A heart transplant is an operation to replace a diseased heart with a healthy human heart from a donor who has died.

Why a heart transplant is needed

When the heart can no longer work efficiently and a person’s life is potentially at risk, a heart transplant may be needed.

Most heart transplants are performed on people with severe heart failure (see box, below left). However, not everyone who has severe heart failure is suitable for a transplant (see Why you might be unsuitable for a heart transplant). 

Most people referred for a transplant assessment will have been treated by a cardiologist, who will have tried appropriate conventional treatments first.

How common are heart transplants?

In 2008, 130 heart transplant operations were carried out in the UK, of which 34 were on young people under the age of 16.

The number of donor organs available is extremely small compared to the number of patients who could benefit from a transplant. 

Alternatives

Other technologies are now becoming available to treat patients with heart failure. 

For example, left ventricular assist devices can be used to support a failing heart until a donor heart becomes available, or can even be used as a permanent alternative to a transplant. 

Outlook

A heart transplant is complicated surgery that usually takes three to five hours. 

Immunosuppressant drugs (which weaken your immune system) are given during and after your transplant and must be taken for life, so your body will not reject your new heart.

You will have a blood test every six weeks and will be seen at the transplant centre every three months for the rest of your life.

If a heart transplant is thought to be an option for you, you will be referred for an assessment. Tests are carried out to find out whether a transplant really is the best treatment for you.

Transplant assessment

You will need to stay in hospital for three to five days for the assessment. Tests may include:

• blood tests
• urine tests
• tests to find out how efficiently your lungs work
• electrocardiogram (ECG), which records the electrical activity of your heart
• echocardiogram, which checks how well your heart is pumping
• cardiac catheterisation and an exercise test (these determine how severely your heart is affected and whether any other treatments might be helpful) 

During the assessment, you will have the chance to meet members of the transplant team and to ask any questions. The transplant co-ordinator (your main point of contact) will talk to you and your family about what happens and the risks involved in a heart transplant.  

When the assessment is complete, it will be decided whether a heart transplant is suitable for you and is the best option.

It may be decided that:

• You should go on the active waiting list (which means you could be called for a transplant at any time).
• A transplant is suitable for you, but your condition is not severe enough. You will be put on a provisional waiting list, and if your condition worsens, you will then be put on the active waiting list.
• You need more investigations or treatment before a decision can be reached.
• A transplant is not suitable for you. In this case, the assessment team will explain why and offer you other options, such as drug therapy or alternative cardiac surgery.
• You need a second opinion from a different transplant centre.

Why you might be unsuitable for a heart transplant

You may be considered unsuitable if:

• Your heart failure is not severe enough. There are only enough donor hearts to treat people who are the most sick.
• You have poor kidney function. One of the drugs given after a transplant is poisonous to the kidneys, so your kidneys need to be in good condition at the start.
• You have not complied with previous advice or been reliable. For example, you have not given up smoking despite being advised to do so, you have a poor history of taking prescribed medication or you have missed hospital appointments. 

The waiting list

Once you are on the active waiting list, the transplant centre may give you a pager so that you can be contacted at short notice.   

The right heart may be available within a few days or it could take years. The length of time you will have to wait will depend on your blood group, donor availability and how many other patients are on the list (and how urgent their cases are).

Around one in three patients on the transplant list is too ill to go home and needs to stay in hospital while they wait for a donor heart. Priority is usually given to these patients.

While you wait, you will be cared for by the doctor who referred you to the transplant centre. Your doctor will keep the transplant team updated with changes to your condition. Sometimes, another assessment is necessary to make sure you are still suitable for transplant.

A heart transplant normally takes between three and five hours.

The procedure is carried out under general anaesthetic, which means you will be put to sleep.

When you are asleep, you will be lying on your back on the operating table with your arms at your sides. A catheter (thin flexible tube) will be inserted to drain your bladder during and after the operation and you will be connected to a heart bypass machine. This acts as an artificial heart, circulating and oxygenating your blood while the heart transplant is being performed.

An incision (small cut) is made over your breastbone and the bone is separated so the surgeon has access to your heart. Your heart is removed, leaving behind a portion of the right and left atria (the top right chambers). The new heart is then connected to the aorta (main artery from the heart), pulmonary artery and the remaining part of the atria. When the heart begins to function and the medical team is happy, you will be taken off the bypass machine.

When the procedure is over, there will be drains (tubes) coming out of your chest. Your breastbone will have been closed with stainless steel wires and the tissues and skin will have been closed with dissolvable stitches.

You will wake up in the intensive care unit, attached by a tube in your throat to a ventilator and with a number of drips in your arms and neck.

Risks of a heart transplant include:

• failure of the transplanted heart to pump properly (primary graft dysfunction)
• rejection of the donor heart (see below)
• infection
• narrowing of the arteries of the new heart

Taking immunosuppressant medication can also make certain types of cancer more likely.

What is rejection?

Rejection is a normal reaction of the body. When a new organ is transplanted, your body’s immune system sees it as a threat and produces antibodies against it, which can stop it from working properly.

Immunosuppressant drugs (which weaken your immune system) are given during and after your transplant and must be taken for life, so your body will not reject your new heart.

After surgery, you will be moved to the intensive care unit. You will be under sedation and will be connected to a ventilator to help your breathing.

The specialist team will constantly check and monitor your condition. You will be given fluid and medication intravenously (directly into a vein) and X-rays will be taken. When your condition is stable, you will usually be moved to a high-dependency ward.

Getting back to normal

You will normally be discharged from hospital two to three weeks after surgery, and will be asked to stay near the transplant centre for one month.

For the second month, you will need to visit weekly for four weeks. After that, for the rest of your life, you will have a blood test every six weeks and will be seen at the transplant centre every three months.

For the first six weeks after surgery, you need to avoid pushing and pulling or lifting anything heavy. You will be encouraged to take part in a rehabilitation programme involving exercises to build up your strength.

Immunosuppressant drugs

You will need to take immunosuppressant drugs, which weaken your immune system so your body does not try to reject the new organ. However, these drugs also reduce your ability to fight infections and can affect the functioning of your kidneys.

You will have your first dose of immunosuppressants during your operation, and then immediately after surgery. For the next few months, you will need to take high doses of immunosuppressant drugs. You will need to take these for the rest of your life (although the high dosage may be gradually reduced).

If you do not take immunosuppressants, your transplant will fail.

In 1998, Andy Cook was told he had just two days to live, but when a donor heart became available, a transplant saved his life. He now works full time in an outdoor job he loves and travels the world to meet other transplant recipients.

Andy, from Halesowen in the Midlands, was 37 when he developed cardiomyopathy, a disease that causes the heart to become enlarged.

“I had a cough that my doctor couldn’t cure and, after several visits, I became more and more short of breath,” Andy says. “I was admitted to the Wordsley Hospital in Stourbridge, where I was diagnosed as having fluid on the chest that was affecting my heart. A little later, I was told I had cardiomyopathy.”

Six days after he was admitted to hospital, Andy had two heart attacks. He was treated, but his condition got worse and he was sent to Queen Elizabeth Hospital in Birmingham for transplant assessment. He was told by his consultant that a transplant was needed. He was put on the transplant list and sent back to the Wordsley to wait.

“Over the next few weeks, my condition worsened and the need for a donor heart became more desperate. My weight plunged from 11 stone to just 7.”

With time running out, a donor heart became available and Andy was transferred back to Queen Elizabeth Hospital.

“The last thing I remember before the operation was the needle being put into the back of my hand. When I woke up, I was being transferred from intensive care to a ward after two days of sedation.”

Bit by bit, Andy regained his strength, but his journey back to health had some setbacks.

“After I had been allowed home, I spent the next six weeks back in and out of hospital with rejection, a stomach problem, a collapsed lung and another related problem. I finally came out of hospital the week before Christmas 1998 and returned to work as a gardener 13 weeks after the transplant.

“I genuinely believe that if you follow medical advice, you will be back to your previous fitness and way of life. I am very grateful for all the help and treatment I received.”