Whitefield - Heart Transplant

Columbia Asia Hospitals has a contemporary heart failure and heart transplant program in Bangalore, which is headed by a Transplant Surgeon, with specialized training and experience from premier transplant centers abroad. The multi-disciplinary team includes transplant surgeons, cardiologists, immunologist, anesthesiologists, intensivists, microbiologist, pathologist, psychiatrist, transplant coordinator, transplant nurses and intensivists, supported by a state of the art transplant critical care unit and a dedicated operation suite. Infrastructural facilities are modern and on par with global standards. Our consultants follow evidence based practice and internationally accepted protocols

Contemporary infrastructure includes an equipment armamentarium of high end devices like the cardiopulmonary exercise testing machine, the ECMO system and the Nitric oxide delivery apparatus

Protocols covering all aspects of the heart failure and transplant process are firmly in place to ensure a smooth seamless running of the program.

The co-managing team includes senior cardiothoracic surgeons who specialize in complex off pump coronary procedures, valvular repairs and replacements, aortic surgery and video assisted thoracoscopic surgeries (VATS).

Anatomy of the Heart

The human heart is a little bigger than the fist and is located just behind the sternum or breast bone, a little to the left. The heart pumps blood to the various parts of the body and receives blood with carbon dioxide, which is pumped to the lungs for oxygenation

The heart has four chambers: the right atrium, right ventricle, the left atrium and left ventricle.

Blood from the body and head enters the right atrium of the heart through a large vein, the vena cava. From here blood passes to the right ventricle and then to the lungs where it loses the carbon dioxide and gets more oxygen. It then returns to the left atrium of the heart, from where it flows to the left ventricle and thereafter to the various parts of the body and brain. There is a bundle of nerves in the wall of the right atrium called the sinus node, from which electrical impulses enable pumping action of the heart.

What is a Heart Transplant?

This is a procedure done to replace the patient’s diseased heart with a suitable cadaveric heart. The donor heart is matched to the recipient by blood type and body size. The heart is removed from the patient with the aorta, the main pulmonary artery, the superior and inferior vena cavae and retaining a cuff of the left atrium with the pulmonary vein openings in place. The surgeon, connects the donor heart by joining corresponding left atriums, vena cavae, aorta and the pulmonary artery.  Immunosuppressants need to be taken lifelong after the transplant to prevent rejection. If the child receives a heart transplant, the heart grows to adult size as the child grows. It is done under general anesthesia and during the procedure a heart lung bypass machine will be used to keep the blood circulating with oxygen rich blood.

When is heart transplant indicated?

  • Inadequate functioning of one or both ventricles leading to irreversible heart failure which is refractory to treatment
  • Refractory angina, despite medical management and not amenable to re-vacularisation procedures
  • Congenital heart diseases with progressive ventricular failure that is not amenable to conventional surgical repair
  • Congenital defects with single ventricle
  • Severe hypertrophic or restrictive cardiomyopathy
  • Refractory life threatening arrhythmias
  • Long standing valve obstruction
  • Leakage
  • Patients who underwent Fontan procedure for complex congenital heart defects with reduced blood flow through the venous system and congested veins

Steps to the transplant

  1. Evaluation that one is a candidate for a heart transplantation.
  2. Listing with the Zonal Co-ordination Committee of Karnataka and National Organ and Tissue Transplant Organisation (NOTTO).
  3. The donor must be a person who is brain dead and continued on life support. The donor heart must be matched to the recipient’s blood type to reduce the chances of rejection

Criteria for heart transplant

  • Have severe heart failure refractory to other treatment
  • On objective assessment noted to have very poor myocardial reserve
  • Not suffering from increased pulmonary pressure (pulmonary hypertension) and vascular disease
  • Satisfactory health of the other organs like kidney, liver etc
  • Diabetes interferes with wound healing and increases vascular complications. However, a patient who is well controlled and has no complications can undergo heart transplant
  • Not currently suffering from cancer or infection
  • Agree not to smoke, drink alcohol or use drugs
  • Be willing to take medicines for the rest of one’s life

 Contraindications

 Absolute contraindications

  • High pulmonary vascular resistance or pulmonary hypertension
  • High panel of reactive antibodies in allosensitised patients
  • Advanced kidney, lung or liver disease
  • Active cancer
  • Acute infections
  • Systemic diseases like systemic lupus erythematosus, sarcoidosis or amyloidosis
  • Vascular disease of the neck and leg arteries
  • Severe stroke or dementia
  • HIV infection

Relative contraindications

  • Insulin dependent diabetes with severe end organ dysfunction
  • Recent thromboembolism episodes such as stroke
  • Severe obesity BMI > 35
  • Active substance abuse
  • Malnourishment

Evaluation

  • An assessment will include alternatives to transplant being explored.
  • A multi-disciplinary team will conduct an exhaustive evaluation to assess the condition of the patient and ensure if he/ she will be able to withstand the surgery and the post-operative medication. The team will include a transplant surgeon, cardiologist, pulmonologist, immunologist, diabetologist, psychiatrist and others as required
  • Blood tests, x rays and other diagnostic procedures will be done to ensure that transplant is the best option. If any infection, high pressures in the pulmonary arteries or severe thickening of the peripheral arteries is detected, transplant may not be an option.
  • 12 lead ECG, Echocardiogram, stress test, 24 hour Holter and right heart catheterization will be done as part of evaluation of the heart functions. If required, an endo myocardial biopsy may be done.
  • Ultrasound of the neck and legs
  • Tests to look for cancer
  • Blood typing to ensure zero risk of rejection
  • A virtual cross match will be done in allosensitised individuals
  • In addition to evaluating the heart, kidneys, lungs, digestive system, bladder and other organs will also be evaluated
  • Mental health to assess substance abuse and also ability to withstand the transplant and follow up actions. A psychiatrist will evaluate whether the patient will be able to cope with the stress of a transplant and commitment to the post transplant care.
  • An evaluation of the family support system to aid in this complex undertaking
  • A dental evaluation is done to rule out potential sources of infection in the mouth, as this can lead to problems after transplant.

Pre-operative preparation

Blood and urine tests will be repeated to get the current status of key parameters. Chest hair will be removed and chest washed thoroughly with an antiseptic solution. A sedative will be given. 

Heart transplant procedure

This is done under general anesthesia. The surgeon will cut through the rib cage and expose the chest cavity. During surgery the blood flows through a heart lung bypass machine, to enable the surgeon to perform the surgery in a bloodless field. The machine does the work of the heart and supplies oxygen and nutrients to the rest of the body. The pericardium (the membrane which covers the heart) is cut through to expose the heart. The back part of the patient’s atrium will be left in place and rest of heart removed. The new heart will be sewn to fit the retained part of the old heart. The breast bone will be closed with wire. Medication will be given before, during and after the transplant procedure. The heart lung machine is disconnected and blood begins to flow into the new heart, which now takes over.

Post-operative period

Post-operative recovery will be in the transplant ICU. Tubes are inserted to drain air, fluid and blood out of the chest for several days and to allow the lungs to fully expand. The recipient will be on a ventilator until one is able to breathe spontaneously. Post-operative stay in the hospital will be around two weeks, all going well. The first 48 hours are very critical and requires continuous monitoring to ensure there is stable hemodynamics and no hyper-acute rejection

Risks

From anesthesia

  • Adverse reaction to medicines
  • Breathing problems

From surgery

  • Bleeding
  • Infection
  • Deep vein thrombosis
  • Heart attack
  • Stroke
  • Lung and renal failure
  • High levels of cholesterol, diabetes and bone thinning due to anti-rejection medicines

Complications

  • Rejection of the new heart which is recognized as a foreign body
  • Graft failure where the new heart fails to work
  • Narrowing of blood vessels supplying blood to the heart
  • Side effects of anti-rejection medicines

Rejection of the transplanted heart

The recipient’s body considers the transplanted heart as a foreign body and fights it. To prevent rejection, drugs are given to suppress the body’s immune response. Biopsies of the heart muscle is done on a regular basis during the first 6-12 months after transplant and less often thereafter to detect early signs of rejection. Anti-rejection medication is given for the rest of the recipient’s life.

Symptoms of rejection

  • Chills and aches
  • Fatigue
  • Shortness of breath
  • Puffy swollen ankles

What Happens When You Get a Heart Transplant?

There are five steps to getting a heart transplant. Your transplant team will:

  1. Decide if you need a new heart.
  2. Decide if you are healthy enough to receive a new heart.
  3. Prepare you for your operation. This can take a long time, and there is no guarantee that a matching heart will be found.
  4. Perform a heart transplant operation.
  5. Help you stay healthy after your operation.

Step 1. Your Transplant Team Decides If You Need a New Heart

Many heart diseases progress very slowly and different patients respond differently to various modalities of treatment. Because of this, the transplant center will first determine which therapy is best for your condition. Your response to other modalities of treatment will be monitored closely.

The transplant center will ensure that treatment provides a better quality of life and you have every chance to live longer with your own heart before they recommend a heart transplant.

Step 2. The Transplant Team Decides If You Are Healthy Enough to Receive a New Heart

Before you have a heart transplant, a team of health care professionals will talk to you about what a heart transplant entails, it’s pros and cons, and all risks involved. What happens can depend on your physical health, mental health, and how your evaluation goes. There are four parts to this phase.

  1. Visit to a transplant center. The transplant co-ordinator is the one point of contact for all transplant related issues. You will have to meet the co-ordinator and hand over all your medical records before your appointment. Apart from seeing your reports, the team will also examine your compliance to treatment, diet, exercise and doctor’s visits till date.
  2. Evaluation: The transplant team will do a complete evaluation of your physical health. They may do more tests to evaluate your:
    • heart
    • kidneys and gallbladder
    • stomach, esophagus, and intestines
    • lungs
    • bladder
    • teeth and gums
    • brain and nervous system
    • prostate, if you are a man
    • breasts and cervix, if you are a woman
    • The transplant team may order other tests as well, depending on your health status.
  3. Psychiatric evaluation: This is done to make sure you are not addicted to alcohol or drugs or any other prohibited substances. It will also evaluate your ability and coping mechanism to the stress related to the transplant, before, during and after. It will assess your commitment to taking medication life long and attending follow up regularly.
  4. Financial counselling: A detailed estimate will be given and you can share your insurance details to review whether your insurance policy covers the transplant operation and the medicines you will need after your transplant.

If the transplant team decides you are a good candidate for the operation, they will work with you to find a new heart. You will be assisted in the registration for a cadaveric heart.

Step 3. Your Transplant Team Prepares You for Your Transplant Surgery

This step involves finding a cadaveric heart suitable and matching for you. Sometimes this can take a long time. While waiting for surgery, you will have regular visits with your transplant team, who will monitor your health, diet and exercise regimen. You need to let them know of any changes in your health status.

Step 4. Your Transplant Team Performs a Heart Transplant Operation

  • Most heart transplant surgeries are done with a method called orthotopic. Your heart is removed, and the donor heart is sewn in place. Once the new heart is in place, the donor's main arteries - the aorta and pulmonary arteries - are sewn to yours.
  • When the right heart is found, the transplant coordinator will call you and you will go to the hospital. So keep your bags ready as you may get a call any time during the day and you will have to report to hospital immediately. The transplant doctors will check the donor heart while you are being evaluated. You will be given medications before and during the operation to prevent your body from rejecting the new heart. If the donated heart is the right match for you, you will be taken to the operating room
  • A transplant surgeon will prepare your chest cavity so your heart can be removed. At the same time, the new heart will be removed from the donor and sent to your hospital. This heart will be placed in your chest through the opening in your chest cavity. This is called a sternotomy.
  • After the operation, you will be taken to a cardiac critical care unit. You will stay in the hospital until your doctor feels you are ready to go home. How long you stay will depend on your health and how well your new heart is working. It will also depend on how quickly and easily you learn to take care of your new heart.

Step 5. Your Transplant Team Helps You Stay Healthy After Your Surgery

  • Maintaining your health after a transplant will ensure a good prognosis. After discharge, follow up as advised by the doctor is to be strictly adhered to.
  • Adhere to the medication schedule strictly
  • Follow the dietary and exercise regimen
  • Inform the transplant co-ordinator or doctor of any change in your health status

Evaluation

  • An assessment will include alternatives to transplant being explored.
  • A multi-disciplinary team will conduct an exhaustive evaluation to assess the condition of the patient and ensure if he/ she will be able to withstand the surgery and the post-operative medication. The team will include a cardiologist, pulmonologist, diabetologist, psychiatrist and others as required
  • Blood tests, x rays and other diagnostic procedures will be done to ensure that transplant is the best option. If any infection, high pressures in the pulmonary arteries or severe thickening of the coronary arteries is detected, transplant may not be an option.
  • Blood tests like complete blood count, electrolytes, iron levels, HIV, Hepatitis A, B or C, renal profile, thyroid profile and coagulation studies
  • Chest x-ray shows the position and size of the heart, lungs and blood vessels, and any increased fluid in and around the lungs without any symptoms.
  • ECG is done to observe the electrical activity of the heart and to determine if there is any change in your heart muscle. It helps detect myocardial infarction, arterial sclerotic disease, cardiac arrhythmias, heart enlargement, electrolyte abnormalities, pericarditis and pericardial effusion.
  • Cardiac catheterization will be done as part of evaluation of the heart functions. It helps measure pressures in all four chambers of the heart through the insertion of a thin plastic tube or catheter into a vein in the neck. IT helps measure oxygen concentration, saturation, tension and pressures in the various heart chambers, detects shunts, provides blood samples for analysis and determine cardiac output and pulmonary blood flow.
  • ECHO is done to visualize the chambers of the heart, thickness of the heart muscle, heart valves, major blood vessels connected to the heart and the pericardium which is a thin sack covering the heart. Abnormalities of the valves, structural deformities, pericardial effusion, cardiac tumors, heart enlargement and asymmetric thickening of the intraventricular septum can be detected.
  • Ultrasound of the neck and legs
  • Pulmonary function studies are done to measure respiratory function abnormalities
  • Tests to look for cancer
  • Tissue and blood typing to ensure risk of rejection is minimal
  • In addition to evaluating the heart, kidneys, lungs, digestive system, bladder and other organs will also be evaluated
  • Mental health to assess substance abuse and also ability to withstand the transplant and follow up actions. A psychiatrist will evaluate whether the patient will be able to cope with the stress of a transplant and commitment to the post transplant care.
  • A dental evaluation is done to rule out potential sources of infection in the mouth, as this can lead to problems after transplant.

Post Operative Instructions After Heart Transplant

Driving: one can resume driving only when the doctor clears you for it. This will be only after a period of at least six to eight weeks after transplant.

Lifting weights: Do not lift weights over 2 kilograms for the first 6 weeks.

Chest precautions:

  • Do not put pressure on your arms when moving or getting out of bed
  • Do not flex or extend shoulders over 90 degrees
  • Avoid twisting or bending
  • Do not hold your breath
  • Support your chest when coughing or sneezing
  • Call the hospital if you hear a clicking or popping sound around your chest
  • Do not perform any vigorous or strenuous activity

Walking: is the best form of activity or exercise. Start slowly and gradually increase based on your doctor’s advice

Wound care:

  • Watch for signs of infection (redness, swelling, soreness, or discharge).
  • Keep sugars under control, if you are a diabetic.
  • Take only showers, no baths till wound is completely healed.
  • Use anti-microbial soap
  • If chest tubes are still draining at discharge, dressing is to be changed once daily

Sexual activity: may be resumed only when the doctor clears it. This may be when you are able to climb the stairs easily. Safe sex practices are encouraged

Nutrition: Maintaining an ideal body weight is essential to prevent coronary artery disease, diabetes and hypertension. Low fat and low salt diet is encouraged

Cancers: The incidence of cancers in those on long term immunosuppressants is known.

  • Skin cancers are common. Change in size of a mole or wart should be reported
  • An annual mammogram is indicated for all adult women
  • All men will have PSA (prostate specific antigen) done annually
  • Colonoscopy is indicated once in three years

Dental care:

  • Dental cleaning is to be avoided within 6 months of a transplant
  • No major dental procedures for one year after a transplant
  • No antibiotic coverage is routinely indicated for any invasive dental procedure thereafter

Immunisation

  • Live or attenuated (weakened) vaccine is contraindicated after transplant
  • Booster dTap and pneumococcal vaccine can be given after the first year following a transplant
  • An annual flu vaccine is indicated
  • Transplant patients should stay away from youngsters who have received live viral vaccines, for 21 days

Complications of a Heart Transplant

  1. Rejection: The risk of rejection is there all throughout the post transplant life. You will need anti-rejection drugs lifelong. The dosage may be lowered but you should never skip or stop taking the drugs. A biopsy of the heart is the best way to know if the body is rejecting the new heart and is biopsy will be done every two weeks, upto four times after the transplant. Thereafter it is done only if a rejection is suspected
  2. Infection: Immunosuppressant drugs can increase the chance of getting infections. These infections can be treated. However, you need to tell your doctor if you have a fever, unusual pain, or any other new feelings. The risk of infection will go down when your doctor lowers the dosage. The immune system attacks any foreign body like bacteria, viruses etc. In order to suppress the immune system from attacking the new heart, immunosuppressants are given. These substances reduce the body’s response to the viruses and bacteria and cause infections
  3. High blood pressure: High blood pressure is a common problem after transplant. It can damage your new heart and cause strokes and heart attacks. The cause of the rise in blood pressure is thought to be due to some immunosuppressive drugs.
  4. Diabetes Mellitus: Anti-rejection medications can cause diabetes. If you had diabetes before your transplant, you may find it harder to control your blood sugar level after your transplant. The risk of developing diabetes after heart transplant is thought to increase in those with a family history, obesity and immunotherapy, most often tacrolimus.
  5. High cholesterol: Your anti-rejection medication can also cause high cholesterol. There are some medications called statins that control cholesterol and help prevent rejection because they also control inflammation.
  6. Heart disease: Some forms of heart disease can come back in the transplanted heart. Your doctor and transplant staff will monitor you for signs of this problem.
  7. Cancer: Anti-rejection drugs can raise the risk of getting cancer, especially blood cancer and skin cancer. Although blood cancer, called lymphoma, can be fatal, your doctor can lower the risk by lowering the dose of anti-rejection drugs. Your transplant team will suggest getting screened for cancer early and on a regular basis. They will recommend you regularly:
    • Get a colonoscopy
    • Get a mammogram
    • Get a pap smear, or prostate exam
    • See a dermatologist
  8. Osteoporosis: This is thinning of the bones. Being ill, eating a poor diet, being inactive, or taking prednisone and other anti-rejection drugs can cause osteoporosis. Your doctor will most likely order a bone density test and may put you on drugs that prevent osteoporosis.
  9. Cataracts: Prednisone (a steroid medication) and other drugs can cause cataracts, which are cloudy spots on the lens of your eye. You cannot prevent cataracts, but they can be surgically removed. Your doctor will ask you to see an eye doctor (ophthalmologist) at least once a year to get checked for cataracts and glaucoma. Glaucoma is pressure in the eye that can damage your vision.
  10. Kidney disease: The main medicines used to treat rejection, and many of the medicines used to treat infection, can hurt your kidneys. Your doctors will try to make sure you have enough medicine to prevent rejection of your new heart, but not so much that it hurts the kidneys. Sometimes this is hard to do. If you are older, or if your kidneys have already been injured by illness or medications, you may have permanent kidney damage. This can cause your feet to swell and your body to retain fluid. You may feel very tired and not feel well overall. Kidney disease is a serious problem. You will need to go for regular blood tests. These tests make sure the levels of your anti-rejection medications are not too high or too low.

Rejection of the Transplanted Heart

A person’s immune system usually identifies a substance foreign to the body and provides protection from harmful germs, poisons and other substances from affecting the body. These harmful substances have proteins coating their surfaces called antigens. When the antigens enter the body, the immune system recognizes them as foreign and attacks them.

This happens when the body of the recipient recognizes the new donor heart as a foreign body and reacts to it. It is known as acute rejection when it happens within the first year of transplant or chronic rejection if it occurs thereafter.

To prevent rejection, the donor and recipient tissues are matched to ensure maximum number of antigens are similar. This helps reduce the likelihood of rejection. No two people have perfect tissue match except perhaps identical twins.

Immunosuppressants are used to suppress the immune system of the recipient, so that the new organ is not attacked.

  • Periodic biopsies are done to detect rejection at a cellular level or through blood tests for antibody mediated rejection.
  • Chances of acute rejection are very high during the first three months and is often symptomless. Hence a biopsy will be done every week for the first month and then less frequently.
  • Rejection, though serious, is treatable with intravenous steroids or other medicines given over 3 days. A check biopsy is done after 2 weeks if it is below 3 months of transplant or after one month. Anti-rejection medication may be changed.
  • A blood test called allomap is done after six months to predict rejection. If values are high or there is a sudden rise, it is a predictor for rejection.
  • After one year, biopsies are only done annually or if the doctor suspects a rejection. 

Types of Rejection

  • Hyperacute rejection occurs a few minutes after the transplant when the antigens are completely unmatched. The tissue must be removed right away so the recipient does not die. It causes immediate organ failure. A retransplantation may be needed or a device support till then.
  • Acute rejection may occur any time from the first week after the transplant upto a year afterward. All recipients have some amount of acute rejection.
  • Chronic rejection can take place over many years. The body's constant immune response against the new organ slowly damages the transplanted tissues or organ

How to Prevent Rejection

  • Take medication prescribed correctly and regularly, without missing a dose. The right dose at the right time is very important. If there is vomiting within one hour of taking the medicine, one has to take another dose. NOT TAKING MEDICINE IS DANGEROUS AS IT CAN LEAD TO REJECTION OF THE TRANSPLANT
  • Get lab tests advised, prior to taking medicine to avoid a false high
  • Do not miss blood tests, other diagnostic tests or appointment with the doctor
  • Learn to recognize symptoms of rejection and immediately contact the hospital
  • Check weight, blood pressure and blood sugar periodically
  • Avoid use of alcohol and tobacco
  • Live a heart healthy life with regular exercise and a healthy diet

Symptoms of Rejection

Symptoms may include but are not limited to:

  • General discomfort, uneasiness or feeling ill
  • Out of breath
  • Fatigue or weakness
  • Weight gain of 1.3 kilograms in 24 hours
  • Temperature of 100 degrees Fahrenheit or above with chills
  • Irregular heart beat or palpitation
  • Drop in blood pressure
  • Swelling in the feet, ankles or hands
  • Decreased urine output
  • Dizziness or fainting episodes
  • Nausea or loss of appetite

Risk factors for rejection

  • High cholesterol
  • Older heart donor
  • Male donor
  • Younger recipient
  • Cytomegalo virus infection
  • Coronary heart disease in the donor or recipient
  • Insulin resistance
  • History of acute heart rejection

How is rejection diagnosed?

  • Heart biopsy
  • Blood test for the expression of certain genes associated with rejection
  • ECG and ECHO
  • Sometimes, coronary angiography and cardiac stress test

Treatment

  • Increasing the dose and frequency of current anti-rejection medicines
  • Changing to a different regimen
  • Addition of drugs such as prednisolone
  • Plasmapheresis filters the blood and removes harmful antibodies

Immunosuppressants

The immune system is the body’s defense against bacteria, virus, fungus or any foreign tissue. In order to ensure acceptance of the donor heart, recipients are given strong medicines to suppress the immune system. these medicines are called immunosuppressants or anti-rejection drugs. They will ensure that the transplanted organ is not identified as a foreign body. These medicines are to be taken for the rest of one’s life. An effort is made to decrease the dose of these immunosuppressants over a period of time.

The regimen will be tailor made for each patient. Your doctor will advise you on dose, when it is to be taken (on empty or full stomach), interaction with other drugs, interaction with certain food stuff, side effects etc

Possible side effects

  • Difficulty sleeping
  • Altered liver and renal functions
  • Diarrhoea, nausea and vomiting
  • Hand tremors
  • Headaches
  • Increased blood pressure
  • Mild hair loss
  • Numbness/ tingling in hands/ feet
  • Nasal congestion
  • Bloating/ gas formation
  • Night sweats
  • Seizures
  • Blurred vision
  • Mood swings

Drug - drug interaction

Some drugs interact with immune-suppressants:

  • Aspirin
  • Erythromycin
  • Ketoconazole
  • NSAIDS like ibuprofen, Indocin, Naprosyn, nuprin etc
  • Allopurinol and immunosuppressants have a lethal drug interaction

 

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