Heart Transplant Process

Many members of the heart transplant group evaluate the eligibility of the potential transplant candidate. This group includes a transplant cardiologist and surgeon and, in some cases, consultants in pulmonary medicine and nephrology. In addition, patients will generally meet with physicians from Endocrinology, Psychology, and Infectious Disease. Certified transplant coordinators and licensed social workers assist the transplant candidate and family during and after the evaluation. The evaluation toward heart transplantation at Mayo Clinic consists of two phases. Phase 1 is the initial appointment which consists of: * a visit with a nurse practitioner and with a cardiologist (heart specialist) * lab work * an echocardiogram * chest x-rays * a treadmill exercise test * a visit with a social worker After a candidate completes Phase 1, the Mayo physician will determine whether or not he or she requires further evaluation. If so, the physician will determine when the candidate should return for Phase 2, leading towards heart transplantation. Phase 2 entails 5-7 days of more invasive and detailed testing. The physician will also determine the urgency with which you must complete your evaluation to be listed for heart transplantation. The transplant program also recommends that someone accompany the patient to Mayo Clinic for his or her evaluations. Phase 2 includes several procedures and tests including: * a visit with a transplant surgeon and a cardiologist (heart specialist) * blood and tissue typing * analysis of the patient's antibodies * evaluation of the patient'simmune status * right heart catheterization * renal (kidney) function studies * additional routine and medical tests as needed If after consultation it is determined that transplantation is not the best option, the transplant cardiologist can make arrangements to refer the patient to another specialty area at Mayo Clinic. In selected cases, patients may need to be considered for multi-organ transplant (such as heart/kidney, heart/liver, or heart/lung transplant). Mayo Clinic is particularly well-positioned to evaluate and manage patients who may be in need of multiple organ transplant via our integrated multidisciplinary transplant center in Arizona, Jacksonville or Rochester. Approved for Transplant Individuals approved for transplantation are placed on the United Network for Organ Sharing (UNOS) waiting list. Transplant candidates on the waiting list will be seen at regular intervals by their primary physicians and by members of the transplant team. Regular communication between the transplant team and the referring physician is essential for successful shared care. There is no way to predict how long a given patient will remain on the wait list; time to transplant varies based on severity of illness and organ availability. If the transplant candidate becomes medically unstable while awaiting transplantation, additional intravenous drug or mechanical support may be used. Low-dose inotropic (heart stimulant) support is often effective in restoring acceptable cardiac function as the individual awaits an appropriately matched donor heart. If necessary, Mayo surgeons and physicians will use a number of mechanical univentricular and biventricular assist devices. These devices may support circulation for weeks or months and allow the person to be fully ambulatory and active. Some individuals may be dismissed from the hospital with the ventricular assist device device such as the Heart Mate in place. People requiring inotropic and mechanical support receive special priority for organs from the UNOS for donor hearts. Transportation Mayo Clinic can help coordinate air transportation for transplant candidates to ensure rapid travel to Mayo Clinic when a donor organ becomes available. Mayo Clinic has transplanted patients in Rochester from both the East and West coasts when organs became available; U.S. and international patients might travel to any of the three locations for their transplant, based on organ availablity and referral. As the time for transplant approaches, patients may consider relocating to be near the center at which they will receive their transplant. Receiving an Organ As a member of UNOS and in conjunction with regional organ organ-procurement agencies such as LifeSource in the Upper Midwest, LifeQuest in Northeast Florida, and the Donor Network of Arizona, Mayo Clinic is in constant contact with national and regional organ-procurement professionals. All transplant candidates are entered into national and regional data banks to help minimize waiting time for matched donor organs. A transplant recipient who receives notice that a compatible donor heart is available must return to Mayo Clinic immediately. The transplant cardiologist then performs a pre-operative examination to ensure that the person is in appropriate condition to undergo the transplant. Coordination between the team of surgeons retrieving the organ and the team caring for the patient is vital to optimize outcomes. Before making the final decision to proceed with the transplant, the transplant surgeon retrieving the heart makes a visual and functional assessment of the organ. After Transplantation Postoperative care Adult heart transplant recipients typically are hospitalized for seven to 14 days following surgery. Education and physical rehabilitation begin in the early postoperative period and continue after hospital discharge. After-hospital care In the early post-hospital phase following heart transplantation, patients are seen by Mayo's transplant team several times per week. Eventually, these visits decrease to one per month. Transplant recipients are usually asked to remain in the clinic area for three months following transplantation, so as to monitor their status closely. During this time, families usually stay in long-term lodging. For example, in Arizona, adults and their immediate family can stay at the Arizona Transplant House. In Rochester, they can stay at the Gift of Life Transplant House. Children undergoing transplant in Rochester can stay at the Ronald MacDonald House. Transplant recipients and their families also participate in educational activities to help them feel comfortable giving medicines, taking measurements like blood pressure and engaging in healthy eating and activities. Post-transplant immunosuppression Daily and lifelong immunosuppressive medication is required to prevent rejection of the newly grafted heart. The threat of rejection is highest in the first six months after surgery. Most people are treated with a combination of drugs including cyclosporine (or tacrolimus), azathioprine (or mycophenolate) and low-dose corticosteroids. With close observation, many people can be weaned from steroids during the first year. After full recovery from surgery, cyclosporine may be replaced by rapamycin, which can help preserve kidney function and prevent the development of coronary artery disease in the transplanted heart. In selected cases, Mayo uses additional or alternative immunosuppression drugs or other immunosuppression treatments including radiation or plasmapheresis. Mayo's transplant team is always available to discuss any modifications in the immunosuppressive program. Because rejection is often subtle until severe, routine surveillance right ventricular endomyocardial biopsies are performed on adults to monitor for rejection. Biopsies are performed with local anesthetic on an outpatient basis. Schedule for right ventricular endomyocardial biopsies: * Weekly three to six weeks after transplant * Biweekly seven to 12 weeks after transplant * Monthly three to six months after transplant * Quarterly beyond six months after transplant Additional biopsies as clinically indicated. Follow-up care at home After transplant recipients are stable and have returned home, they should see their primary physician regularly and undergo quarterly right ventricular endomyocardial biopsies. If the referring physician has the available facilities and wishes to assume some or most of the continuing care, this can be arranged. If the referring cardiologist prefers to perform right ventricular endomyocardial biopsies, Mayo Clinic cardiac pathologists are available to interpret the biopsy. If the referring physician desires, Mayo's heart transplant team will continue primary or shared care throughout the transplant recipient's course. In all cases, transplant recipients are asked to return to Mayo Clinic annually for coronary angiography and general evaluation. Long-term health issues and complications of heart transplantation The mandatory immunosuppressive therapy increases a transplant recipient's risk of developing infectious complications. Therefore, the patient and the primary physician must be attuned to early signs of potentially serious infections. Additional complications of heart transplantation can include hypertension (high blood pressure) and renal insufficiency (poor kidney function) associated with immunosuppressive therapy. Tumors can also develop in patients on immunosuppression drugs, and coronary artery disease may develop in the transplanted heart. Despite the need for lifelong medications and close medical follow-up, the vast majority of cardiac transplant recipients return to an active, productive and satisfying life. They are usually able to return to work and participate in a wide variety of leisure activities. Many post-transplant patients have returned to or taken up bicycling, fishing, hiking, aerobic sports, travel, and, in several cases, even completed marathons. As a particularly inspiring example, Captain Ardell Lien recently completed a solo circumnavigation of the globe in a 20-foot sailboat following his successful heart/ kidney transplant. He is s using his 27,000 mile, 15-month journey to help raise awareness of the critical need for organ donation.