Heart Transplant

A heart transplant is a major open-chest surgery in which a diseased heart that can no longer pump blood adequately is removed and replaced with a healthy heart from a deceased donor.

During the operation, the patient is connected to a heart-lung bypass machine (a device that takes over the job of pumping and oxygenating the blood while the surgeon works). The surgeon detaches the failing heart, leaving the back walls of the upper chambers in place as anchor points, then sews the donor heart into position and connects the major blood vessels. Once blood flow is restored, the new heart usually begins to beat on its own.

A heart transplant is considered only when all other treatments have been tried and the heart failure (the inability of the heart to pump enough blood to meet the body's needs) is severe, irreversible, and life-threatening. The decision is made by a multidisciplinary transplant team after extensive evaluation.

• End-stage heart failure caused by dilated cardiomyopathy (a condition where the heart muscle is stretched and weakened)
• End-stage heart failure caused by ischemic cardiomyopathy (severe damage from multiple or massive heart attacks)
• Severe hypertrophic cardiomyopathy (abnormal thickening of the heart muscle) that does not respond to other treatment
• Certain complex congenital heart defects (heart abnormalities present from birth) that cannot be corrected by other surgery
• Life-threatening, uncontrollable arrhythmias (abnormal heart rhythms) that do not respond to any other therapy
• Heart failure following a failed previous heart surgery

A heart transplant is not suitable for everyone with severe heart disease. Doctors usually consider it unsuitable in the following situations:

• Active serious infection anywhere in the body
• Cancer that is not in remission (not under control)
• Severe irreversible disease of other major organs such as the kidneys, liver, or lungs — unless a combined organ transplant is planned
• Severe and fixed high blood pressure in the arteries of the lungs (pulmonary hypertension), which would cause the new heart to fail quickly
• Recent stroke or significant irreversible brain damage
• Active or very recent substance misuse (alcohol or drugs)
• Inability to commit to the lifelong medical follow-up and medication schedule required after transplant

A heart transplant is one of the most complex surgeries in medicine, and it carries significant risks both during the operation and in the years that follow; your transplant team will explain which risks are most relevant to your specific situation.

• Primary graft dysfunction (when the donor heart does not function well in the first hours or days after transplant — the most immediate life-threatening complication)
• Rejection — the immune system attacking the new heart; this can happen early (acute rejection) or gradually over years (chronic rejection)
• Serious infections, especially in the first year, because the anti-rejection medicines suppress (reduce the activity of) the immune system
• Kidney damage or kidney failure, a known long-term effect of the anti-rejection medicines
• Cardiac allograft vasculopathy (gradual narrowing of the blood vessels inside the transplanted heart, which can lead to heart failure over time)
• Bleeding during or after surgery requiring a return to the operating theatre
• Stroke (a blockage or bleed in the brain) caused by blood clots or changes in blood pressure during surgery
• Abnormal heart rhythms (arrhythmias) in the period after surgery
• Certain cancers, particularly skin cancers and lymphoma (a cancer of the lymph system), linked to long-term use of immune-suppressing medicines
• High blood pressure, high cholesterol, and diabetes as side effects of anti-rejection medicines taken long-term

Preparation for a heart transplant happens in two phases: the evaluation and waiting period before a donor heart becomes available, and the immediate preparation once a matching donor heart is found.

During the evaluation phase, the transplant team will run a thorough series of tests and assessments. These typically include:

• Blood tests to determine your blood type and tissue markers, which are used to match you with a compatible donor
• Heart tests such as an echocardiogram (an ultrasound scan of the heart), cardiac catheterisation (a thin tube inserted into the heart to measure pressures and assess blood vessels), and an EKG (a recording of the heart's electrical activity)
• Lung function tests to assess whether the lungs can tolerate major surgery
• Kidney and liver blood tests to assess how well these organs are working
• CT or MRI scans to examine blood vessels and other organs
• Psychological and social evaluation to ensure the patient can manage the demands of life after transplant
• Dental check-up, because mouth infections can become dangerous after surgery when the immune system is suppressed
• Cancer screening appropriate to the patient's age and sex

While waiting on the transplant list, patients are usually asked to maintain a stable weight, avoid alcohol and smoking, take all prescribed medicines reliably, and keep all hospital appointments. The transplant centre must be reachable at all times, as a donor heart must be transplanted within hours of becoming available.

Once a matching donor heart is found, the preparation moves very quickly. The steps during this phase and during the operation itself typically follow this sequence:

• The patient is called to the hospital immediately and asked not to eat or drink anything from the moment of the call.
• On arrival, the team repeats blood tests and confirms the cross-match (a final compatibility check between donor and recipient blood).
• An anaesthesiologist (a doctor who administers anaesthesia, or sleep medicine) meets the patient and explains what to expect.
• The patient is taken to the operating theatre and general anaesthesia (medicine that puts the patient into a deep, painless sleep) is given.
• A breathing tube is placed and the patient is connected to the heart-lung bypass machine.
• The surgeon opens the chest through the breastbone (sternotomy) to reach the heart.
• The diseased heart is removed, leaving key attachment points in place.
• The donor heart is sewn into position and the major blood vessels are connected.
• Blood flow through the new heart is gradually restored; the bypass machine is switched off once the heart is beating adequately.
• The chest is closed and the patient is transferred to the intensive care unit (ICU) while still under sedation (a medicine-induced state of deep calm and sleep).

Recovery after a heart transplant is a long-term process that begins in the ICU and continues for the rest of the patient's life. The transplant team — including cardiologists (heart doctors), transplant coordinators, nurses, pharmacists, and dietitians — remains closely involved throughout. The first year after transplant requires the most intense monitoring, as this is when rejection and infection are most likely.

• ICU stay: most patients spend several days to a couple of weeks in the ICU while the new heart stabilises, the breathing tube is removed, and drainage tubes from the chest are taken out.
• Hospital ward stay: after the ICU, patients move to a specialised cardiac ward for further weeks of monitoring before discharge; the total hospital stay varies considerably depending on the patient's recovery.
• Anti-rejection medicines (immunosuppressants): these must be taken every day for life without interruption. The transplant team adjusts the doses over time based on regular blood tests.
• Regular endomyocardial biopsies (a procedure where tiny samples of the heart muscle are taken through a vein in the neck or groin to check for signs of rejection) — these are done frequently in the first year and less often over time.
• Frequent outpatient clinic visits for blood tests, heart function tests, and blood pressure monitoring — especially in the first year.
• Wound care: the chest wound is usually closed with internal sutures; the transplant team will give specific instructions on cleaning and dressing the wound until it fully heals.
• Activity restrictions: strenuous lifting and driving are typically restricted for several weeks to months; the team will advise when it is safe to return to each activity.
• Infection precautions: because immunosuppressants (medicines that reduce immune system activity) lower the body's defences, patients are advised to practise careful hand hygiene, avoid crowded places during periods of heightened risk, and report any fever or unusual symptoms immediately.
• Diet and lifestyle: a heart-healthy diet, no smoking, no alcohol or very strictly limited alcohol, and a gradual return to physical activity guided by a cardiac rehabilitation (structured exercise and education) programme.
• Lifelong follow-up: annual or more frequent comprehensive reviews continue indefinitely, including imaging, kidney function tests, cancer screening, and review of all medicines.