HEART

TRANSPLANT
I. INTRODUCTION

The heart is a muscular organ about the size of a fist, located just behind
and slightly left of the breastbone. The heart pumps blood through the network of
arteries and veins called the cardiovascular system. The heart is a solid organ that
serves to gather deoxygenated blood from all parts of the body, carries it to the
lungs to be oxygenated and discharge carbon dioxide. Then it transports the
oxygenated blood from the lungs and
disseminates it to all the body parts.
The heart consists of four chambers,
each separated by valves that only
permit blood to flow in one direction.
A heart transplant is the
surgical replacement of a person's
diseased heart with a healthy donor's
heart. The donor is a person who has
died and whose family has agreed to
donate their loved one's organs. Since
the performance of the first human
heart transplant in 1967, heart
transplantation has changed from an
experimental operation to an
established treatment for advanced heart disease. Like other organ
transplantations, the number of heart transplantations in the U.S. is on the rise. In
2019, 3,552 were performed, up from 3,408 in 2018
II. INDICATION OF THE SURGERY
1. Advanced heart failure
Heart transplantation is the treatment of choice for carefully
selected patients with advanced or end-stage heart failure. Although
controlled trials have never been conducted, there is consensus within the
cardiology community that heart transplantation significantly improves
survival, exercise capacity, quality of life and return to work compared with
conventional treatment, provided that proper selection criteria are applied
(Table 8).9,25 The main limitation of heart transplantation is the limited
supply of donor hearts, which can vary substantially by country. Availability
may impact indications and contraindications for heart transplant applied
locally.

2. Congenital Heart Disease

Refers to disorders of the heart
that are present at birth and that can
affect adult patients in many ways. You
may require a heart transplant for
several reasons. The most common
reason is that one or both ventricles
aren't functioning properly and severe
heart failure is present. Ventricular
failure can happen in many forms of
congenital heart disease, but is more
 common in congenital defects with a single ventricle or if long-standing
valve obstruction or leakage has led to irreversible heart failure. Patients
who as children had the Fontan procedure, which helps complex congenital
heart defects, may need a heart transplant because the blood flow through
the venous system is slow and the veins are congested, which can lead to
swelling, fluid accumulation, and protein loss.

3. Cardiomyopathy
Heart transplantation can be a lifesaving therapeutic option for
patients with hypertrophic cardiomyopathy in a burn-out end-stage phase.
Patients showing signs or symptoms of advanced heart failure should be
early considered for aggressive management. Heart transplantation should
be considered in hypertrophic cardiomyopathy patients showing refractory
heart failure signs and symptoms, or considered in an end-stage state.
Younger patients have a faster progression to end-stage disease in
hypertrophic cardiomyopathy, so these patients with heart failure
symptoms should be early recognized and carefully monitored.

4. Heart valve diseases

Sometimes heart valves can’t be repaired and must be replaced.
This surgery involves removing the faulty valve and replacing it with a man-
made or biological valve. Biological valves are made from pig, cow, or
human heart tissue and may have man-made parts as well. These valves are
specially treated, so you won’t need medicines to stop your body from
rejecting the valve.

5. Congestive Heart Failure

Some people have such severe heart failure that surgery or
medications don't help. They may need to have their diseased heart
replaced with a healthy donor heart. Heart transplants can improve the
survival and quality of life of some people with severe heart failure.
However, candidates for transplantation often have to wait a long time
before a suitable donor heart is found. Some transplant candidates improve
during this waiting period through drug treatment or device therapy and can
be removed from the transplant waiting list. A heart transplant isn't the
right treatment for everyone. A team of doctors at a transplant center will
evaluate you to determine whether the procedure may be safe and
beneficial for you.

III. SURGERY PROCESS

1. Diagnosis/ Preparation

Not everyone is a candidate for heart transplant. Because of the

wide range of information needed to know if a person is eligible for
transplant, a transplant team will review the evaluation. The team includes a
transplant surgeon, a transplant cardiologist (doctor specializing in the
treatment of the heart), nurse practitioners or physician assistants, one or
more transplant nurses, a social worker, and a psychiatrist or psychologist.
 Other team members may include a dietitian, a chaplain, hospital
administrator, and an anesthesiologist (doctor who uses medicines to keep
you asleep during surgery).

The transplant evaluation process will include:

 Psychological and social evaluation. Some psychological and social
issues that are involved in organ transplant include stress, financial
issues, and support from family or significant others. These factors
can greatly affect how you do after the transplant.

 Blood tests. You will need blood tests to help find a good donor
match and help improve the chances that the donor heart will not
be rejected.

 Diagnostic tests. You will need tests to assess your lungs as well as
your overall health. These tests may include X-rays, ultrasound
procedures, CT scan, pulmonary function tests (PFTs), and dental
exams. Women may get a Pap test, gynecology evaluation, and a
mammogram.

 Other preparations. You will get several vaccines to decrease the

chances of developing infections that can affect the transplanted
heart.

The transplant team will consider all the information from

interviews, your health history, the findings from your physical exam, and
your diagnostic test results when deciding if you are eligible for a heart
transplant.
Once you have been accepted as a transplant candidate, you will be
placed on the United Network for Organ Sharing list. When a donor organ
becomes available, candidates are selected based on the severity of their
condition, body size, and blood type. If the heart is to be yours, you will
need to go to the hospital right away so you can get ready for the
transplant. (Most hearts must be transplanted within 4 hours after they’ve
been removed from the donor.)
2. Approaches for Heart Transplant

There are two very different surgical approaches to heart

transplantation: the orthotopic and the heterotopic approach. Because the
length of this surgery is different for every patient, families should talk with
the surgeon about what to expect. Orthotopic approach. The more common
of the two procedures, the orthotopic approach, requires replacing the
recipient heart with the donor heart. After the donor heart is removed,
preserved and packed for transport, it must be transplanted into the
recipient within four to five hours. Heterotopic heart transplantation (HHT)
is a surgical procedure that allows the graft to be connected to the native
heart in a parallel fashion. The main advantage of HHT is to assist the
 patient's native heart and to maintain circulation in the cases of severe
acute rejection. Heterotopic transplantation, also called “piggyback”
transplantation, is accomplished by leaving the recipient's heart in place and
connecting the donor heart to the right side of the chest.

3. Risk and Complications

 Failure of the Donor Heart

Over time, the new heart may fail due to the same reasons
that caused the original heart to fail. Failure of the donor heart also
can occur if your body rejects the donor heart or if cardiac allograft
vasculopathy (CAV) develops. CAV is a blood vessel disease. Patients
who have a heart transplant that fails can be considered for another
transplant (called a retransplant).

 Primary Graft Dysfunction

The most frequent cause of death in the first 30 days after
transplant is primary graft dysfunction. This occurs if the new donor
heart fails and isn't able to function. Factors such as shock or trauma
to the donor heart or narrow blood vessels in the recipient's lungs
can cause primary graft dysfunction. Doctors may prescribe
medicines (for example, inhaled nitric oxide and intravenous
nitrates) to treat this condition.

 Rejection of the Donor Heart

Rejection is one of the leading causes of death in the first
year after transplant. The recipient's immune system sees the new
heart as a foreign object and attacks it. During the first year, heart
transplant patients have an average of one to three episodes of
rejection. Rejection is most likely to occur within 6 months of the
transplant surgery.

 Cardiac Allograft Vasculopathy

CAV is a chronic (ongoing) disease in which the walls of the
coronary arteries in the new heart become thick, hard, and less
stretchy. CAV can destroy blood circulation in the new heart and
cause serious damage. CAV is a leading cause of donor heart failure
and death in the years following transplant surgery. CAV can cause
heart attack, heart failure, dangerous arrhythmias, and sudden
cardiac arrest. To detect CAV, your doctor may recommend
coronary angiography yearly and other tests, such as stress
echocardiography or intravascular ultrasound.

 Complications from Medicines

Taking daily medicines that stop the immune system from
attacking the new heart is crucial, even though the medicines have
serious side effects. Cyclosporine and other medicines can cause
 kidney damage. Kidney damage affects more than 25 percent of
patients in the first year after transplant.

 Infection
When the immune system—the body's defense system—is
suppressed, the risk of infection increases. Infection is a major cause
of hospital admission for heart transplant patients. It also is a
leading cause of death in the first year after transplant.

 Cancer
Suppressing the immune system leaves patients at risk for
cancers and malignancies. Malignancies are a major cause of late
death in heart transplant patients. The most common malignancies
are tumors of the skin and lips (patients at highest risk are older,
male, and fair-skinned) and malignancies in the lymph system, such
as non-Hodgkin's lymphoma.

 Other Complications
High blood pressure develops in more than 70 percent of
heart transplant patients in the first year after transplant and in
nearly 95 percent of patients within 5 years. High levels of
cholesterol and triglycerides in the blood develop in more than 50
percent of heart transplant patients in the first year after transplant
and in 84 percent of patients within 5 years. Osteoporosis can
develop or worsen in heart transplant patients. This condition thins
and weakens the bones.

 Complications from Not Following a Lifelong Care Plan

Not following a lifelong care plan increases the risk of all
heart transplant complications. Heart transplant patients are asked
to closely follow their doctors' instructions and check their own
health status throughout their lives.

4. What’s life like after a heart transplant?

Recovery after your heart transplant is similar to the recovery after

any heart surgery. It takes about six to eight weeks for your incisions to heal.
At first, you may have some muscle or incision discomfort in your chest
during activity. Itching, tightness, or numbness along your incision are also
normal. Good nutrition is an important part of healing. You will need to eat a
diet that is low in salt and fat, but also one that includes a variety of healthy
foods to help you heal. If you are having trouble with your appetite or
understanding your dietary guidelines, please ask your transplant team to
speak to a dietitian.

IV. NURSING CONSIDERATIONS

a. PRE-OPERATION
A. Obtain the patient’s psychological status in order to reinforce the
use of coping strategies during the surgical experience.
 B. Determine physiologic factors directly or indirectly related to the
surgical procedure that may contribute to operative risk factors.

C. Establish baseline data for comparison in the intraoperative and

postoperative period.
D. Participate in the identification and documentation of the surgical
site and/or side (of body) on which the surgical procedure will be
performed.

E. Identify prescription drugs, over-the-counter medications, and

herbal supplements taken by the patient that may result in drug
interactions affecting the surgical outcome.

F. Instruct the client to stop smoking because it can delay the healing
process and may contribute to more complications especially those
involving infection and lung problems.

G. Document the results of all preoperative laboratory and diagnostic

tests in the patient’s record, and communicate this information to
appropriate health care providers.

H. Coordinate the patient teaching and plan of care with nursing staff
and other health team members.

I. Identify cultural and ethnic factors that may affect the surgical
experience.

J. Provide routine preoperative care and explain phases in

perioperative period and expectations.

K. Determine if the patient has received adequate information from

the surgeon to make an informed decision to have surgery and that
the consent form is signed and witnessed.

L. Answers patient’s and family’s questions.

b. DURING OPERATION

A. The nurse must ensure the integrity of sterile field.

B. Positions patients to ensure correct alignment, exposure of surgical

site, and prevention of injury.

C. Ensures that sponge, needle, instrument, and medical device counts

are correct.

D. Prevents chemical injury from prepping solutions, pharmaceuticals,

etc.

E. Ensures safe use of electrical equipment.

 F. Safely administers medications.

G. Monitor Physical Status.

H. Monitors and reports changes in patient’s vital signs.

I. Monitors blood loss and urine output.

c. POST OPERATION
A. Communicate intraoperative information upon transferring the
patient to Open Heart Recovery intensive care unit (ICU) and
determine the patient’s response to the surgical intervention.

B. Monitors ABCs, vital signs, level of consciousness.

C. Proceed to the initial assessment of the patient when it is admitted

to the unit. This assessment will include the conditions of
neurological, respiratory, cardiovascular and renal systems;
nutritional support and eliminations; venous access, drains; surgical
wound; positioning, pain, safety, and comfort.

D. Monitor carefully for hemorrhage and shock on the client.

E. Monitor postoperative temperature elevation: fever may not be the

best indicator of post-operative.

F. If in place, maintain a nasogastric tube and monitor patency and

drainage.

G. The nurse must safely administer medications per MD order.

H. Determines patient’s psychological status.

I. Assists with discharge planning such as consulting with a dietitian

for diet instructions and menu planning; reinforce teaching.

J. Teach the client about potential postoperative complications

K. Determines caregiver’s perceptions of surgery.

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