In general, patients with advance heart failure, or on maximal medical therapy, should be considered for transplant evaluation. Patients with increasing medication requirements, frequent hospitalizations, or overall deterioration of clinical status should be referred for evaluation.
Causes
Some causes of heart failure that result in cardiac transplantation are primary cardiomyopathy, coronary artery disease, with either resultant ischemic cardiomyopathy and symptoms of congestive heart failure or inoperable ischemic heart disease with refractory chest discomfort or arrhythmia.
A small percentage of patients who undergo cardiac transplantation do so for idiopathic dialated cardiomyopathy, valvular heart disease, congenital heart disease and inoperable hypertrophic cardiomyopathy.
How It Works
All candidates for transplantation enter the program with a comprehensive series of tests conducted by our multidisciplinary team of specialists. Some of these tests are required for any operative procedure (history and physical chest x-ray EKG etc.) while others (such as specific blood tests) are required for transplantation surgery.
Once the evaluation is complete, the transplant team will recommend treatment options and discuss if heart transplant is the best option. The risks and benefits will be discussed with each patient. After a candidate is accepted for transplantation, the patient is then placed on the national transplant waiting list maintained by the United Network for Organ Sharing (UNOS). Depending on the blood group, the average waiting time on our list is currently less than 12 months. The time may be shorter or longer depending on the donor supply and the patient waiting list. While waiting, the patient is followed in the office periodically to assist with any medical issues that may arise.
The TCI Heartmate Left Ventricle Assist Device is a mechanical circulatory support system and can serve as a bridge to transplantation. The use of the Heartmate including enhanced intra-operative technique allows patients to be in better condition for transplantation.
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The Program
A Network of Support: During the initial stages of evaluation, the patient undergoes many tests and sees many specialists. This is also the time when the patient is first introduced to the support network. The transplant coordinators, social worker, and Financial Coordinator play an extremely important role in providing this support.
The Transplant Coordinators are involved in the pre-transplant screening and stay involved throughout the years of follow-up care. In this way, patients benefit from having the same people throughout their participation in the program. Our patients tell us that the transplant coordinators, because of the range of their involvement and the depth of their concern, are essential participants in the support network.
Our social worker is a resource, advocate and a link between patients and all the services designed to assist them. The social worker helps patients and their families address the many complex social and personal that arise for transplant patients. The services range from helping with personal and psychological issues that result from living with a chronic medical condition, to lodging, joining support groups and receiving vocational rehabilitation.
The Financial Coordinator assists patients with financial and insurance issues related to transplantation. The services include assessing patient insurance for hospital and pharmacy benefits, identifying and attempting to resolve patient financial problems, and helping patients in requesting and applying for assistance from transplant resource programs.
Support groups are also available.
Eligibility
Indications for Heart Transplantation: In general, pediatric and adult patients with advanced irreversible heart failure, on maximal medical therapy with a limited life expectancy should be considered for transplantation evaluation. Patients with increasing medication requirements, frequent hospitalizations or overall deterioration of clinical status should be considered.
The causes of congestive heart failure that result in heart transplantation are primary cardiomyopathy, coronary artery disease, or inoperable ischemic coronary disease with arrhythmias. A small percentage of patients who undergo heart transplantation do so for valvular heart disease, congenital heart disease, and inoperable hypertrophic cardiomyopathy.
A suitable heart transplant candidate should at a minimum meet the following criteria:
- Cardiac disease, NYHA advanced Class III or Class IV;
- Condition is not amenable to other forms of medical or surgical therapy;
- Endstage cardiac disease with less than a 25% likelihood of survival at one year without a transplant.
- Patients with potentially fatal arrhythmia not amenable to other therapies.
It is important that candidates be in, otherwise, good health and be without serious medical illness.
Factors That Can Rule Out Heart Transplantation
Relative Factors:
- Unusual weight loss
- Drug or alcohol abuse
- Cigarette smoking
- Advanced age (over 65 years). However, the physiological age of the candidate rather than the chronological age is the major consideration
- Severe cachexia
- Psychiatric illness which may interfere with compliance
- Morbid obesity
- Advanced, generalized atherosclerosis; severe peripheral vascular disease
- Diabetes Mellitus in poor control
- History of cancer (detailed information needed for evaluation)
Absolute Factors:
- Fixed pulmonary hypertension (as reflected by a calculated pulmonary resistance above 6 Wood units, or a pulmonary arteriolar gradient greater than 15mm.)
- Active systemic infection
- Severe cerebral or carotid vascular disease not amenable to surgery
- Severe chronic obstructive pulmonary disease or severe chronic bronchitis
- Irreversible and severe hepatic or renal dysfunction (unless combined transplant is possible)
- Active Malignancy
- Unmanageable and/or severe psychiatric disease
- The patient (or parent if the patient is a child) is unable to understand the issues related to transplant and unable or unwilling to take medications as instructed
- Active peptic ulcer disease
- Substance addictions including tobacco use
The Procedure
When a compatible organ becomes available, the transplant patient is immediately contacted by a transplant coordinator or transplant surgeon and admitted to the hospital.
At this time, a history is taken of any medical events, which may have occurred since initial transplant evaluation. All appropriate testing is also done to ensure the patient’s readiness for surgery.
The surgery lasts approximately five to eight hours. When the surgery is completed, the patient is transferred to the Cardiac Intensive Care Unit. Once stable, the patient is transferred to the transplant patient care unit on North 11.
The average length of stay in the ICU is 3-7 days. The average total length of stay in the hospital is 2-3 weeks.
Careful, comprehensive post-surgical monitoring constantly evaluates whether the body is accepting the new organ. Patient education is a major focus of the post transplant care. Patients must understand their medical regimen and be responsible for their follow-up care.
Going Home
A Program That Changes Lives: The Heart & Vascular Institute's Transplant Program has saved and greatly improved the lives of hundreds of people in recent years. By replacing organs that have ceased to function effectively, the program has given new life, new energy, and new possibilities to people whose lives have been restricted by debilitating conditions.
We have worked to build a team of committed and gifted physicians, nurses, researchers, counselors, and social worker whose special expertise guarantees that our patients receive the best treatment available. We are dedicated to providing the comprehensive care from the time a patient is referred and indefinitely after the transplant.
The Patient’s Responsibility: While transplantation can greatly improve the recipients’ quality of life, it also demands much of them. Recipients must become active participants in preserving their health. In addition to regular follow-up, patients must call the Hartford Transplant Associates’ Office with any concerns or questions that they have about their health. For the rest of their lives, they must take their medications especially immunosuppression (anti-rejection) medications.
Immunosuppressive Medication: Transplantation has become increasingly successful in recent years in large part through the development of new, more effective drugs which prevent the body from rejecting the donated organs. These drugs inhibit the body’s immune system from identifying the new organ as foreign. It is necessary for all patients to take immunosuppressive medication for the rest of their lives following the transplant. A successful transplant can be undermined very quickly if patients fail to take their medications appropriately and responsibly.
Outpatient Visits: Follow-up care initially involves returning to the Hartford Transplant Associates’ office several times per week during the first month after leaving the hospital. A series of blood tests and occasionally heart biopsies are conducted to closely monitor the patient’s progress. This is a period when medications are precisely adjusted to reach a point of effective stability. As time goes on, blood tests and office visits are extended. Monthly blood tests and three month office visits are required indefinitely.