Heart Transplant

How long will it take for me to get a heart transplant?

Unfortunately, there is no way to predict how long you will have to wait for a donor heart. The wait time is dependent on several factors including the urgency for transplantation, the size of the heart, blood type, tissue type and how long you have been on the waiting list. The time may vary from several days to months or, in some cases, years. Focus on staying healthy during the waiting period.

What happens if my condition gets worse while I wait for a donor heart?

Members of the transplant team will evaluate you regularly and adjust medical treatment as necessary. Sometimes patients may need hospitalisation to support them during the waiting period. Occasionally we might recommend other procedures, or mechanical circulatory support devices are necessary. Our team will ensure you have the appropriate care for your needs.

How long will I be in the hospital after my transplant surgery?

After the surgery, you will typically spend 5 to 7 days in the cardiac ICU and about 5 to 7 days on the transplant observation rooms. During this time, you will be constantly monitored to ensure that your new heart is functioning well and that there are no complications from the surgical procedure. You also will begin taking special medications to help prevent your body from rejecting your new heart.

Before you are discharged, you and your family will receive education and instructions about how to manage your medications, take care of your surgical incision, and schedule follow-up visits in our outpatient clinic.

What kind of medications will you prescribe?

Heart transplant recipients must take many different medications, each prescribed for a specific therapeutic reason. They fall into four categories:

Immunosuppressants: Drugs and agents that shut down the body's natural immune responses that would damage your new heart.
Antibiotics, antivirals, and fungicides: Drugs that fend off infection while your natural immune responses are disabled.
Vitamins, minerals, and nutritional supplements: Compounds to aid your body in its efforts to heal and maintain proper functioning.
Coronary disease prevention and antihypertensive medications: Drugs to prevent coronary artery disease and regulate blood pressure.

What are the post-discharge procedures?

After your hospital discharge, the post-transplant team will closely monitor you on an outpatient basis. This will include regular tests on your new heart, including blood tests, ECGs, heart biopsies, and clinic visits with the cardiologist. The transplant team will communicate with your cardiologist and primary care physician to provide seamless, coordinated care.

How soon can I return to work?

The appropriate time for you to return to work will depend on at least two factors: how you are feeling after surgery, and what type of work you will be doing. As soon as your incision is healed, and you are feeling well, you can discuss with your transplant cardiologist when to return to work. Some patients can return to work quickly. We encourage patients to resume working as soon as they feel ready and the transplant cardiologist considers the decision medically safe. Typically, most recipients can return to work within 6 months following surgery.

Be in touch with us

Please feel free to reach out to our team whenever you have questions. Keep your family, friends, and loved ones informed about the procedure. Some people find it helpful to speak to patients who have undergone heart transplantation, and if that is of interest to you the team can help make that happen. Keep the conversation open and let the people around you help you in this difficult time.

Lung Transplant

What happens in the transplant assessment process?

Your lung transplant journey starts with a referral from your primary physician or referring pulmonologist. Our administrative team will connect you with our lung transplant pulmonologist. At this appointment, you will learn about your current health status and outlook in much greater and elaborate detail. After this appointment and your consent, the lung transplant pulmonologist will ask the transplant evaluation team to plan a transplant assessment. This process helps to determine if transplantation is the right treatment for you and ensures that it is as safe as possible for you to have a transplant. The assessment process will involve coming to the hospital to have a number of tests, and meeting with key members of your team. Having a lung transplant is a big decision. You need to understand the benefits, the risks, and our program requirements.

The assessment process will give you, your family and our team the information to make an informed decision about having a lung transplant. Once your assessment is complete, the transplant team will meet to review your results. This assessment process can take up to one week (7 days). Your transplant coordinator will call you to meet our specialists that includes pulmonologists, surgeons, intensivists, dieticians, psychologists, infectious disease specialists, transplant coordinators, physiotherapists and financial counsellors to discuss the results of your assessment after the pre-transplant selection meeting.

If a transplant is recommended, the choice to proceed is up to you. We will support you whether you go forward with a transplant or not. While waiting on our list you decide to have a lung transplant you will meet with one of our transplant surgeons and your transplant coordinator to discuss your surgery and to sign surgical consent forms. Post financial clearance and psychological clearance, you are officially placed on the lung transplant waiting list by registering with Jeevandan/ZCCK TRANSTAN /NOTTO depending on your location of transplant. The time that you wait for your lung transplant is unpredictable because you have to be matched to a suitable donor. Our surgeons use several factors to match donors with patients on the waiting list. Two of the most important factors are: Blood type and lung size. Because of this, there is no “TOP” spot on the waiting list.

While you are waiting for your lung transplant there are three main goals:

Maintain your health and improve your strength. Our physiotherapy program will help you achieve this goal. The physiotherapists will also work with the doctors to ensure your oxygen needs are met.
Identify and manage any new and existing problems that may arise. We will partner with your family to manage your health. You and your support person will attend frequent appointments at our hospital.
Continue to learn about life with a lung transplant through our support and education groups and by speaking to your transplant team.

How is the surgery performed, what are its steps?

Immediately before transplant, we will do a few tests and you will receive anti-rejection medications and antibiotics. There is a chance that the surgery will be cancelled at the last moment as the team is assessing the donor lungs right up to the moments before the surgery. If the organ is found to be sub-optimal the call will be terminated, and you will be discharged home. It is not unusual for this to happen a couple of times. In the operating room, you will be given medication to keep you unconscious.

Several tubes are inserted into your body, including an endotracheal tube, which is a breathing tube that extends from your mouth into the lungs, an intravenous line in your neck, a nasogastric or “NG” tube that goes into your stomach through your nose, and a urinary catheter that drains urine freely into a bag. The surgery itself can take 8 or more hours depending on your condition and whether you have a double or a single lung transplant.

Some people need to have their lung or heart function supported by machines before, during, or after the surgery. Your chest will be opened between the ribs in the front across the breast bone or at the side. The diseased lungs will be removed and replaced with the donor lungs, one at a time. The new lung will be connected to the main bronchus, the pulmonary artery, and the pulmonary vein. After the lung is connected, the surgeons will leave drainage tubes around the lungs and heart and carefully close the layers of bone, muscle, and skin. After the surgery, you will be taken to the intensive care unit or ICU. You will remain there until you can breathe without the help of the ventilator, or breathing machine, and until your condition is stable.

What is organ rejection following transplantation?

The natural response in our body is to defend itself from harmful foreign substances like viruses and bacteria. In the case of lung transplantation, the donor lung is recognized as a foreign substance. Rejection is a process by which the body’s immune system attacks the transplanted lung, recognizing it to be different from your own tissues. You must take medicines to reduce your natural immune response and trick the body into accepting the new lung(s). However, even with these medicines, rejection can still happen.

Why does the body recognise the donor lung as 'different?

Your body's natural immune cells are able to recognize small, unique proteins called "antigens" that are present on the surface of all cells or infectious particles. These immune cells called the T cells and the B cells can recognize the antigens as "self" if they belong to you or "non-self" if they do not belong to you (such as those in the donor lung). This recognition occurs mainly through complex proteins on the cell surface called HLA antigens. The HLA system is made up of three classes with many subtypes, each person has a combination of these HLA proteins that makes him or her unique like a thumbprint, a signature. The differences in these signatures help our immune cells to separate "self" from "non-self".They then direct an attack on the foreign donor lung, resulting in "rejection".

What do rejection and infection entail in a post-transplant setting?

Two of the most common complications following the transplant are rejection of the lung and infections. Rejection is common and can happen any time after your transplant. Rejection happens because your immune system attacks your transplanted lungs. Your immune system sees your new lungs as invading cells and can damage them. To prevent this, you will take anti-rejection medications, also called immunosuppression medications. You will need to take these medications every day for the rest of your life to protect your new lungs.

Despite taking anti-rejection medications, rejection can still occur. It is often reversible as long as it detected and treated quickly. If the rejection is detected your treatment plan may include additional medications, adjusting your current medications, and other treatments.

Unfortunately, immunosuppressive medications also decrease the body’s ability to fight infection, and infections of the lungs are very common. Your weekly clinic visits will allow the transplant team to monitor for rejection and infection.

You will also need to:

Perform home spirometry readings once daily and keep a record of your readings.
Learn the signs and symptoms of rejections and infections and report any unusual symptoms to your transplant team right away.

The transplant programme will continue to monitor your health and will work closely with you and your support person, your family doctor, and your pulmonologist for the rest of your life. Your family doctor will continue to help you to maintain your general health and well-being. You will be assigned a transplant nurse coordinator and physician whom you and your caregivers can communicate with. Your team is there to help you, but it is important that you play an active role in maintaining your health and keep them informed about changes.

What are the different types of rejection?

Rejection can be classified by how the immune system attacks the donor lung and the time after transplant when it occurs. “Acute Cellular Rejection" occurs when your immune T cells directly attack the donor lung tissue. An “Antibody Mediated Rejection" may occur where the recipient's B cells produce antibodies that attack the donor lung. These antibodies that develop in some patients can be detected by blood tests (called "donor-specific antibodies" or "DSA”. Cellular rejection is more common early on after transplant. Both of these types of rejection need to be diagnosed by a combination of clinical assessment, symptoms, and signs, testing such as spirometry, x-ray imaging, CT scans.

LVAD

What is a Left Ventricular Assist Device (LVAD)?

A left ventricular assist device (LVAD) is a mechanical pump that is implanted in patients with heart failure. It helps the bottom left chamber of your heart (left ventricle) pump blood out of the ventricle to the aorta and the rest of your body. That is why it is called a Left Ventricular Assist Device.

When is a Ventricular Assist Device (VAD) used?

VADs are used to increase blood flow when your heart failure has become severe and is not responding well to medications and other treatments.

Does an LVAD take the place of your heart?

No. A left ventricular assist device does not replace the heart. The LVAD receives blood from the left ventricle and delivers it to the aorta. It pumps along with the patient’s own heart. This helps the left ventricle pump blood.

Why am I being recommended an LVAD?

Your doctors feel you have advanced heart failure. Heart failure is a condition in which your heart is unable to pump enough blood to support the basic needs of your body. Heart failure can make you feel weak and tired; have swollen feet and be short of breath. Although medications and lifestyle changes can improve heart function initially, for most people heart failure gets worse over time. As heart failure becomes more severe, symptoms increase, and other organs may begin to fail (often the liver and kidneys).

You are being asked to consider the possibility of having a ventricular assist device (VAD) surgically implanted in your body. Your doctors feel without a VAD your chance of dying from heart failure in the coming months is very high. Before you undergo this surgery, it is important you and your family understand the options including potential benefits, risks, and expectations associated with having a VAD (heart pump). It is important for you and your caregiver(s) to understand and to agree with the treatment plan and you are willing to participate in the guidelines outlined in the following pages.

How does the LVAD work?

There are a few different LVADs available at KIMS Heart and Lung Transplant Institute. The doctor will recommend the one that is best for you based on your needs and medical condition.

The LVAD is implanted during open-heart surgery. The parts of the LVAD may vary based on the type of device but typically, there are four basic parts:

The pump unit is placed in the chest. It is implanted by the surgeon into the apex of the heart where it receives blood. A tube then delivers this blood from the device to the aorta (the large artery that takes blood from the heart to the rest of the body. It works by pumping blood by continuous flow from the left ventricle to the aorta.

The pump is attached to a driveline (cable) and a control system (controller). The driveline passes from the device through the skin on your belly (abdomen) to the controller (a small computer) on the outside of your body. The controller runs the pump and provides messages and alarms to help you operate the system.

A power supply (rechargeable batteries or cord that plugs into an electrical socket) keeps the LVAD running.

What is the evaluation process?

The evaluation process is designed to help decide if a VAD is the best choice for you. You will undergo (or may have undergone) several blood tests, and consultations. Some of the people that may help evaluate you include Cardiologists, Heart Surgeons, Social Workers, Chaplain, members from the Palliative Care Team, and VAD Coordinators. This evaluation includes assessing your personal support system, your previous medical compliance as well as providing you information about the financial and long-term self-care requirements.

The entire team will assess your readiness, willingness, and the ability for activities that are required as part of the follow-up after the VAD surgery. Your social support and willingness to participate in your care are essential to living successfully with the VAD and will be looked at during your treatment and evaluation for VAD therapy.

Other medical concerns that are found during the evaluation may need to be addressed before a VAD can be implanted. The intent is to evaluate any medical concerns and potential issues to VAD implantation in order to make sure the therapy is right for you.

After the evaluation, the VAD Team will decide if you meet the criteria to have a heart pump implanted. If it is a medically reasonable option, you will also need to decide if it is the right personal choice for you. If you choose that this is not the best option for you, you may choose to be re-evaluated at a later time. In the future, if your condition worsens, you may need to repeat tests to determine if you are eligible for treatment.

Why would I not be a candidate for a Ventricular Assist Device (VAD)?

VADs improve blood flow. These devices can only fix health problems that will improve with better blood flow.

Implantation of a VAD requires major surgery that you must be able to survive. There will also be ongoing issues with the VAD which you must be able to manage. Some of the reasons a VAD may not be a good option include the following:

Medical issues that would make surgery too difficult or dangerous. For example, if the chances of surviving VAD surgery is felt to be too small. Other examples include; high lung artery pressures and right heart failure, problems with the existing heart valves, a small left ventricle, a damaged aorta, blood clotting disorders, poor food intake, current pregnancy, or high risk of infection.
Other non-heart diseases that would increase the risk of VAD therapy include; cancer, permanent kidney disease, liver disease, severe emphysema of the lung, blockages of the arteries to the legs, or the brain, uncontrolled diabetes, and frailty.
Factors that would likely limit the ability of the patient to properly care for the VAD long term. Examples include; impaired thinking (dementia or significant psychiatric disorder), use of illicit drugs or alcohol, a history of not following medical recommendations or self-destructive behavior, inadequate social support (patients must identify a primary “caregiver”), or financial hardship.

What are my other options?

If you are not found to be a candidate for a VAD, or if you decide that a VAD is not the best option for you, you will continue to receive standard medical care. The reason you are being evaluated for a VAD is that the current therapies you are receiving are not adequately treating your heart failure. Without a VAD your doctors feel it is likely your condition will worsen and there is a high chance of death in the coming weeks to months. Patients with advanced heart failure who do not proceed with VAD surgery often use palliative care and hospice to help them with end of life care.

What will the VAD surgery be like?

The surgery to implant the VAD will be open-heart surgery and can take between 6-12 hours. The surgeon will make an incision (cut) down the front of your chest to reach your heart. You will have a breathing tube and be under general anesthesia. In some cases, you will be on a heart/lung machine during the surgery. The VAD is placed below the heart and the surgeon will connect the pump to your heart and secure it in place. Once the pump is in place, the VAD and your heart will together pump blood through your body. After the surgery is completed, you will return to the intensive care unit (ICU).

What about my medical care post-discharge?

Our team including including your surgeon, your cardiologist, VAD coordinators, nurses, nurse practitioners, physician assistants, pharmacists, physical/occupational therapists, and social workers will follow up with you on an everyday basis. They will monitor your recovery and help you adjust to life with your VAD. Soon after your surgery, it will be very important to begin preparing to go home. You will have to be both physically strong and able to care for your VAD to be discharged from the hospital. Most patients return home, but some patients choose to live with a caregiver or need a rehabilitation facility for a short period before returning home. If necessary, a home health nurse may come to your home for a few hours a week to help with your care.

What do I need to learn before going home with a VAD?

During the time in the hospital after surgery, it is expected that you and your family will learn how to take care of the VAD and how to take care of yourself at home. You and your caregiver(s) will be trained by a VAD coordinator to take care of your VAD. Other staff, such as your bedside nurse, the occupational and physical therapists, and cardiac rehabilitation therapists will also provide training. You and your caregiver(s) must be able to manage the VAD, understand how it works, troubleshoot problems, and care for your driveline exit site. It is expected that a caregiver(s) will be present and available while you are in the hospital to learn how to take care of you and your VAD before leaving the hospital. The education will be ongoing while you are in hospital. Your home must have consistent electricity and phone services, so it is vital that you pay your utility and phone bills on time.

How often do I see my doctors after I go home?

After you are discharged, you will follow up in the clinic with your Advanced Heart Failure/VAD/Transplant Team. They will work together to care for you and make decisions about your treatment. Typically, your first visit will be every alternate day for the first week after discharge. As your health improves, visits may be further apart. Once you are considered stable and ready to go home, your doctors may decide that you can follow-up every 2-3 months. Along with seeing a Heart Failure Cardiologist, you will have testing done regularly to monitor and maintain your health. The types of testing that you may need will be decided by your doctors, but the most common tests include blood tests, electrocardiograms, echocardiograms, and implantable cardioverter-defibrillator (ICD) checks.

Dr. Prabhat Dutta Mahesh Chandra

Dr. Anoop M