Heart Transplant /Lung Transplant Surgery

HEART TRANSPLANTATION

A heart transplant, or a cardiac transplant, is a surgical transplant procedure performed on patients with end-stage heart failure or severe coronary artery disease when other medical or surgical treatments have failed. As of 2016, the most common procedure is to take a functioning heart from a recently deceased organ donor (cadaveric allograft) and implant it into the patient. The patient’s own heart is either removed and replaced with the donor heart (orthotopic procedure) or, less commonly, left in place to support the donor heart (heterotopic procedure). Approximately 3500 heart transplants are performed every year in the world, more than half of which occur in the US. Post-operation survival periods average 15 years. Heart transplantation is not considered to be a cure for heart disease, but a life-saving treatment intended to improve the quality of life for recipients.

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Pre-operative

Our Heart transplant surgery in Mumbai begins when a suitable donor heart is identified. The heart comes from a recently deceased orbrain dead donor, also called a beating heart cadaver. The patient is contacted by a nurse coordinator and instructed to come to the hospital for evaluation and pre-surgical medication. At the same time, the heart is removed from the donor and inspected by a team of surgeons to see if it is in suitable condition.

The patient must also undergo emotional, psychological, and physical tests to verify mental health and ability to make good use of a new heart. The patient is also given immunosuppressant medication so that the patient’s immune system does not reject the new heart.

Operative

Schematic of a transplanted heart with native lungsand the great vessels.

Once the donor heart passes inspection, the patient is taken into the operating room and given a general anaesthetic. Either an orthotopic or a heterotopic procedure follows, depending on the conditions of the patient and the donor heart.

Orthotopic procedure

The orthotopic procedure begins with a median sternotomy, opening the chest and exposing the mediastinum. The pericardium is opened, the great vessels are dissected and the patient is attached to cardiopulmonary bypass. The donor’s heart is injected with potassium chloride (KCl). Potassium chloride stops the heart beating before the heart is removed from the donor’s body and packed in ice. Ice can usually keep the heart usable for four[9] to six hours depending on preservation and starting condition. The failing heart is removed by transecting the great vessels and a portion of the left atrium. The patient’s pulmonary veins are not transected; rather a circular portion of the left atrium containing the pulmonary veins is left in place. The donor heart is trimmed to fit onto the patient’s remaining left atrium and the great vessels are sutured in place. The new heart is restarted, the patient is weaned from cardiopulmonary bypass and the chest cavity is closed.

The orthotopic procedure was developed by Shumway and Lower at Stanford-Lane Hospital in San Francisco in 1958.

Heterotopic procedure

In the heterotopic procedure, the patient’s own heart is not removed. The new heart is positioned so that the chambers and blood vessels of both hearts can be connected to form what is effectively a ‘double heart’. The procedure can give the patient’s original heart a chance to recover, and if the donor’s heart fails (e.g., through rejection), it can later be removed, leaving the patient’s original heart. Heterotopic procedures are used only in cases where the donor heart is not strong enough to function by itself (because either the patient’s body is considerably larger than the donor’s, the donor’s heart is itself weak, or the patient suffers from pulmonary hypertension).

‘Living organ’ transplant

In February 2006, at the Bad Oeynhausen Clinic for Thorax and Cardiovascular Surgery, Germany, surgeons successfully transplanted a ‘beating heart’ into a patient. Rather than cooling the heart, the living organ procedure keeps it at body temperature and connects it to a special machine called an Organ Care System that allows it to continue pumping warm, oxygenated blood. This technique can maintain the heart in a suitable condition for much longer than the traditional method.

Non-beating heart transplant

The first successful non-beating heart transplant was achieved in Australia in 2014, performed by cardiothoracic surgeon Kumud Dhital. The transplant was made possible by the development of preservation technology able to preserve a heart, resuscitate it and to assess the function of the heart. The first patient to have this surgery was 57-year-old Michelle Gribilas. Papworth Hospital in England (where the first non-beating heart transplant in Europe was carried out) stated that the technique could increase the number of hearts available for transplant by at least 25%.

Post-operative

Transplanted heart in the thorax of recipient

The patient is taken to the ICU to recover where they are started on immunosuppressants. When they are stable, they may move to a special recovery unit for rehabilitation. The duration of in-hospital, post-transplant care depends on the patient’s general health, how well the heart is working, and the patient’s ability to look after the new heart. Doctors typically prefer that patients leave the hospital 1–2 weeks after surgery, because of the risk of infection and presuming no complications. After release, the patient returns for regular check-ups and rehabilitation. They may also require emotional support. The frequency of hospital visits decreases as the patient adjusts to the transplant. The patient remains on immunosuppressant medication to avoid the possibility of rejection. Since the vagus nerve is severed during the operation, the new heart beats at around 100 beats per minute unless nerve regrowth occurs.

The patient is regularly monitored to detect rejection. This surveillance can be performed via frequent biopsy or a gene expression blood test known as AlloMap Molecular Expression Testing. Typically, biopsy is performed immediately post-transplant and then AlloMap replaces it once the patient is stable. The transition from biopsy to AlloMap can occur as soon as 55 days after the transplant.

Lung Transplantation

Lung transplantation, or pulmonary transplantation is a surgical procedure in which a patient’s diseased lungs are partially or totally replaced by lungs which come from a donor. Donor lungs can be retrieved from a living donor or a deceased donor. A living donor can only donate one lung lobe. With some lung diseases a recipient may only need to receive a single lung. With other lung diseases such as cystic fibrosis it is imperative that a recipient receive two lungs. While lung transplants carry certain associated risks, they can also extend life expectancy and enhance the quality of life for end-stage pulmonary patients.

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Requirements for potential donors

There are certain requirements for potential lung donors, due to the needs of the potential recipient. In the case of living donors, this is also in consideration of how the surgery will affect the donor

  • healthy;
  • size match; the donated lung or lungs must be large enough to adequately oxygenate the patient, but small enough to fit within the recipient’s chest cavity;
  • age;
  • blood type.

Requirements for potential recipients

While a transplant center is free to set its own criteria for transplant candidates, certain requirements are generally agreed upon:

  • end-stage lung disease;
  • has exhausted other available therapies without success;
  • no other chronic medical conditions (e.g., heart, kidney, liver);
  • no current infections or recent cancer. There are certain cases where pre-existing infection is unavoidable, as with many patients with cystic fibrosis. In such cases, transplant centers, at their own discretion, may accept or reject patients with current infections of B. cepacia or MRSA;
  • no HIV or hepatitis;
  • no alcohol, smoking, or drug abuse;
  • within an acceptable weight range (marked undernourishment or obesity are both associated with increased mortality);
  • age (single vs. double tx);
  • acceptable psychological profile;
  • has social support system;
  • financially able to pay for expenses (where medical care is paid for directly by the patient);
  • able to comply with post-transplant regimen. A lung transplant is a major operation, and following the transplant, the patient must be willing to adhere to a lifetime regimen of medications as well as continuing medical care.

Medical tests for potential candidates for Lung transplant in Mumbai

Patients who are being considered for placement on the organ transplant list undergo extensive medical tests to evaluate their overall health status and suitability for transplant surgery.

  • blood typing; the recipient’s blood type must match the donor’s, due to antigens that are present on donated lungs. A mismatch of blood type can lead to a strong response by the immune system and subsequent rejection of the transplanted organs;
  • tissue typing; ideally, the lung tissue would also match as closely as possible between the donor and the recipient, but the desire to find a highly compatible donor organ must be balanced against the patient’s immediacy of need;
  • Chest X-ray – PA & LAT, to verify the size of the lungs and the chest cavity;
  • pulmonary function tests;
  • CT Scan (High Resolution Thoracic & Abdominal);
  • Bone mineral density scan;
  • MUGA (Gated cardiac blood pool scan);
  • Cardiac stress test (Dobutamine/Thallium scan);
  • ventilation/perfusion (V/Q) scan;
  • Electrocardiogram;
  • cardiac catheterization;
  • echocardiogram.

Lung allocation score

Main article: lung allocation score

Before 2005, donor lungs within the United States were allocated by the United Network for Organ Sharing on a first-come, first-served basis to patients on the transplant list. This was replaced by the current system, in which prospective lung recipients of age of 12 and older are assigned a lung allocation score or LAS, which takes into account various measures of the patient’s health. The new system allocates donated lungs according to the immediacy of need rather than how long a patient has been on the transplant list. Patients who are under the age of 12 are still given priority based on how long they have been on the transplant waitlist. The length of time spent on the list is also the deciding factor when multiple patients have the same lung allocation score.

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Patients who are accepted as good potential transplant candidates must carry a pager with them at all times in case a donor organ becomes available. These patients must also be prepared to move to their chosen transplant center at a moment’s notice. Such patients may be encouraged to limit their travel within a certain geographical region in order to facilitate rapid transport to a transplant center.