Surgical Options

Heart Transplantation

Information for Families of Pediatric Patients and Adults

Look up a term in The Heart Center glossary.

What is cardiac transplantation?

Orthotopic cardiac transplantation is the process of explanting (removing) a person's failing heart and replacing it with a suitable donor heart from a person who has been declared clinically brain dead. Orthotopic refers to placing the new heart in the chest and contrasts the procedure from "heterotopic" transplantion (placed elsewhere in the circulation) performed in the experimental setting.

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Heart transplantation indications

Heart transplantation is used as a last resort for people with end-stage heart disease who have no other surgical or medical therapy available.

Generally, people listed for heart transplantation have a life expectancy of less than one year, and often much less. In addition, candidates often have significant limitations of their activity and lifestyle prior to transplantation.

The goal of heart transplantation is to return the patient to as functional a state as possible with the least amount of limitations and best quality of life.

The most common causes of end-stage heart disease requiring a transplant in children include viral or idiopathic cardiomyopathy -- a progressive deterioration of the function of the heart muscle, acute myocarditis -- an inflammation of the heart muscle, and congenital heart defects that are not amenable to further correction or palliation.

In adults ischemic heart disease (coronary artery disease) is the most common reason for heart transplantation. Re-transplantation due to rejection is another reason for transplantation in both children and adults.

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How a heart transplant is performed

Once a patient has been accepted for transplantation they are placed on a nationwide list. Based on their urgency, blood type, size, and time on the list, donor hearts are offered to a transplant center for a particular patient.

Once a donor organ is accepted, the procurement team travels to the donor hospital to retrieve the heart. Other physicians are usually present as well procuring other organs such as the liver and kidneys for transplantation.

The heart is cooled with a special solution called cardioplegia that stops the heart and preserves it. The heart is placed in cold saline and transported in an ice cooler back to the recipient's hospital.

The recipient's chest is opened and they are placed on the heart-lung machine (cardiopulmonary bypass). The failing heart is removed and the new donor heart is sutured into place.

In most cases, a heart from a donor bigger than the recipient can be used to fit the space left by removing the failing heart because of the enlargement a failing heart often undergoes.

In patients who have not had prior surgery, the operation takes about five hours. Generally, the patient is in much better condition immediately following the operation than prior to surgery. Post-operative recovery usually involves a 7-14 day hospital stay.

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Risks or possible complications of heart transplantation

The immediate risks of transplantation include the usual risks of open-heart surgery. The risks may be increased based on the patient's pre-operative condition.

Acute graft failure either from pre-formed antibodies (rejection) or from primary non-graft function is quite rare in the current era.

The early mortality is less than 5 percent for non-redo transplants in patients in reasonable pre-operative condition.

The most frequent early complications include renal insufficiency (kidneys not functioning properly), infection and bleeding.

Temporary right ventricular dysfunction may occur secondary to elevations in pulmonary vascular resistance that many recipients may have as a result of longstanding heart failure.

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Special preparation for heart transplantation

Patients evaluated for transplantation invariably have an echocardiogram and usually a cardiac catheterization prior to being accepted for transplantation.

Patients awaiting transplantation may be on anticoagulants to prevent clots from forming in the heart. They may also be on medications to prevent dangerous rhythms from occurring, which are more frequent in failing hearts.

If the pulmonary resistance is significantly elevated or the heart function too poor on its own, patients may remain on intravenous medications in the hospital while awaiting transplantation.

Mechanical ventricular support may also be employed to support a patient awaiting transplantation. Just prior to surgery patients begin their immunosuppression therapy by receiving a dose of cyclosporin and immuran.

Literature on transplantation is provided to all patients and their families during the evaluation process.

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Who decides whether a patient should be considered for a transplant?

Potential heart transplant recipients are usually identified by their surgeon or cardiologist. The patient and family is presented the option of transplantation and educated about the process and care involved.

The evaluation process involves blood work, further studies of heart function if needed, a general medical evaluation, and evaluation of the patient and their family's social situation and support system.

If all are in agreement, the patient is presented at a multidisciplinary transplant meeting and a group decision is made. Patients may occasionally be turned down for transplantation, but this is rare in pediatric patients.

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How often are heart transplants done and when?

Approximately 700 heart transplants are done in the United States each year, about 150 of which are in pediatric patients.

Once a patient is on the waiting list, they may wait anywhere from 1 day to as long as 6 months or more depending on their size, blood type, and waiting status.

Once a suitable donor heart is available, a patient generally has 2-6 hours to get to the hospital and be prepared for surgery.

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What is the likelihood of success with orthotopic heart transplantation?

Heart transplantation should be considered a palliative and not a curative operation. While most patients return to very good functional status, transplanted hearts do not last as long as a normal native heart in many patients.

Survival rates have continued to improve with experience, better techniques and medications, and improved rejection surveillance and immunosuppression.

Patients must remain on immunosuppressant medication for the rest of their lives. Some of these medication can have significant side effects, requiring other medicines for treatment. It is not unusual for a heart transplant recipient to be on 10 to 12 medicines at one time. It is critical that the patient adheres strictly to these regimens to avoid the many potential complications of transplantation.

Transplant patients are at risk for infection, and the development of lymphoproliferative disorders (cancers such as lymphoma) because of these medications. Rejection may also occur. The dosage of these medicines has to be altered at times based on blood tests, evidence of infection or cancer, or evidence of rejection. Close follow up with the transplant team and physicians is necessary and it is not unusual for patients to come back to the hospital frequently for these assessments.

An aggressive form of coronary artery disease has also been described in transplanted hearts that may represent a form of chronic rejection.

Patients may undergo retransplantation if the transplanted heart starts to fail, however, repeat transplants do not tend do as well.

The overall survival for orthotopic transplantation is currently around 80 percent to 85 percent at 1 year and 70 percent to 75 percent at 5 years. About 50% of transplant recipients make it out to 12 years.

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Patient Stories

The Heart Center team at Cincinnati Children's understands that the best reassurance and support for our families comes from stories shared by other families in similar situations. Here's one such story: