Transplant Center

Should transplantation be determined as a patient's best treatment option, the following describes the transplant surgery.

THE HEART TRANSPLANT OPERATION

Surgical Consent Forms
You will be asked to sign a consent form after your physician explains the procedure, expected results, and possible complications and risks. Please read through the form carefully. If you have questions about anything in the consent form, please ask your physician to explain the information to you.

Research Studies
You may be asked before or after your procedure if you would like to participate in a research study. We believe research is important to our continued effort to improve care for the patients of tomorrow. However, you are not obligated to participate in any study, nor will your medical care be affected by your decision. Nonetheless, we would like you to make an informed decision. Should you have any questions about the research study you may decide to participate in, please feel free to ask your physician or the research associate during your visit.

Pre Op and Operating Room
Once a suitable donor organ that matches your needs has been identified, the preparations for surgery can start. You will be taken to a holding room where an intravenous (IV) line will be started in your hand or arm for injection of medication and to administer IV fluids. Your skin will be scrubbed with a special soap in preparation for surgery. You will be given a hospital gown to wear. You will need to remove your dentures, glasses, and any prosthetic devices such as hearing aids, contact lenses, or artificial limbs. In addition, you will need to remove all jewelry and either give the items to a family member for safekeeping, or place them in a secure envelope. Your nurse will contact Security to arrange this option. You will receive a sedative medication in your IV to help you relax. You will also get your first dose of immunosuppressant medication. Once this has been done, the operation can take place. The operation usually lasts five to seven hours from beginning to end, but can last longer if a patient had previous open heart surgery or have a left ventricular assist device in place.

From the holding area, you will be taken to the operating room where the procedure will actually take place. The room will feel cool. You will lie on a table and you will be connected to equipment that will monitor your heart rhythm, blood pressure, and oxygen levels. A probe will be placed on your finger or ear lobe to constantly monitor your oxygen levels.

Once you are in the operating room, the anesthesiologist or anesthetist will give you medication in your IV to sedate you. Once you are sedated, a breathing tube will be inserted through your throat into your lungs and you will be connected to a ventilator, which will breathe for you during the surgery. A tube will be inserted through your mouth into your stomach to drain your stomach fluids. A special IV will be placed into an artery in your wrist and connected to a monitor in order to monitor your blood pressure during the procedure. In addition, blood will be drawn from this special IV, called an arterial line, to check the oxygen levels in your blood during the operation.

Another special type of IV will be inserted into your neck and connected to a monitor so that your heart's status can be closely monitored during and after the procedure. This neck IV is called a pulmonary artery catheter, because the tip of it is in the pulmonary artery.

You will lie flat on your back during the entire procedure. The operating room is a sterile area, so everyone in the room will wear gowns, masks, and caps. The physician and assistants actually performing the procedure will wear sterile gloves.

When the new heart is on its way to The Nebraska Medical Center, the transplant surgeons begin preparing for the removal of the diseased heart from the patient's chest. The surgeon will begin by opening the chest through an incision in the breast bone. This incision will be just like that used for heart bypass surgery. No other incision is needed. Once the chest is opened, the outer layer of the heart (called the pericardium) is opened and the heart is separated from it.

When the new heart arrives, the patient will be connected to the heart-lung machine and it will take over the function of the heart and lungs for the rest of the procedure.

ORTHOTOPIC TRANSPLANT
In an orthotopic heart transplant, surgeons remove the failing heart except for the back walls of the atria, the heart's upper chambers.

The donor heart is then attached to the remaining part of the patient's heart. The backs of the atria on the new heart are opened and the heart is sewn into place. Since the chest cavity is used to a large heart, tubes will be inserted to drain the fluid that will naturally collect in the "empty" spaces. The heart can also be attached using what is called the bicaval procedure. In this procedure the heart is attached using the superior and inferior vena cava.

After the heart is attached, surgeons connect the blood vessels, allowing blood to flow through the heart and lungs. As the heart warms up, it begins beating. If it starts beating abnormally (fibrillating), the heart is given an electrical shock to correct the rhythm. Surgeons check all the connected blood vessels and heart chambers for leaks before removing you from the heart-lung machine. The heart-lung machine is turned off, leaving the new heart to work by itself. When the transplant procedure has been completed, the blood circulating through the bypass machine will be let back into the heart and the tubes to the machine removed. Temporary wires for pacing may be inserted into the heart. These wires can be attached to a pacemaker box and your heart can be paced, if needed, during the initial recovery period. Finally, the breastbone is fastened together using heavy steel wire and the chest incision is closed with stitches.

POTENTIAL COMPLICATIONS
There are always risks and potential complications with any surgery. A patient may bleed more than usual, get an infection, have trouble breathing, get blood clots or the body may reject the heart. Medical personnel will watch closely and treat these problems.

REJECTION
One of the possible complications that you can develop after transplantation is rejection. Rejection is not a disease; it is the normal reaction of the body to a foreign object. Rejection can be acute or chronic.

• Acute Rejection - Rejection that occurs in the first weeks to months after transplant. Acute transplant rejection is an expected part of the recovery process and can develop at anytime. To allow the donor organ to successfully live in the body, medications must be given to trick the immune system into accepting the transplant and not think it is a foreign object.
• Chronic Rejection - Chronic rejection occurs later after the transplant. It is somewhat common and develops more gradually and can go on for months or years. It often presents like coronary artery disease. Preventing and treating acute rejection may reduce the possibility of chronic rejection.

Since rejection is caused by the immune system, we call methods to prevent it immunosuppression. Many of the medications given to patients are to prevent this antigen-antibody reaction from occurring. Each patient has a medication plan uniquely designed for them and may use different immunosuppressive combinations and dosages at various times. The ideal goal of an individual medication plan is to hold back organ rejection while reducing drug toxicity and the risk for infection.