Where can I get more information on transplants?
Introduction
In the three
decades since the performance of the first human heart transplant
in December 1967, the procedure has changed from an experimental
operation to an established treatment for advanced heart
disease. Approximately 2,300 heart transplants are performed
each year in the United States.
In 1981, combined
heart and lung transplants began to be used to treat patients
with conditions that severely damage both these organs.
As of 1995, about 500 people in the United States and 2,000
worldwide have received heart-lung transplants.
There have been
two main barriers to increasing the number of successful
operations. In 1983, the first barrier to successful transplantations--rejection
of the donor organ by the patient--was overcome. The drug
cyclosporine was introduced to suppress rejection of a donor
heart or heart-lung by the patient's body. Cyclosporine
and other medications to control rejection have significantly
improved the survival of transplant patients. About 80 percent
of heart transplant patients survive 1 year or more. About
60 percent of heart-lung transplants live at least 1 year
after surgery. Research is under way to develop even better
ways to control transplant rejection and improve survival.
Organ availability
is the second barrier to increasing the number of successful
transplantations. Hospitals and organizations nationwide
are trying to increase public awareness of this problem
and improve organ distribution.
A transplant is
the replacement of a patient's diseased heart or heart and
lungs with a normal organ(s) from someone--called a donor--who
has died. The donor's organ(s) is completely removed and quickly
transported to the patient, who may be located across the
country. Organs are cooled and kept in a special solution
while being taken to the patient.
During the operation,
the patient is placed on a heart-lung machine. This machine
allows surgeons to bypass the blood flow to the heart and
lungs. The machine pumps the blood throughout the rest of
the body, removing carbon dioxide (a waste product) and
replacing it with oxygen needed by body tissues. Doctors
remove the patient's heart except for the back walls of
the atria, the heart's upper chambers. The backs of the
atria on the new heart are opened and the heart is sewn
into place. A similar process is followed in heart-lung
transplants, except doctors remove the heart and lungs as
a unit from the donor; the new lungs are attached first,
followed by the heart.
Surgeons then
connect the blood vessels and allow blood to flow through
the heart and lungs. As the heart warms up, it begins beating.
Sometimes, surgeons must start the heart with an electrical
shock. Surgeons check all the connected blood vessels and
heart chambers for leaks before removing the patient from
the heart-lung machine.
Patients are
usually up and around a few days after surgery, and if there
are no signs of the body immediately rejecting the organ(s),
patients are allowed to go home within 2 weeks.
A transplant is
considered when the heart is failing and does not respond
to all other therapies, but health is otherwise good. The
leading reasons why people receive heart transplants are:
- Cardiomyopathy--a
weakening of the heart muscle.
- Severe coronary
artery disease--in which the heart's blood vessels become
blocked and the heart muscle is damaged.
- Birth defects
of the heart.
Heart-lung transplants
are performed on patients who will die from end-stage lung
disease that also involves the heart. Alternative therapies
for these patients have been tried or considered. Leading
reasons people receive heart-lung transplants are:
- Severe pulmonary
hypertension--a large increase in blood pressure in the
vessels of the lungs that limits blood flow and delivery
of oxygen to the rest of the body.
- A birth defect
of the heart that results in Eisenmenger's complex--another
name for acquired pulmonary hypertension.
Patients under age
60 are the most likely heart transplant candidates. Patients
under age 45 are generally accepted for heart-lung transplants.
In both cases, patients must be suffering from end-stage disease
and be in good health otherwise. The doctor, patient, and
family must address the following four basic questions to
determine whether a transplant should be considered:
- Have all other
therapies been tried or excluded?
- Is the patient
likely to die without the transplant?
- Is the person
in generally good health other than the heart or heart
and lung disease?
- Can the patient
adhere to the lifestyle changes--including complex drug
treatments and frequent examinations--required after a
transplant?
Patients who do
not meet the above considerations or who have additional problems--other
severe diseases, active infections, or severe obesity--are
not good candidates for a transplant.
Donors are individuals
who are brain dead, meaning that the brain shows no signs
of life while the person's body is being kept alive by a machine.
Donors have often died as a result of an automobile accident,
a stroke, a gunshot wound, suicide, or a severe head injury.
Most hearts come from those who die before age 45. Donor organs
are located through the United Network for Organ Sharing (UNOS).
Not enough organs
are available for transplant. At any given time, almost
3,500 to 4,000 patients are waiting for a heart or heart-lung
transplant. A patient may wait months for a transplant.
More than 25 percent do not live long enough. Yet, only
a fraction of those who could donate organs actually do.
After a heart or
heart-lung transplant, patients must take several medications.
The most important are those to keep the body from rejecting
the transplant. These medications, which must be taken for
life, can cause significant side effects, including hypertension,
fluid retention, tremors, excessive hair growth, and possible
kidney damage. To combat these problems, additional drugs
are often prescribed.
A transplanted
heart functions differently from the old one. Because the
nerves leading to the heart are cut during the operation,
the transplanted heart beats faster (about 100 to 110 beats
per minute) than the normal heart (70 beats per minute).
The new heart also responds more slowly to exercise and
doesn't increase its rate as quickly as before.
A patient's prognosis
depends on many factors, including age, general health,
and response to the transplant. Recent figures show that
73 percent of heart transplant patients live at least 3
years after surgery. Nearly 85 percent of patients return
to work or other activities they like. Many patients enjoy
swimming, cycling, running, or other sports.
As noted, 60
percent of patients who receive combined heart-lung transplants
survive at least 1 year. Fifty percent live at least 3 years.
The most common
causes of death following a transplant are infection or rejection
of the heart. Patients on drugs to prevent transplant rejection
are at risk for developing kidney damage, high blood pressure,
osteoporosis (a severe thinning of the bones, which can cause
fractures), and lymphoma (a type of cancer that affects cells
of the immune system).
Coronary artery
disease (atherosclerosis) is a problem that develops in
almost half the patients who receive transplants. Normally,
patients with this disease experience chest pain and/or
other symptoms when their hearts are under stress. This
is called angina and is an early warning sign of a blocked
heart artery. However, transplant patients may have no early
pain symptoms of a blockage building up because they have
no sensations in their new hearts.
Thirty to fifty
percent of patients who receive a heart-lung transplant
develop bronchiolitis obliterans, in which there are obstructive
changes in the airways of the lungs.
The body's immune
system protects the body from infection. Cells of the immune
system move throughout the body, checking for anything that
looks foreign or different from the body's own cells. Immune
cells recognize the transplanted organ(s) as different from
the rest of the body and attempt to destroy it--this is called
rejection. If left alone, the immune system would damage the
cells of a new heart and eventually destroy it. In a heart-lung
transplant, immune cells may also destroy healthy lung tissue.
To prevent rejection,
patients receive immunosuppressants, drugs that suppress
the immune system so that the new organ(s) is not damaged.
Because rejection can occur anytime after a transplant,
immunosuppressive drugs are given to patients the day before
their transplant and thereafter for the rest of their lives.
To avoid complications, patients must strictly adhere to
their drug regimen. The three main drugs now being used
are cyclosporine, azathioprine, and prednisone. Researchers
are working on safer, more effective immunosuppressants
for future testing. Some of the more promising drugs are
FK-506 and mycophenolate mofetil.
Doctors must
balance the dose of immunosuppressive drugs so that a patient's
transplanted organ(s) is protected, but his or her immune
system is not completely shut down. Without an active enough
immune system, a patient can easily develop severe infections.
For this reason, medications are also prescribed to fight
any infections.
To carefully
monitor transplant patients for signs of heart rejection,
small pieces of the transplanted organ are removed for inspection
under a microscope. Called a biopsy, this procedure involves
advancing a thin tube called a catheter through a vein to
the heart. At the end of the catheter is a bioptome, a tiny
instrument used to snip off a piece of tissue. If the biopsy
shows damaged cells, the dose and kind of immunosuppressive
drug may be changed. Biopsies of the heart muscle are usually
performed weekly for the first 3 to 6 weeks after surgery,
then every 3 months for the first year, and then yearly
thereafter.
According to the
UNOS, the estimated first year charges for a heart transplant
is $209,100, and annual followup charges are $15,000. In most
cases these costs are paid by private insurance companies.
More than 80 percent of commercial insurers and 97 percent
of Blue Cross/Blue Shield plans offer coverage for heart transplants.
Medicaid programs in 33 states and the District of Columbia
also reimburse for transplants. Heart transplants are covered
by Medicare for Medicare-eligible patients if the operation
is performed at an approved center.
Approximately
70 percent of commercial insurance companies and 92 percent
of Blue Cross/Blue Shield plans cover heart-lung transplants.
Medicaid coverage for heart-lung transplants is available
in 20 states. According to the UNOS, estimated first year
charges for a heart-lung transplant is $246,000, and annual
followup charges are $18,400.
Hospitals nationwide
are trying to set up a better system for distributing organs
to patients in need. Researchers are looking for easier methods
to monitor rejection to replace the regular biopsies that
are needed now. Work is progressing to make immunosuppressive
drugs with fewer long-term side effects so that coronary artery
disease development and lung destruction may by prevented.
Information is available
24 hours a day, 7 days a week from the UNOS at 1-800-24-DONOR.
This hotline provides general information on transplants,
current statistics, and listings of transplant centers.
- Internet address:
http://www.ew3.att.NET/UNOS
Additional information
is available from the
- Division of
Transplantation
- Health Resources
and Services Administration
- Room 7-29,
5600 Fishers Lane
- Rockville,
MD 20857.
- Telephone:
301-443-7577
- Internet address:
http://www.hrsa.DHHS.gov/bhrd/dot/dotmain.htm
For More Information
on Heart and Lung Diseases, Contact:
- NHLBI Information
Center
- P.O. Box 30105
- Bethesda,
MD 20824-0105
- Telephone:
301-251-1222
- Fax: 301-251-1223
- Internet address:
../../../../index.htm
NIH Publication
No. 97-2990
Revised August 1997
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