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Heart Consult

Cardiac Transplantation

Cardiac transplantation is the most widely accepted therapy for congestive heart failure at its final stage. It is mainly performed on patients who do not respond to medical therapy. Most of the patients who are recommended to go in for a heart transplant have complaints of either ischemic cardiomyopathy or dilated cardiomyopathy. In some cases congenital heart diseases and other diseases related to the heart which are non-responsive to medical treatment are also causes for this line of treatment.

Contraindications
The absolute contraindications for this therapy include malignancy for the past few years and other life threatening medical conditions. High level of alcoholism and drug abuse, any active ascending infection, peptic ulcer and cerebrovascular diseases also fall in the category of contraindications. Patients above the age of 65, those who are obese and those who are diagnosed with kidney disorders, diabetes or osteoporosis (brittleness of bones) are relative contraindications of a heart transplant.
Pediatric Heart Transplant
Cardiac transplantation in infants and children has been an accepted therapy since its successful application to infant recipients began in 1985. According to the International Society for Heart and Lung Transplantation, about 10% of the total heart transplants are performed on children every year. Cardiac tumors, infections, errors in the formation of the heart and toxins that cause damage to the myocardium are the four etiologies that lead to conditions that might require heart transplantation in pediatric patients. Cardiomyopathy, congenital heart diseases which are uncorrectable or at a high risk for repair, refractory  heart failure after a previous cardiac surgery, significant cardiac allograft vasculopathy of a previous heart transplant and unresectable symptomatic cardiac neoplasms are the various conditions considered for a pediatric cardiac transplantation. Some of the absolute contraindications for pediatric heart transplantation include irreversible elevated pulmonary vascular resistance, malignancy, Ectopia Cordis, active systemic infection, severe primary renal or hepatic dysfunction, multi-organ system failure, major CNS abnormality etc.
Heart Transplant Procedure
Once a compatible donor organ is located, the recipient will be evaluated and started on medications in preparation for transplantation. Once the patient is under anaesthesia the surgeons begin the process by exposing the chest cavity through a cut in the rib cage. The normal functioning of the body is kept intact by a mechanical pump that circulates blood through the body while the diseased heart is removed after opening up the pericardium. However the back part of the left atrium is left in place. In a method called as ‘orthotopic procedure’, the donor’s heart is carefully trimmed and sewn to fit the remaining parts of the old heart. The patient is given immunosuppressants both before and during the surgery in order to prevent rejection. After a successful transplantation the patient is shifted to the ICU for recovery. The duration of stay in the hospital will depend on the patient’s health and how well the recipient’s body is responding to the new heart.
Post-Operative Care
After a successful transplantation, a patient is immediately started on immunosuppressants. The immunosuppressant “cyclosporin” revolutionized the area of cardiac transplantation. There are instances when these are given prior to the surgery. The choice of the regimen of treatment is mainly dependant on the consultant. As a regular procedure, a patient who has undergone a successful cardiac transplantation without any further complications is usually discharged two weeks after the surgery.
Heart Transplant Centers
Various centers all around the globe have proved their expertise in cardiac transplantation. The Global group of hospitals at Hyderabad, The Apollo Heart Institute and the Frontier life line hospital in Chennai are some of the leading heart transplant centers in India. More than 40 hospitals with state of the art facilities in Germany offer heart transplant programmes.One of the biggest cardiac transplant centers in Europe is the Heart and Diabetes Center NRW at Bad Oeynhausen. The University Hospital at Heidelberg,the University Medical Center at Freiburg etc are some of the other famous hospitals here.The United States Of America is also home to several highly sought out world class cardiac transplant centers.
Heart Transplant Life Expectancy and Survival Rate:
The life expectancy after a cardiac transplantation depends on a number of factors such as patient – compliance, age, immunological donor – recipient match and also the year of transplant. According to a survey conducted by the American Heart Association, the average survival rates, one year after the transplant are 88% in males, 77.2% in females and 80-90% in children. This average has been found to steadily decline as the years progress and so the five year survival rates are found to be 73.1% in males, 67.4% in females and less than 70-80% in children. However, in pediatric cases a slow attrition rate continues beyond ten years which requires an additional transplant. There have even been rare instances where the recipients have survived for more than two decades. Generally, the heart transplant survival rate immediately after the surgery is 95% in most of the centers. If the patient survives after the first thirty days, then there are 90% chances that he/ she will cross the coveted one year mark.
Complications and Follow-Up
Even after a successful transplantation, the medical practitioner should be on the lookout for various complications such as acute rejections, bleeding from suture lines, ascending infections, cardiac allograft vasculopathy, renal failure, malignancy etc. Appropriate remedial measures should be undertaken in accordance with the risen problem. Though regular check-ups are a must for the first month after surgery, its frequency and also the dosage of immunosuppressants can be regulated over time.
In conclusion it can be rightly said that, cardiac transplantation has been a miraculous breakthrough in the field of medical sciences. Not ruling out the side-effects, it is still an expensive line of treatment. Even though its prognosis is uncertain and places a person on a lifelong financial burden and drug therapy, it is still opted as the most sought out therapy for end stage congestive heart failure.