Heart Transplantation

A heart transplant removes a damaged or diseased heart and replaces it with a healthy one. The healthy heart comes from a donor who has died. It is the last resort for people with heart failure when all other treatments have failed. Heart transplants are now the third most common organ transplant operation in the U.S.

Doctors may recommend a heart transplant for heart failure caused by

• Coronary artery disease
• Cardiomyopathy - disease of the heart muscle
• Heart valve disease
• In babies, multiple congenital heart defects that are too complex to repair

Getting a Heart Transplant

What is a heart transplant?

A heart transplant is an operation in which a heart from someone who has died is placed into another person whose own heart has failed due to severe heart disease. The survival rates for heart transplants have improved steadily since the first successful human heart transplants were done in the late 1960s.

In 2000, 2,197 heart transplants were done at transplant programs in this country.
In 2002, 1,643 people in the United States received a heart transplant, falling short of the projections that more than 2,000 would be transplanted.
Each year, about 16,000 Americans under age 55-and 40,000 under age 65-could benefit from a heart transplant. However, because of the shortage of donated hearts, many people who need a heart transplant die while waiting for one. As of December 26, 2003, 3,591 people in the United States were waiting for a heart transplant, 271 of them younger than 18 years of age.

How Common is Serious Heart Disease?

• It affects approximately 60 million people in the United States.
• It is the leading killer of all Americans.
• Nearly 750,000 Americans die each year from heart disease.
• It is the leading cause of death in American women, claiming the lives of nearly 500,000 women each year.

When is a Heart Transplant needed?

When the heart is permanently damaged by viral infections or by long-lasting heart disease, a heart transplant may be needed. Candidates for heart transplants may include:

• Adults with heart failure that does not respond to other available treatment;
• Infants and children with congenital heart defects or a disease affecting the heart muscle, called dilated cardiomyopathy;
• People with other types of acute or chronic heart problems;
• People who have advanced (end stage) heart failure, but are otherwise healthy

How long is the wait for a heart transplant?

Depending on how ill a patient is, the length of time a heart transplant candidate spends on the waiting list may range from 50 days to two years. The average time a heart transplant candidate spends on the waiting list is about 266 days.

How successful are heart transplants?

Success depends on a variety of factors, including age, how well transplant team's instructions are followed, especially about taking medications, and a variety of other issues.

Statistics show that 85 percent of heart recipients still have a well-functioning transplant after one year, and 68 percent have a well-functioning transplant after five years. As of August 1, 2002, statistics show that nearly 86 percent of heart recipients still have a well-functioning transplant after one year. The overall five-year survival rate reported from the 2000 Annual Report of the U.S. Scientific Registry of Transplant Recipients and the Organ Procurement and Transplantation Network was 69.6 percent.

Some heart transplant centers have patients who have had their transplant for ten years or more.

A few of the milestones in heart transplantation underscore the fact that heart transplantation makes a difference across the life span.

• The longest-living heart transplant recipient, alive and well at age 43, was transplanted more than 23 years ago at Stanford University.
• The youngest heart transplant recipient was transplanted at Loma Linda University only three hours after being born; that person, too, is alive and well more than 14 years later.
• The oldest heart transplant recipient, transplanted at age 81 at the University of Alberta, is alive and well two years later.

How much does it cost?

As of 1998, the estimated first-year cost of a heart transplant in the United States was about $311,000. This includes the cost of the evaluation, organ procurement, hospital charges, physician fees, follow-up care and anti-rejection medications. After the first year, the estimated annual cost for follow-up care was $40,000.

Currently, Medicare offers coverage for heart transplants performed at a Medicare-approved center. If patients have private insurance, they should check with their insurance representative about whether their policies cover heart transplants. This may help to pay for part of the cost.

Average transplant costs vary a great deal from person to person. Complications after surgery, the length of hospital stay(s), and differences in hospital costs can affect the total cost greatly. The approximate price range for a heart transplant in the United States is between $110,000 and $287,000.

Many heart transplants are paid for by private health insurance. However, patients must contact their insurance company to know if they are covered and for how much. Medicare and Medicaid also pay for transplants for certain people.

The social worker or a financial counselor at the transplant center may be able to help find local, state or national programs that can help with the costs of transplantation and postoperative care-including anti-rejection medications. Medicare covers 80% of the cost of immunosuppressive medications, as long as you are covered by Medicare, with some restrictions.

How do you I the process?

You start the process by talking to your doctor about a heart transplant. If your doctor feels that a transplant is a good treatment choice, you will be referred to a heart transplant center. You will need to speak to the transplant coordinator at the center, who will make arrangements for you to have a medical evaluation. This will help you and your health care team decide whether a heart transplant is a good option for you.

How am I evaluated for a heart transplant?

When patients have life-threatening heart disease, alternative treatments may be considered and tried. If these fail, however, an evaluation for a heart transplant may be considered.

Generally, chronological age is not as important as overall health. Heart transplant recipients can be in their 70s.

The majority (52 percent) of candidates are aged 50 to 64; 22 percent are aged 35 to 49. You will meet with a transplant surgeon and with a transplant coordinator at the heart transplant center. In addition to a medical history review and physical examination by the transplant doctor, you may receive:

• blood tests, including blood and tissue typing
• evaluation of your heart function, including echocardiogram and heart catheterization
• pulmonary function tests
• evaluation of your kidneys, including a 24-hour urine test
• social and psychological evaluation
• eye and dental exams.

If everything goes well, you will be placed on the center's waiting list until a suitable deceased (nonliving) donor becomes available. You will also be registered with the national computerized registry, which is maintained by the United Network for Organ Sharing (UNOS).

What does the procedure involve?

During the operation to remove your diseased heart and replace it with the donor heart, you are placed on a heart-lung machine, which pumps blood through your body, removing carbon dioxide and replacing it with oxygen. This allows the surgeon to bypass the blood flow to the heart.
A healthy heart is obtained from a donor who has died and kept on a ventilator. The healthy heart is transported to the transplant center in a special solution that preserves the organ. Through the use of a general anesthetic, you are kept deeply asleep and pain-free. An incision is then made through the breast bone (sternum), and your blood is re-routed through tubes to a heart-lung bypass machine in order to keep the blood oxygen-rich and circulating. Your diseased heart is removed, and is replaced with the donor heart.

What should I expect after the transplant?

If the post-operative course is a smooth one and no rejection occurs, you should be able to go home from the hospital as soon as seven to 12 days. However, if there are complications such as infection or rejection, the hospital stay will be extended. Remember that you will need to take special medicines, called immunosuppressive or anti-rejection medications, following your transplant surgery to help prevent your body from rejecting your newly transplanted organ. It is necessary to take these medications exactly as the doctor prescribes for the rest of your life. In addition, you will have regularly scheduled tests as an outpatient to monitor the function of your transplanted organ and will be encouraged to maintain a healthy lifestyle through diet and exercise.

What complications may occur?

Complications that may occur include infection and rejection. In order to prevent rejection it is important to take your medications faithfully, exactly as ordered by your doctor. Your transplant team will check you regularly to help detect any problems early and plan appropriate treatment. If you notice any symptoms of rejection such as fatigue or shortness of breath, speak to your transplant team right away.

The medications you need to take to prevent rejection lower your body's immune defenses, which increases your chance of getting an infection. This risk is higher right after your transplant because the doses of your medications are higher. During this time, it is important to avoid large crowds and people who are sick, especially with contagious diseases such as colds or flu. You should wash your hands often. After a while, the doses of your medications will be reduced, and the chance of getting infections will be less.