Heart transplantation
A failing heart is removed and replaced with a donor heart.
Why it's done
- End-stage heart failure despite optimal medicines and devices, for example dilated or ischaemic cardiomyopathy.
- Assessment includes exercise testing, right heart catheterisation for pulmonary vascular resistance, and a full look at other organs, infection and cancer.
- High fixed pulmonary vascular resistance is a key contraindication, because a donor right ventricle can't cope with it.
The steps
- Donor heart: Donation after brain death (DBD), or donation after circulatory death (DCD) with the heart kept beating on a normothermic perfusion device during transport.
- Explant: The recipient goes on bypass and the failing heart is removed, leaving cuffs of atrium, aorta and pulmonary artery.
- Implant: The left atrial connection is made first, then the venae cavae (bicaval technique) or right atrium, then the pulmonary artery and aorta.
- Reperfuse and wean: The donor heart is reperfused, often paced, and supported with inotropes while it recovers.
Risks
- Primary graft dysfunction (the new heart doesn't work well early)
- Acute rejection
- Infection from immunosuppression
- Long term: cardiac allograft vasculopathy, kidney damage from calcineurin inhibitors, cancer
Recovery
Lifelong immunosuppression (commonly tacrolimus, mycophenolate and steroids), regular endomyocardial biopsies early on to look for rejection, and long-term follow-up. Median survival in adults is now more than a decade.
St George's Cardiothoracic Surgery Society, City St George's, University of London.