Heart Transplantation Procedure*
(Transplant-Heart, Heart Transplant, Cardiac Transplant)
What is a heart transplant?
A heart transplant is a surgical procedure performed to remove the diseased heart
from a patient and replace it with a healthy one from an organ donor. In order to
remove the heart from the donor, two or more physicians must declare the donor brain-dead.
Before a person can be put on a waiting list for a heart transplant, a physician makes
the determination that there is no other treatment option available for the person's
About the heart:
The heart is the hardest working muscle in the human body. Located almost in the center
of the chest, the adult human heart is about the size of one fist.
At an average rate of 80 times a minute, the heart beats about 115,000 times in one
day or 42 million times in a year. During an average lifetime, the human heart will
beat more than 3 billion times - pumping an amount of blood that equals about 1 million
barrels. Even when a person is at rest, the heart is continuously hard at work.
How the heart works:
The cardiovascular system, composed of the heart and blood vessels, is responsible
for circulating blood throughout your body to supply the tissues with oxygen and nutrients.
The heart is the muscle that pumps blood filled with oxygen and nutrients through
the blood vessels to the body tissues. It is made up of:
Four chambers (two atria and two ventricles) that receive blood from the body (the
atria) and pump out blood to it (the ventricles).
The right atrium receives blood from the body, which is high in oxygen and low in
The right ventricle pumps the blood from the right atrium into the lungs to provide
it with oxygen and remove carbon dioxide.
The left atrium receives blood from the lungs, which is rich in oxygen.
The left ventricle pumps the blood from the left atrium into the body, supplying all
organs with blood.
Blood vessels, which compose a network of arteries and veins that carry blood throughout
Four valves to prevent backward flow of blood.
An electrical system of the heart that stimulates contraction of the heart muscle.
Reasons for the Procedure
Heart transplantation is performed to replace a failing heart that cannot be adequately
treated by other means.
Congestive heart failure (CHF):
End-stage heart failure is a disease in which the heart muscle is failing severely
in its attempt to pump blood through the body, and in which all other available treatments
are no longer helping to improve the heart's function. End-stage heart failure is
the final stage of heart failure. Heart failure, also called congestive heart failure,
or CHF, is a condition that occurs when the heart is unable to pump blood sufficiently.
Despite its name, a diagnosis of heart failure does NOT mean the heart is about to
stop beating. The term "failure" refers to the fact that the heart muscle is failing
to pump blood in the normal manner because it has become weakened.
Some causes of CHF, or weakening of the heart muscle, may include, but are not limited
to, the following:
heart attack (also called myocardial infarction, or MI)
viral infection of the heart muscle
high blood pressure (hypertension)
valvular heart disease
congenital (present at birth) heart conditions
cardiac arrhythmias (irregular heartbeats)
pulmonary hypertension (elevated blood pressure within the lungs' blood vessels)
alcoholism or drug abuse
chronic lung diseases, such as emphysema or chronic obstructive pulmonary disease
cardiomyopathy (an enlargement of the heart muscle)
anemia (low red blood cell count)
There may be other reasons for your physician to recommend heart transplantation.
Risks of the Procedure
As with any surgery, complications may occur. Potential risks associated with heart
transplantation may include, but are not limited to, the following:
bleeding during or after the surgery
blood clots that can cause heart attack, stroke, or lung problems
coronary arteriopathy (similar to coronary artery disease)
The new heart may be rejected. Rejection is a normal reaction of the body to a foreign
object or tissue. When a new heart is transplanted into a recipient's body, the immune
system reacts to what it perceives as a threat and attacks the new organ, not realizing
that the transplanted heart is beneficial. To allow the transplanted organ to survive
in a new body, medications must be taken to trick the immune system into accepting
the transplant and not attacking it as a foreign object.
The medications used to prevent or treat rejection have side effects. The exact side
effects will depend on the specific medications that are taken.
Contraindications for heart transplantation include, but are not limited to, the following:
current or recurring infection that cannot be treated effectively
metastatic cancer - cancer that has spread from its primary location to one or more
additional locations in the body
severe medical problems preventing the ability to tolerate the surgical procedure
serious conditions other than heart disease that would not improve after transplantation
noncompliance with treatment regimen
There may be other risks depending upon your specific medical condition. Be sure to
discuss any concerns with your physician prior to the procedure.
Before the Procedure
Because of the wide range of information necessary to determine eligibility for transplant,
the evaluation process is carried out by a transplant team. The team includes a transplant
surgeon, a transplant cardiologist (physician specializing in the treatment of the
heart), one or more transplant nurses, a social worker, and a psychiatrist or psychologist.
Additional team members may include a dietician, a chaplain, and/or an anesthesiologist.
Components of the transplant evaluation process include, but are not limited to, the
psychological and social evaluation: Psychological and social issues involved in organ transplantation, such as stress,
financial issues, and support by family and/or significant others are assessed. These
issues can significantly impact the outcome of a transplant.
blood tests: Blood tests are performed to help determine a good donor match and to help improve
the chances that the donor organ will not be rejected.
diagnostic tests: Diagnostic tests may be performed to assess your lungs as well as your overall health
status. These tests may include x-rays, ultrasound procedures, computed tomography
(CT scan), pulmonary function tests, and dental examinations. Women may receive a
Pap test, gynecology evaluation, and a mammogram.
other preparations: Several immunizations will be given to decrease the chances of developing infections
that can affect the transplanted heart.
The transplant team will consider all information from interviews, your medical history,
physical examination, and diagnostic tests in determining your eligibility for heart
Once you have been accepted as a transplant candidate, you will be placed on the United
Network for Organ Sharing (UNOS) list. When a donor organ becomes available, heart
recipients are selected based on the severity of their condition and their blood type.
You will be notified and told to come to the hospital immediately so you can be prepared
for the transplant.
The following steps will precede the transplant:
Your physician will explain the procedure to you and offer you the opportunity to
ask any questions that you might have about the procedure.
You will be asked to sign a consent form that gives your permission to do the surgery.
Read the form carefully and ask questions if something is not clear.
You should begin to fast once you are notified that a heart has become available.
You may receive a sedative prior to the procedure to help you relax.
The area around the surgical site may be shaved.
Based upon your medical condition, your physician may request other specific preparation.
During the Procedure
Heart transplantation requires a stay in a hospital. Procedures may vary depending
on your condition and your physician's practices.
Generally, heart transplantation follows this process:
You will be asked to remove any jewelry or other objects that may interfere with the
You will be asked to remove your clothing and will be given a gown to wear.
An intravenous (IV) line will be started in your hand or arm prior to the procedure
for injection of medication and to administer IV fluids, if needed. Additional catheters
will be inserted in your neck and wrist to monitor the status of your heart and blood
pressure, as well as for obtaining blood samples. Alternate sites for the additional
catheters include the subclavian (under the collarbone) area and the groin.
A catheter will be inserted into your bladder to drain urine.
Heart transplant surgery will be performed while you are asleep under general anesthesia.
A tube will be inserted through your mouth into your lungs. The tube will be attached
to a ventilator that will breathe for you during the procedure.
The anesthesiologist will continuously monitor your heart rate, blood pressure, and
blood oxygen level during the surgery.
The skin over the surgical site will be cleansed with an antiseptic solution.
The physician will make an incision (cut) down the center of the chest from just below
the Adam's apple to just above the navel.
The sternum (breastbone) will be divided in half with a special operating instrument.
The physician will separate the two halves of the breastbone and spread them apart
to expose the heart.
Tubes will be inserted into the chest so that the blood can be pumped through your
body by a cardiopulmonary bypass machine (heart-lung machine).
Once the blood has been completely diverted into the cardiopulmonary bypass machine
for pumping, the diseased heart will be removed.
The donor heart will be sewn into place. Once the new heart is in place, blood vessels
will be connected.
When the transplant procedure has been completed, the blood circulating through the
cardiopulmonary bypass machine will be allowed back into the heart and the tubes to
the machine removed. The heart will be shocked with small paddles to restart the heartbeat.
Once your new heart begins to beat again, the physician will observe the heart to
assess the function of the heart and to make sure there are no leaks where the blood
vessels are connected.
Temporary wires for pacing may be inserted into the heart. These wires can be attached
to a pacemaker and your heart can be paced, if needed, during the initial recovery
The sternum will be rejoined and sewn together with small wires.
The skin over the sternum will be sewn back together. The incision will be closed
with sutures or surgical staples.
Tubes will be inserted into your chest to drain blood and other fluids from around
the heart. These tubes will be connected to a suction device to drain fluids away
from the heart.
A sterile bandage/dressing will be applied.
After the Procedure
In the hospital:
After the surgery you may be taken to the recovery room before being taken to the
intensive care unit (ICU) to be closely monitored for several days. Alternatively,
you may be taken directly to the ICU from the operating room. You will be connected
to monitors that will constantly display your electrocardiogram (ECG or EKG) tracing,
blood pressure, other pressure readings, breathing rate, and your oxygen level. Heart
transplant surgery requires an in-hospital stay of seven to 14 days, or longer.
You will have a tube in your throat so that your breathing may be assisted with a
ventilator until you are stable enough to breathe on your own. The breathing tube
may remain in place for a few hours up to several days, depending on your situation.
You may have a thin, plastic tube inserted through your nose into your stomach to
remove air that you swallow. The tube will be removed when your bowels resume normal
function. You will not be able to eat or drink until the tube is removed.
Blood samples will be taken frequently to monitor the status of the new heart, as
well as other body functions, such as the lungs, kidneys, liver, and blood system.
You may be on special IV drips to help your blood pressure and your heart, and to
control any problems with bleeding. As your condition stabilizes, these drips will
be gradually decreased and turned off as your condition allows.
After the breathing tube is out, your nurse will assist you to cough and take deep
breaths every two hours. This will be uncomfortable due to soreness, but it is extremely
important that you do this in order to keep mucus from collecting in your lungs and
possibly causing pneumonia.
You may receive pain medication as needed, either by a nurse, or by administering
it yourself through a device connected to your intravenous line.
Once the breathing and stomach tubes have been removed and your condition has stabilized,
you may start liquids to drink. Your diet may be gradually advanced to more solid
foods as you tolerate them.
Your immunosuppression (anti-rejection) medications will be closely monitored to make
sure you are receiving the optimum dose and the best combination of medications.
Nurses, respiratory therapists, and physical therapists will work with you as you
begin physical therapy and breathing exercises.
When your physician decides you are ready, you will be moved from the ICU to a private
room on a post-surgical unit or transplant unit. Your recovery will continue to progress.
Your activity will be gradually increased as you get out of bed and walk around for
longer periods of time. Your diet will be advanced to solid foods as tolerated.
Nurses, pharmacists, dietitians, physical therapists, and other members of the transplant
team will teach you how to take care of yourself once you are discharged from the
Once you are home, it will be important to keep the surgical area clean and dry. Your
physician will give you specific bathing instructions. The sutures or surgical staples
will be removed during a follow-up office visit, if they were not removed before leaving
You should not drive until your physician tells you to. Other activity restrictions
Follow-up visits will be scheduled frequently after returning home from the hospital.
These visits may include blood tests, chest x-ray, and biopsy (removal of tissue from
the heart for examination under a microscope.) The transplant team will explain the
schedule for these tests. The rehabilitation program will continue for many months.
Notify your physician to report any of the following:
fever and/or chills - may be a sign of infection or rejection
redness, swelling, or bleeding or drainage from the incision site
increase in pain around the incision site
Your physician may give you additional or alternate instructions after the procedure,
depending on your particular situation.
What is done to prevent rejection?
To allow the transplanted heart to survive in your body, you will be given medications
for the rest of your life to fight rejection. Each person may react differently to
medications, and each transplant team has preferences for different medications. The
anti-rejection medications most commonly used include:
New anti-rejection medications are continually being approved. Physicians tailor medication
regimes to meet the needs of each individual patient.
Usually, several anti-rejection medications are given initially. The doses of these
medications may change frequently, depending upon your response. Because anti-rejection
medications affect the immune system, persons who receive a transplant will be at
higher risk for infections. A balance must be maintained between preventing rejection
and making you very susceptible to infection.
Some of the infections you will be especially susceptible to include oral yeast infection
(thrush), herpes, and respiratory viruses. You should avoid contact with crowds and
anyone who has an infection for the first few months after your surgery.
What are the signs of rejection?
The following are some of the most common symptoms of rejection. However, each individual
may experience symptoms differently. Symptoms may include:
The symptoms of rejection may resemble other medical conditions or problems. Consult
your transplant team with any concerns you have. Frequent visits to and contact with
the transplant team are essential.
The content provided here is for informational purposes only, and was not designed
to diagnose or treat a health problem or disease, or replace the professional medical
advice you receive from your physician. Please consult your physician with any questions
or concerns you may have regarding your condition.
This page contains links to other Web sites with information about this procedure
and related health conditions. We hope you find these sites helpful, but please remember
we do not control or endorse the information presented on these Web sites, nor do
these sites endorse the information contained here.
American College of Cardiology
American College of Chest Physicians
National Heart, Lung, and Blood Institute (NHLBI)
National Institutes of Health (NIH)
National Library of Medicine
United Network for Organ Sharing