Heart transplantation surgical procedure

Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D.; Associate Editor-In-Chief:

Pre-operative Procedure
A typical heart transplantation begins with a suitable donor heart being located from a recently deceased or brain dead donor. The transplant patient is contacted by a nurse coordinator and instructed to attend the hospital in order to be evaluated for the operation and given 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 a suitable condition to be transplanted. Occasionally it will be deemed unsuitable. This can often be a very distressing experience for an already emotionally unstable patient, and they will usually require emotional support before being sent home.

Operative Procedure
Once the donor heart has passed its inspection, the patient is taken into the operating theatre and given a general anesthetic. Either an orthotopic or a heterotopic procedure is followed, depending on the condition of the patient and the donor heart.

Orthotopic Procedure
The orthotopic procedure begins with the surgeons performing a median sternotomy to expose the mediastinum. The pericardium is opened, the great vessels are dissected and patient is attached to cardiopulmonary bypass. The failing heart is removed by transecting the great vessels and a portion of the left atrium. The 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 patients remaining left atrium and great vessels and sutured in place. The new heart is restarted, the patient is weaned from cardiopulmonary bypass and the chest cavity is closed.

Heterotopic procedure
In the heterotopic procedure, the patient's own heart is not removed before implanting the donor heart. 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 patients original heart a chance to recover, and if the donor's heart happens to fail (eg. through rejection), it may be removed, allowing the patients original heart to start working again. Heterotopic procedures are only used in cases where the donor heart is not strong enough to function by itself (due to either the patients body being considerably larger than the donor's, the donor having a weak heart, or the patient suffering from pulmonary hypertension).

Post-operative
The patient is taken into ICU to recover. When they wake up, they will be transferred to a special recovery unit in order to be rehabilitated. How long they remain in hospital post-transplant depends on the patient's general health, how well the new heart is working, and their ability to look after their new heart. Once the patient is released, they will have to return to the hospital for regular check-ups and rehabilitation sessions. They may also require emotional support. The number of visits to the hospital will decrease over time, as the patient adjusts to their transplant. The patient will have to remain on lifetime immunosuppressant medication to avoid the possibility of rejection. Since the vagus nerve is severed during the operation, the new heart will beat at around 100 bpm until nerve regrowth occurs.

"Living organ" transplant
Doctors made medical history in February 2006, at Bad Oeynhausen Clinic for Thorax and Cardiovascular Surgery, Germany, when they successfully transplanted a 'beating heart' into a patient. Normally, potassium chloride injected donor's heart (in order to stop it beating, before being removed from the body) packed in ice in to preserve it. The ice can usually keep the heart fresh for up to four to six hours, depending on its condition to start with. Rather than cooling the heart, this new procedure involves keeping it at body temperature and hooking it up to a special machine called an Organ Care System that allows it to continue beating with warm, oxygenated blood flowing through it. This can maintain the heart in a suitable condition for much longer than the traditional method.