Heart Transplantation

Patients may be evaluated for a heart transplant where heart disease is so advanced that there are no other treatment options and the patient would be a good candidate for this surgery.

Causes

A number of different conditions can damage the patient's heart to the point where other treatments are unsuccessful and a transplant is the best chance for cure. These include:

• Congenital heart disease
• Coronary artery disease
• Heart Failure
• Pulmonary hypertension
• Valvular heart disease

Other conditions may exclude a patient from consideration for a transplant, such as irreversible pulmonary hypertension, cancer, HIV, active drug or alcohol addiction, acute mental incompetence and severe muscle loss due to malnutrition, called cardiac cachexia. A number of other conditions are evaluated on an individual basis to determine transplant suitability.

Once it is determined that the patient would benefit from transplant surgery, the patient's name will be placed on a waiting list to receive a donor heart. There currently are not enough donor hearts available for the people who need them. Under national regulations, hearts must go to the sickest patients first in a given area.

Research currently is being done to evaluate devices that potentially could act as a "bridge" to transplantation by replacing heart function with a machine until a donor heart is available.

Evaluation

Our staff will determine the patient's general suitability for transplantation using preliminary information from the patient's referring doctor. After this initial assessment, a very comprehensive evaluation is conducted. Our approach to this is flexible although we do insist that every potential candidate and their family visit UCSF Medical Center at least once before the transplant.

All candidates are seen by UCSF's transplant team that includes a cardiologist, surgeon, transplant coordinator and social worker. If the patient lives far away from San Francisco, the team works with the referring doctor to complete portions of the pre-transplant selection protocol in the patient's local community.

The pre-transplant evaluation includes assessment of both the cardiac and extra-cardiac systems. Stable patients usually are able to complete the standard pre-transplant selection protocol on an outpatient basis.

One of the most important components of the cardiac evaluation is an assessment of pulmonary vascular health. If the patient has pulmonary hypertension, it is essential to determine its severity and potential for cure. These trials are conducted in the hospital with right heart catheterization and continuous hemodynamic monitoring often for periods of six to 12 hours. Because the outcome of these trials is pivotal in determining the patient's suitability for transplant, we prefer to perform this part of the assessment at UCSF Medical Center.

Additional routine components of the cardiac assessment include:

• Non-invasive studies the evaluate the function of the heart muscle, including echocardiography and radionuclide scans.
• Perfusion tests, which measure the amount of blood flow to tissue, including resting and stress radionuclide scans or echocardiography.
• The measurement of maximal oxygen uptake during standard exercise studies.

Some patients also may need formal cardiac catheterization, including coronary angiography and ventriculography, myocardial biopsy and electrophysiologic studies.

In addition, there are a number of non-heart-related tests and other components that are part of the pre-transplant evaluation, including:

• Pulmonary function testing including spirometry and arterial blood gases.
• Lab tests for kidney and liver function.
• Interviews with the social worker, transplant coordinator and psychiatrist.
• Interviews with the hospital administration about financial security.
• Infectious disease screening including serology and skin testing.
• Immunogenetics including blood and tissue typing as well as checking the patient's human leukocyte antigens (HLA) level.
• Cancer screening that includes chest X-rays and stools samples for everyone; mammograms, breast and pelvic exams for women; and prostate-specific antigen (PSA) and prostate exams for men.

Depending on the patient's specific situation, additional tests may be run during the initial screening.

While the main focus of the evaluation is to determine whether the patient is a suitable candidate for transplantation, the team also works with the patient and family to resolve any potentially reversible conditions such as smoking, drug addition, obesity, mental distress, financial problems and so on.

The selection of patients for heart transplantation is based on a recommendation from the multidisciplinary heart transplant team that is comprised of representatives from various departments including surgery, internal medicine, nursing, psychiatry, social work, pathology and hospital administration. The potential heart transplant candidate's case is presented at the weekly transplant meeting after the members of the team complete the interviewing process and the patient completes all pre-transplant testing.

After this discussion, the team will decide to do one of the following:

• Accept the patient for transplantation.
• Provisionally accept the patient pending resolution of one or more minor issues.
• Not accept the patient at the present time but recommend that he or she be followed with possible reconsideration at a future date.
• Categorically not accept the patient.

All decisions of the committee are based upon group consensus. In difficult cases, the medical center's ethics committee is available to offer their expertise.

Waiting for a Donor Heart

Patients deemed to be acceptable candidates for transplantation are listed nationally with the California Transplant Donor Network. The listing is made according to the organ(s) required, heart or both heart and lung, blood group and acceptable donor height range. Allocation of donor hearts is done at the local and regional level strictly according to national policy. The two main features of this policy include the following:

• Patients who require combined heart and lung transplantation are given priority over those requiring isolated heart transplantation.
• Heart transplant recipients are prioritized according to the duration of time that they have been "actively" on the waiting list.

Most patients continue to receive all of their medical care from doctors in their local community. A few choose to transfer their care to UCSF Medical Center. In either case we maintain close contact with the patient's referring doctor.

All patients on the waiting list are seen by the transplant cardiologist and transplant coordinator in the outpatient clinic every three months or as dictated by his or her medical condition. During these visits the patient's continued candidacy for transplantation is reassessed and, if necessary, further medical consultations or studies are performed. These visits usually coincide with the monthly meetings of the Transplant Program's support group, which patients on the waiting list are encouraged to attend.

Local doctors immediately inform the transplant team if a medical condition arises that could affect the patient's transplantation eligibility. If the patient's clinical condition warrants, they may be temporarily or permanently removed from the "active" waiting list. Patients whose clinical condition deteriorates while on the waiting list are either admitted directly or transferred to UCSF Medical Center from the community hospital once his or her condition has stabilized.

The Transplant Program has access to a variety of medications and devices, including pacemakers, defibrillators and ventricular assistance devices, to support patients with severe heart disease until they can be transplanted.

UCSF Medical Center is a member of the United Network for Organ Sharing (UNOS) and a founding member of the California Transplant Donor Network (CTDN), an independent regional organ procurement organization supported by regional transplant centers. The network has developed and maintains working relationships with more than 150 hospitals in Northern and Central California as well as Northern Nevada where it assists in the identification of potential donors, provides donor management, procurement, preservation, transportation and distribution of donor organs as well as formal and informal education concerning organ donation and transplantation.

Heart Transplant Procedure

Heart transplant surgery involves removing most of the patient's diseased heart and inserting one from a person who has died. The patient will be called to come to the hospital immediately once the patient have been assigned a donor heart. Upon arrival, the patient will go the Coronary Care Unit for a physical exam and more tests, including blood and urine samples.

The patient will be prepared for surgery, which includes the insertion of intravenous lines and a catheter in the patient's neck to measure the pressure in the patient's heart.

The patient will be given anesthesia so that the patient will sleep through the surgery. The patient also will receive immunosuppressive drugs before and during the procedure to prevent the patient's body from rejecting the new heart.

The surgery involves:

• A major incision down the patient's chest. The patient's breastbone is split in half.
• The patient's main arteries are connected to a heart lung bypass machine to pump the patient's blood and a ventilator will help the patient breathe.
• Most heart transplants are done with a method called orthotopic surgery, where most of the patient's heart is removed but the back half of both upper chambers, called atria, are left in place. Then the front half of the donor heart is sewn to the back half of the old heart.
• The donor's aorta and pulmonary arteries are connected to yours. The bypass machine is disconnected and the patient's new heart begins the work of pumping blood.
• The patient's incisions are closed.

This surgery is considered less complicated than most heart bypass surgeries, including coronary artery bypass graft (CABG).