- Immunosuppressants: Drugs and agents that shut down your body's natural immune responses that would damage your new heart.
- Antibiotics, antivirals, and fungicides: Drugs that intercede to fend off infection because your natural immune responses are now disabled.
- Vitamins, minerals, and nutritional supplements: Compounds to aid your body in its efforts to heal and maintain proper functioning.
- Coronary-disease preventing and antihypertensive medications: Drugs to prevent coronary artery disease and regulate blood pressure.
1 AnswerYou know that after your heart transplant, you will be taking many different medications, each prescribed to you for a specific therapeutic reason. They fall into four categories:
Your mouth is a potential source of infection because so many bacteria and fungi are normally present there. This is why we insist that you have a dental evaluation before your heart transplant surgery. After transplant, it is important that you have regular checkups and maintain good dental hygiene.
1 AnswerAfter your heart transplant, you will be taking immunosuppressant, or anti-rejection, medications for the rest of your life to prevent your immune system from targeting your new heart as a "foreigner," and damaging it. Sometimes, the immune cells attack even though you are taking these medications.
Rejection occurs most often in the first six months after transplant. The chance of rejecting your new heart decreases with time, but rejection can occur at any time after transplant. Endomyocardial or cardiac biopsy is the way your transplant team monitors your heart for rejection. Because rejection can occur without any symptoms, cardiac biopsies are performed with regularity in the first year after transplant.
1 AnswerYour immune system recognizes and attacks anything different from the substances normally present in the body, even those only slightly different like your transplanted heart. Rejection is the term used when your body's immune system is attacking your transplanted organ. Nearly all patients will experience at least one rejection episode, especially in the first year after transplantation.
1 AnswerAfter surgery, you will regain consciousness in the open heart recovery intensive care unit (ICU). Among all the people moving around you, there will be one nurse who is assigned to caring just for you. All the cardiac ICU nurses are specially trained to care for transplant patients, and you are in expert hands. While you are in the ICU, blood tests, EKGs, and chest x-rays will be done frequently to follow your progress. Some of the drugs you will be taking affect the blood's components, and we want to be sure they remain in the normal range. One of the most important blood specimens taken daily will measure the amount of cyclosporine in your blood. We monitor this carefully to adjust your cyclosporine dosage to prevent organ rejection.
Your new heart will be supported with intravenous medications for about one to two days until it recovers from the "shock" of the transplant, but you will immediately feel the difference a healthy heart makes. Because the immune system gets activated immediately when the heart is transplanted, you will begin taking medications to prevent rejection even in the hours before your transplant and immediately afterwards. A typical stay in the intensive care unit is one to three days, and then you continue your postoperative care on a regular hospital floor. You can expect to be in the hospital 10 to14 days after your transplant.
1 AnswerYou will be laying on your back on the operating table; your arms will be placed at your sides, padded and tucked in place after your chest has been cleansed with antiseptic solution. A Foley catheter will be inserted to drain your bladder during and after the operation. An incision will be made over your breastbone or sternum and the bone divided to allow access to all parts of the heart.
You will be connected to a heart-lung machine which will circulate and oxygenate your blood during the operation. The operation is carefully synchronized to the progress being made by the donor organ harvesting team. While you have been preparing for surgery, another group of surgeons has traveled, usually by jet, to the donor hospital where they remove your new heart, examine its health, and carefully pack it in a special cold fluid for transportation back to you in the OR. There is continuous communication between the harvest team and your transplant surgeon's team to coordinate your operation with the timing of your new heart's arrival.
When the timing is right, your surgeon will open the pericardium that surrounds your diseased heart. Your heart is removed from its connections to the great arteries, leaving in place the back parts of your right and left atria. Your new heart is carefully fitted and sewn to the remaining portions of your atria. This method is called an orthotropic procedure and is the most common method of heart transplantation. After your new heart is completely sewn in place and begins to function, you are removed from the heart-lung machine.
With the completion of the operative procedure, one or more tubes are placed in your chest to permit drainage of fluids that accumulate as you recover. Pacing wires are also brought out of your chest cavity through the skin's surface in case there is need for electrical pacing of your new heart. The sternum is brought together with stainless steel wires, and the fatty tissues and skin are closed with absorbable sutures. This ensures the best cosmetic results in healing and avoids the need for later suture removal.
1 AnswerWhen a transplant team at the matched recipient's hospital is notified of a suitable heart, they travel quickly to the donor hospital. There, they remove the heart and place it in a special cold preservation solution. A heart can be outside the body for only about four hours before it loses the ability to function once transplanted. Thus, timing is crucial. When the heart is removed, the recovery team returns to their hospital where the transplant operation will be performed.
1 AnswerOnce you have been accepted into a heart transplant program, you are registered on the national UNOS (United Network for Organ Sharing) waiting list. Established by a Congressional Act in 1984 as a nationwide umbrella organization for transplantation, UNOS's mission is to promote and advance the science of transplantation and to increase the availability of donor organs. UNOS manages the national transplant waiting list, matching donor organs to recipients 24 hours a day, 365 day a year. It monitors every organ allocation to ensure compliance with equitable policies that maximize the limited supply of organs and give all patients a fair chance at receiving the organ they need, regardless of gender, race, religion, lifestyle, and financial or social status.
Hospitals are now required to have organ recruitment policies and procedures to identify potential donors, tell their families about organ donation opportunities, and to notify a local organ procurement organization (OPO) about potential organ availabilities.
Once a donor is identified by the hospital and the OPO is contacted, the OPO will determine the organ's suitability for donation and, if suitable, coordinate its distribution. However, if the potential donor's family decides not to allow the organ to be used, it is not removed.
A suitable heart donor is a young to middle-aged person who has been declared "brain dead" based on standard criteria, and whose heart is still functioning. All donors are screened to make sure the hepatitis B and C and HIV viruses are not present. Any evidence of these infections precludes use of the organ for transplantation.
Donor hearts are provided to patients based on the donor's blood type and body weight, the recipient's severity of illness, and geographic location. These data are contained in the UNOS computer database.
UNOS maintains the national patient waiting list, but all transplant hospitals and OPO personnel can access the information. Although you may hear of a local, regional or national list, they are all just parts of the same list.
1 AnswerTo help determine the severity of your heart disease, many diagnostic tests are performed in the evaluation phase. These tests typically take place over three consecutive days.
- Blood and urine testing: There will be many blood tests. One is performed to determine the presence of the HIV antibody; it will require your consent and results will remain confidential. You will be required to collect your urine for 24 hours prior to coming in for evaluation testing.
- EKG and chest x-ray: An electrocardiogram (EKG) is a method for recording the electrical activity of the heart and its effect on the function and efficiency of your heart. Electrodes placed across the chest convey impulses to a device that produces a graphic representation of your heart's activity. A standard chest x-ray will be performed to indicate the relative size and position of your heart and lungs.
- Cardiopulmonary stress test: By walking on a treadmill until a target heart rate is achieved, or until your heart disease forces you to stop, doctors are able to evaluate the extent of damage to your heart and measure its functional capacity.
- Echocardiogram: Using ultrasound, doctors can examine the size, shape, and motion of the heart's valves and chambers.
- MUGA scan: Also known as radionuclide angiography, this test determines how effectively the heart functions either at rest or during exercise. It involves adding a tracing radioisotope to the bloodstream and scanning its flow with a gamma camera. An EKG is performed simultaneously.
- Heart catheterization: To determine if there are any blockages in the arteries, contrast dye is injected through a thin catheter inserted into the neck or groin. Pressures in the heart's chambers are also measured to determine the resistance to blood flow.
- Carotid Doppler studies: An ultrasound procedure, this test evaluates blood flow to the brain to determine if there are any arterial blockages.
- Noninvasive flow study: This test measures the pressure of blood flow through your lower extremities by applying blood pressure cuffs to each calf.
- Abdominal ultrasound: Sound waves are used to examine the state of your liver, gallbladder, kidneys, and abdomen.
- Pulmonary function testing: By breathing into a tube connected to a monitor, we can determine if you have any breathing problems not caused by your heart disease.
1 AnswerWhen you are referred to NYPH/Columbia for evaluation as a candidate for heart transplantation, you may be seen as an outpatient or admitted to the hospital. The purpose of the evaluation is to determine if transplantation is the right choice for you.
You will have many tests, including blood and skin tests, x-rays, dental examination, and perhaps even cardiac catheterization. Some testing may be conducted locally and results faxed to the transplant office for review; this would also be reviewed with your referring physician.
Sometimes a condition is discovered that would make transplantation too difficult or dangerous. This could be an active infection in the body, high blood pressure in the lungs, or severe thickening of the arteries. Or, if you were found to have a condition making it dangerous to take the steroid drugs that are used to prevent rejection after transplant, you might not be a suitable candidate.
During evaluation, you meet various members of the transplant team. The transplant coordinator will plan your care and provide answers to your questions. You consult with numerous physicians to discuss the specifics of the transplantation process. A psychiatrist, physical therapist, and social worker may each examine you from their care-giving perspective.
Most patients will require a full dental examination with x-rays to rule out any sources of hidden or potential infection. Infections in the mouth can be very troublesome if they occur after the transplant operation. Your local dentist can provide results of this exam to us.
Women are typically required to have a complete gynecologic exam, including PAP smear and, if over 40 years of age, a mammogram. This can be done by your gynecologist with results forwarded to the transplant coordinator.