Heart Transplant

Washington University heart surgeons established the heart transplant program at Barnes-Jewish Hospital in 1985 and have since performed more than 400 heart transplants. The hospital is considered a leading institution in heart transplantation.

The program is integrated with the comprehensive heart failure program, offering a full spectrum of cardiac care around the clock. The integrated program manages both heart transplant patients and heart failure patients who are not candidates for transplantation. The large volume of patients — more than 600 a year — along with the variety of their conditions, contributes to the high skill level of specialists in the program.

History of Heart Transplantation 
What is Heart Failure? 
Who is a Candidate for Heart Transplantation? 
The Process of Transplantation 
What to Expect After Being Transplanted  

History of Heart Transplantation

Dr. Christiaan Barnard performed the first successful heart transplantation on Dec. 3, 1967, on a 53-year-old patient with end-stage heart disease. Unfortunately, after an early recovery, the patient developed pneumonia and died 18 days after his transplant. This landmark operation encouraged the initiation of programs aimed at bringing this life-saving procedure to clinical practice. Dr. Norman Shumway performed the first successful heart transplantation in the United States at Stanford University on Jan. 6, 1968. Unfortunately, his patient died two weeks later.

By the end of 1968, 102 patients in 50 institutions and 17 countries had undergone heart transplantation. Because the results were poor, the initial enthusiasm gradually tapered. It was clear that progress was needed in several areas, most importantly in the field of immunology. Without better understanding of the immune system, transplant surgeons were unable to counter the body’s natural defensive response, which inevitably was activated to reject the new heart.

In the early 1980s, the immunosuppressive drug cyclosporine was developed. Along with other anti-rejection medications, the development of cyclosporine was the most important contribution allowing transplantation of all organs, including the heart, to become a reality. Over the years, there has been continued improvement in techniques for preservation of the donor heart, surgical techniques, immunosuppression and overall patient management. Cardiac transplantation is now a well-established procedure for patients with end-stage heart failure who have not been helped with medical therapy. Between 2,200 and 2,500 such procedures are performed annually in the United States, with excellent survival and improvement in quality of life for the thousands of patients who have benefited from this procedure.

What is Heart Failure?

Nearly 5 million Americans suffer from heart failure, a condition that afflicts 550,000 new persons each year. Over the last two decades, the incidence of heart failure has continued to increase in both men and women. In simple terms, the most common form of heart failure is a condition in which the heart’s pumping function does not meet the needs of the body.

In the United States, heart attacks are the most common cause. Typically, a patient has sustained a significant heart attack damaging the heart muscle. Over a period of years, the heart undergoes changes in shape and structure to keep up with the necessary workload. This “remodeling,” which initially improves the output from the heart, is also progressive, and the heart continues to dilate. The initial compensatory mechanism after a heart attack eventually becomes maladaptive, leading to reduced pumping function of the heart. During these changes, patients can have a range of symptoms. Some may be completely asymptomatic; others will develop a gradual decrease in their ability to exercise (as manifested by fatigue and shortness of breath). Finally, symptoms progress until heart function becomes severely compromised. At this point, patients usually experience fatigue and shortness of breath with minimal activity. They also may develop significant swelling of the body from excess fluid accumulation. Although medical treatment of patients with heart failure has made dramatic advances, and new therapies are available for treatment and alleviation of symptoms, some individuals do not benefit from treatment, or their condition continues to deteriorate. These individuals generally are referred for heart transplantation.

Who is a Candidate for Heart Transplantation?

To be eligible for cardiac transplantation, patients must meet certain criteria at all transplant centers. In general, the cut-off age for heart transplantation is 65 years of age. However, in some programs, including the Heart Transplant Program at Barnes-Jewish Hospital, individuals up to the age of 70 have received transplants. In addition, a battery of tests is performed to ensure that patients do not have any evidence of cancer, active infections, or major lung, kidney, liver, or peripheral vascular disease. Blood tests also are performed to screen for viral infections such as hepatitis and HIV.

Once all the data are collected, patients are referred to a panel of specialists consisting of heart failure cardiologists, surgeons, nurses, transplant coordinators, nutritionists, social workers and other experts who work with heart transplant patients. After a thorough review, a decision is made to list a patient on the transplant waiting list. This is a national list that prioritizes organ allocation on the basis of the severity of illness, blood type and geographic location.

For more information on organ transplants and allocation, see the United Network for Organ Sharing (UNOS) website.

The Process Of Transplantation

Once an appropriate heart becomes available, patients are told to come to the hospital for surgery. The unpredictable nature of when the opportunity for a heart transplant will occur requires that patients be available to come to the hospital at a moment’s notice. Timing is carefully coordinated to minimize the interval between removal of the heart from the donor and implantation in the patient. It is important to minimize this critical period when the heart is not getting any blood supply (the ischemic time). This period is usually limited to between four and six hours for the heart. The entire process of transplantation generally lasts six hours. Patients are then taken to the intensive care unit for further observation and management. Patients typically spend 10 to 14 days in the hospital.

Immunosuppressive medications are started before the operation and continued indefinitely. The dosage of these drugs is adjusted during the postoperative period. During the recovery period, patients receive continuing education about the new heart and immunosuppressive medications.

What To Expect After Being Transplanted

Heart transplantation is truly a life-saving operation. Most patients resume their normal lives and many go back to full-time employment. Many have become actively involved in transplant issues in their communities and participate in educational activities to promote public awareness.

Overall, one-year survival after heart transplantation is more than 90 percent. During the first year, rejection of the heart and infections (because of the body’s lowered immune response) are the leading cause of hospital admissions. As a result, surveillance for rejection, involving a biopsy of the heart, is performed weekly during the first month and decreases in frequency thereafter. These biopsies are continued indefinitely at yearly intervals after the first year. If rejection is detected by microscopic evaluation of the biopsy specimen, the immunosuppressive regimen is intensified. On rare occasions, rejection cannot be controlled. Infections are treated in the opposite manner — through a decrease in immunosuppressive regimen and treatment with appropriate antibiotics.

Recent data have shown the 10-year survival rate for heart transplant patients to be in the range of 50 to 60 percent. The primary cause of late failure of a transplanted heart is diffuse narrowing of the heart’s coronary arteries. This process, termed coronary artery vasculopathy, is caused by many factors, some of which — such as high blood pressure or blood lipid abnormalities — are treatable.

For a consultation regarding a heart condition, call:

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