sugar and acetone
• Stool check for unseen blood
• Shortness of breath
• Cough
• Sputum production
• Urine output

Once you have received your new heart or lung, you will undergo many different tests at the transplant center.

• Your blood pressure and lung function will be checked often for signs of organ rejection or side effects of medications.
• You will be checked for new cancers, which can be related to the immune-suppressing drugs you take to fight rejection. Skin cancers are the most common in transplant individuals.
• You will learn about healthy lifestyle choices to reduce your risk of future heart and lung disease.
• Blood tests will be done to monitor for medication complications, signs of infection, or rejection.
• You will undergo repeated cardiac biopsies and cardiac catheterizations to monitor for early signs of rejection and blocked coronary arteries.
• Lung recipients will undergo lung function tests and bronchoscopy to monitor lung function and signs of rejection.

To prevent rejection, powerful drugs must be used to suppress the immune system after a heart or lung transplant. In general, most people take a "triple therapy" of drugs, which includes tacrolimus, corticosteroids, and azathioprine.

• tacrolimus: This drug interferes with communication between the T cells of the immune system. The drug is used immediately after the transplant and for the maintenance of immunosuppression. Common side effects include tremors, high blood pressure, and kidney damage. Other minor side effects include excessive hair loss, high blood pressure, and diabetes. These side effects are usually related to the dose and can often be reversed with proper dosing.
• Corticosteroids: These drugs block T-cell communication as well. They are usually used at high doses initially after the transplant and if the rejection is detected. Corticosteroids have many different side effects, including easy bruising of the skin, osteoporosis, damage or death of portions of bone, high blood pressure, high blood sugar or diabetes, stomach ulcers, weight gain, acne, mood swings, and a "moon" face. Because of these side effects, many transplant centers are trying to reduce the maintenance dose of this drug as much as possible or even to replace it with other drugs.
• Azathioprine: This drug slows the production of T cells in the immune system. It is usually used for the long-term maintenance of immunosuppression. The most common side effects of this drug are suppression of bone marrow functions, such as making blood cells, and liver damage. Many transplant centers are now using a newer drug called mycophenolate mofetil instead of azathioprine.

Other drugs include cyclosporine, sirolimus, and mizoribine (not approved in the U.S.). These drugs are used in an attempt to reduce side effects. They are also used as replacement drugs after episodes of rejection.

If you receive a transplant, you must work closely with both the transplant team and your primary care provider.

• You must schedule regular visits for biopsies, blood tests, and evaluation of heart or lung.
• You must report immediately if you develop fever, chest pain, shortness of breath, or fluid retention.

You should call your health care provider immediately if, in the time immediately after leaving the hospital, any of the following occur:

• Your surgical incision opens.
• Fluid, blood, or pus leaks from the incision.
• You develop a fever, have weight gain, or notice an increase in blood pressure.
• You experience shortness of breath, a persistent cough, or bring up sputum.

To prevent rejection, transplant recipients must take all their medications as prescribed.

Your chances for recovery from heart and lung transplants today are improved greatly since the first transplant operations were done in the 70s and 80s.

• With advances in surgical techniques and immune-suppressing drugs, more than 80% of heart recipients survive more than 3 years after the operation.
• Lung transplantation is a relatively new procedure that continues to be improved. Currently, more than 65% of lung recipients survive at least 3 years after a transplant.

Overall, transplantation leads to improvement in your well-being because you regain the ability to carry out normal activities.

Rejection of the transplanted organ and infections are the most serious complications after this procedure. Different complications occur at different times after the operation.

• In the first few weeks after transplantation, bacterial lung infections are common in people who have heart and lung transplantation. These are treated with antibiotics. Fungal infections may also occur early after transplant but are less common.
• In the second month after transplant, cytomegalovirus (CMV) lung infections are common. You may receive antiviral medications to prevent this infection.

Acute rejection may occur within days after the transplant operation and anytime thereafter.

• Signs of heart rejection include fatigue, swelling of the arms or legs, weight gain, and fever.
• After a heart transplant, you are monitored for acute rejection by taking a tiny piece of the heart muscle called a biopsy and examining it with a microscope.
• Signs of lung rejection include cough, shortness of breath, fever, elevated white blood cell count, and a feeling of not getting enough oxygen.
• After a lung transplant, doctors may need to check the lung tissue by using a long flexible tube with a tiny camera on the end (bronchoscopy).
• If you have any signs of rejecting the transplanted organ, you will be given powerful immunosuppressive medications to stop the rejection.

Rejection of the transplanted organ can also occur months or years later.

• Rejection occurring months or years later and that results in permanent changes in the transplant is called chronic rejection. Signs are similar to those of acute rejection but are often slow to develop.
• Chronic lung rejection usually occurs because of fibrosis (scarring) of the smaller airways and blockages. This process is sometimes called bronchiolitis obliterans syndrome and can be very serious.
• Treatment includes altering the immunosuppressive medications or retransplantation.
• Chronic rejection of the heart occurs because of the development of blockage of the coronary arteries in the transplanted heart. Unfortunately, the cause remains unknown and retransplantation is the only solution. Patients will have all symptoms of heart failure. With a lack of organ donors, retransplantation is not common.
• Some transplant specialists believe that chronic rejection is a long-term complication brought on by acute rejection. For this reason, contact with the transplantation team about any new symptoms is very important.