Cardiac transplantation is indicated, as our patient has end stage heart failure that is unresponsive to medical treatment. The natural history of congestive heart failure is one of progressive deterioration. In eligible patients, cardiac transplantation may dramatically improve survival. In NY Heart Association class IV patients who have symptoms at rest, survival may be up to fifteen years post transplantation.
Other procedures
Cardiac transplantation is the only established surgical approach to treatment of patients with medical refractory end stage heart failure. Other surgical procedures, such as left ventricular assist devices and the artificial heart, are used as stabilizing bridges to transplant until a heart donor becomes available. They are being used with increasing frequency in lieu of transplantation, that is, "destination" therapy in the setting of scarce donor organs.
Transplant candidates
Ideal transplant candidates should have no other serious life limiting diseases. They must also have a history of compliance with medical treatment and be willing to undergo long term follow-up. In general, the younger the patient's age, the better. The contraindication to transplantation is high pulmonary vascular resistance which is unresponsive to medical therapy. The normal, thin walled right ventricle of the transplanted heart will immediately fail if the recipient's pulmonary vascular resistance is too high.
Our patient listed
Our patient was listed for cardiac transplanta. While the mortality of the procedure is low, the major problem is a shortage of donor hearts. Intensive medical therapy including an IV inotrope was continued in the hospital while waiting for a donor heart. Fortunately, a heart became available in one week and a bridging procedure was unnecessary.
Cardiac transplantation surgery
The following cardiac transplantation surgery is presented through the courtesy of Dr. Jack Copeland, and was carried out at the University of Arizona.
The patient has already been placed on bypass. In this still-frame, his poorly functioning heart is being removed. While he was being prepared for surgery, his new heart was resected from the donor. A potassium solution was injected directly into the donor's coronary arteries to arrest the heart and an ice saline slush was placed on the heart to cool it down. The donor heart was brought to the operating room as quickly as possible. The total ischemic time should not exceed four to six hours.
In the brief video that follows, note that the residual cuff of our patient's left atrium is left for attachment to the donor heart.
The patient's heart has now been removed. In the brief video that follows, the donor heart will be lowered into place.
To complete the procedure, the donor heart was sutured to the atrial cuff and the great vessels were anastomosed. The patient was then weaned off the bypass machine and the new heart allowed to function on its own.
Transplant succsessful
Our patient's cardiac transplant was successful and his postoperative course was uneventful. He received immunosuppressive agents and had no evidence of rejection or infection. He did well after discharge and resumed a near normal lifestyle.