Heart transplantation can be a lifesaving therapy. It is an option for the sickest patients who continue to have symptoms of heart failure or require admission to hospital for heart failure, despite being on the best medical therapy and having the appropriate device therapies.
Unfortunately, a major limitation is the availability of donor organs. Because of the critical shortage of available organs, strict criteria must be met before a patient is considered a potential candidate for a heart transplant. This means that there are many more people who need a heart transplant than will actually receive one.
It is also important to understand that while heart transplantation is a lifesaving therapy, it is not a cure. Although the failing heart is replaced, receiving a new heart requires one to be on lifelong immunosuppression, which increases the risk of infection, diabetes, and cancer.
Heart Transplant Candidacy Evaluation
If you are being considered for a transplant, your doctor will order a number of tests in order to determine whether you are a suitable candidate or not. These will include:
- Bloodwork to look at:
- Your kidney and liver function
- Your immune status to Hepatitis A, B and C
- Whether you have contracted viruses including: HIV, CMV and EBV
- A Cardiopulmonary Test (see section on How Heart Failure is diagnosed for more information) to assess the severity of your heart failure
- An Echocardiogram to assess your heart function
- A Right Heart Catheterization (see Glossary for more information) to measure the pressures in your heart and lungs
- Lung function tests
- Ultrasounds of your abdomen, neck and legs (to look for narrowing’s or blockages of the arteries)
- If you have diabetes, an eye examination by an ophthalmologist, to ensure that the diabetes hasn’t affected the blood vessels of your eyes (called diabetic retinopathy)
- If appropriate, screening tests for breast and cervical cancer (in women) and prostate cancer (in men)
Depending on the results of these investigations, further testing may be needed.
Once all of the tests are complete, your case will be discussed with all the members of the Heart Transplant team (includes Cardiologists, Cardiac Surgeons, Anesthetists, Nurse Practitioners, Psychiatrists and Social Workers) and a decision will be made.
Unfortunately, not everyone who is evaluated is a candidate for a heart transplant. There are a number of reasons why someone may not be considered to be a good candidate.
Reasons someone may not be a candidate
- Advanced liver disease (cirrhosis), lung disease (like COPD), or kidney failure
- Active cancer, or cancer within the last 5 years
- High pressures in the lungs (called pulmonary hypertension) that does not reverse with medications. This is a problem because if a new heart is implanted, the right ventricle (which pumps the blood to the lungs) will fail.
- An active infection
- Diabetes that has affected your kidneys, eyes, or nerves
- Plaque buildup in your arteries (other than the arteries around your heart)
What Happens After Listing?
Once you are considered a candidate, you will be put on the Heart Transplant List. Your rank on the list is determined by the severity of your condition (for example, someone who is sick and admitted to hospital is given a higher priority than someone who is stable at home) and how long you have been on the list.
Other factors that determine the amount of time you wait for a transplant include your blood group, your body size and how ‘sensitized’ you are. ‘Sensitization’ refers to the number and type of antibodies that your body has produced against foreign substances. The more antibodies you have, the more difficult it is to find an organ that is a right match for you.
Occasionally a patient is called in for transplant, but when the donor organ is examined, it is found to not be a good match, and the transplant is canceled. Think of this as a test-run.
Sometimes other medical problems arise while a person is waiting for a transplant. You may be ‘put on hold’ on the list while your doctor treats this problem. In some cases, a medical problem may arise that can make someone no longer eligible for a heart transplant.
What Happens After a Transplant?
After your heart transplant, you will be in the hospital for several days. Your doctors will watch you closely to make sure that your new heart is functioning properly and that other complications (like infections or kidney failure) do not occur.
After a heart transplant, you will need to take medications for the rest of your life. These medications are called anti-rejection or immunosuppressant’s. They are meant to help the body’s natural infection fighting mechanisms accept the new heart.
Normally the immune system is in place to prevent infections by attacking “foreign objects” (like bacteria or viruses). Rejection is when your body’s immune system recognizes the transplanted heart as foreign and attacks it. The immunosuppressant medications you will take will prevent the immune system from attacking and rejecting the new heart. Immunosuppression may also affect the way your body fights off infection.
Your dose of immunosuppression medication will change over time. The biggest dose of immunosuppression medications is usually at first, and the dose is then decreased over time. Because one of the side effects of taking immunosuppression is infection, you will also likely be prescribed medication(s) to prevent infection. While you are in the hospital, you will be taught all about your medications, when to take them, and their side effects, etc.