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A heart transplant is performed to treat heart failure due to disease or injury. A donor heart is removed from a person deemed brain dead. The heart is then transplanted into the recipient.

Who is a candidate for the procedure?

A heart transplant is offered only to people who, because of irreversible, chronic heart failure, are expected to die very soon otherwise.

Heart failure may be due to a variety of causes, such as:

• coronary artery disease
• damage to the heart muscles
• congenital heart disease
• valve disease
• immune system rejection of a prior transplanted heart

Heart transplants have been successful in persons ranging in age from infancy through the 60s. Potential candidates are evaluated by a multidisciplinary team.

The team may include:

• transplant surgeons
• medical heart specialists called cardiologists
• social workers
• nurses
• transplant coordinators

The team considers many factors. The person's general health and suitability for major surgery are taken into account, as are the following risk factors:

• emphysema
• poor leg circulation
• smoking
• liver or kidney problems and other conditions that may be treated before the transplant.

Treatment of these problems improves the chance of success and reduces complications. Only a few conditions would absolutely rule out a heart transplant. These include:

• cancer within the past 5 years
• some infections that cannot be completely treated or cured, such as tuberculosis
• severe lung, liver, or kidney problems that would make the operation too risky

The candidate must be willing to take anti-rejection medicines, such as prednisone, tacrolimus (i.e., FK506, Prograf) and cyclosporine (i.e., Gengraf, Neoral, Sandimmune), indefinitely to keep the body from rejecting the new heart.

If a person is a suitable candidate, a donor must be found. The recipient's name is put on a waiting list. There are now more than 4,000 people in the US waiting for a donor heart.

Waiting time may extend several years, if the person survives that long. People waiting for donor hearts are grouped by the severity of illness. Within any given group, hearts may be allocated based on the length of time a person has been on the waiting list.

How is the procedure performed?

Two or three surgical teams may operate on the donor at the same time so that several organs can be removed. Even though the donor is brain dead, the procedure is done in a sterile operating room just like any other surgery. The organs are removed, preserved, and packed for transport. After this, the donor's incisions are closed and normal preparations for a funeral or cremation take place.

The heart must be transplanted into the recipient within 4 to 5 hours. The recipient is given general anesthesia and placed on the cardiopulmonary bypass machine. This machine oxygenates the blood while the heart transplant is being performed.

Once the transplant is done, the donor heart may need shocking to start beating again. Special drugs are given to establish a stable heart rate and blood pressure. A careful check is made for any bleeding and the heart is observed to see if it is pumping normally. The recipient is then taken to the intensive care unit for recovery.

What happens right after the procedure?

After a heart transplant, a person usually stays in the intensive care unit for 7 to 14 days. Often he or she will stay on an artificial breathing machine, or ventilator, overnight. On the second or third day, the person may be well enough to move out of the ICU. Generally, he or she can start eating again within 2 to 5 days.

Two or three different medications to prevent rejection of the new heart are given beginning at the time of surgery. Because rejection of the heart may occur without any early symptoms, frequent biopsies are done. A small tube is passed through the jugular vein in the neck and into the heart. A tiny piece of heart muscle tissue is removed and is examined under a microscope for signs of tissue rejection.

Before leaving the hospital, the person will receive a lot of information from the transplant team. He or she will learn the importance of taking medications as prescribed. Signs of rejection are stressed so that the person and family know what to watch for. A program of exercise and rehabilitation will also be prescribed.

What happens later at home?

• Walking is encouraged to prevent lung problems and restore strength.
• Heavy lifting and straining should be avoided for 4 to 6 weeks.
• Driving is permitted once the incision is painfree.
• Sexual activity can be resumed when the person is comfortable.

Overall results of heart transplants are quite good, depending on the level of the person's illness at the time of the transplant. The American Heart Association reports that as of 2005, 85 percent of heart transplant patients survive for at least one year, and 70 percent for at least five years.

What are the potential complications after the procedure?

Many complications are possible after a heart transplant.

Infection. An infection can be very serious for a heart transplant recipient because the medicine he or she takes to prevent rejection of the heart also suppresses the immune system. This raises the overall risk of infection.

Fortunately, common postoperative infections, such as those of the urinary tract, are usually not serious. A serious infection, such as one that affects the sternal incision and bone, can be very hard to treat and may be fatal. Pneumonia after a heart transplant can also be very serious.

Vascular problems. Major bleeding after a transplant is not uncommon. Virtually all heart transplant recipients need a blood transfusion during the operation. About 5% of heart transplant patients need a second operation within 24 to 48 hours to correct bleeding. This is often a result of constant oozing from the raw operated surfaces or leakage from sutures or staples.

Rejection. The body's normal response to a transplanted organ is to reject it. The immunosuppressive medications that are prescribed prevent rejection in 50% to 75% of cases. People who do have rejection episodes can be diagnosed with an electrocardiogram and analysis of a sample of tissue from the transplanted heart.

Rejection is usually treated by increasing the amount of drugs taken or switching to different medications. Most of the time, it can be reversed. The more severe the rejection episode, the more likely there will be permanent scarring in the heart. That affects how long the organ will continue to work.

Cancer. Another long-term complication of immunosuppressive medications is cancer. This happens because the medications interfere with the function of immune cells that would normally get rid of a malignant cell before it can grow into a tumor. The most common malignancy is skin cancer. Usually, it can be successfully treated.