1. Most Common Cause: Heart Failure
When patients suffer a massive heart attack or have a severe viral infection that affects the heart muscle, the only treatment option may be a heart transplant. A large heart attack that destroys the anterior portion of the muscle pump can often result in severe shock, especially if the patient doesn't get to the hospital in a timely fashion for an angioplasty procedure. Extensive myocarditits is a rare condition that damages the heart muscle after a viral infection creates antibodies that attack the heart. In both situations, medications and assist devices may be enough to stabilize the patient. Even after stabilization, some patients may develop intractable symptoms of heart failure (shortness of breath and leg swelling) that the only treatment left is to consider a heart transplant.
2. Candidates for Transplant
Not all patients are good candidates for heart transplant. In many programs, an age cut off of 65 years is considered appropriate. Although age is considered a factor, in many intuitions the physiologic age of a patient may be more important. Many patients may have no medical issues except for heart failure and may qualify for programs that allow older patients to receive hearts that otherwise might not be used for a transplant in younger patients. These include donor hearts from older patients and patients with medical conditions that would normally exclude them from donation. Contraindications for receiving a heart transplant include a severe infection in the recipient that cannot be treated successfully prior to transplant, kidney failure, severe diabetes with end organ involvement, and elevated lung pressures. When patients are considered as appropriate candidates for transplants, they often have to wait for years until a heart is found with the appropriate blood type and size.
3. Transplant Rejection
Many transplant patients will state that a transplant is not always a cure but is a trade for another disease. Transplant patients are at risk for lifelong rejection of the new organ. Medications are required to prevent the body from considering the new heart as a foreign object and attacking it. The medications, known as immunosuppressants, reduce the host's ability to fight infection. Early rejection can be catastrophic and leave the patient unable recover in the postoperative period. Late rejection can be insidious, often showing up in a very subtle fashion and then fulminating in a very short period of time.
4. Lifelong Medications
Transplant patients require medication for the rest of their lives. Immunosuppressants prevent the body form rejecting the organ. Prednisone is also used routinely to prevent rejection. A common side effect of prednisone is elevated blood sugar or diabetes. It can also cause osteoporosis and high blood pressure. These side effects may also require treatment with other medications. As described above, immunosuppressant medications can reduce the body's ability to fight infection. These medications can also be associated with the development of transplant-associated malignancy.
5. Regular Procedures to Monitor for Rejection
Shortly after a transplant, a patient will undergo a biopsy of the newly transplanted heart to evaluate for rejection. Over the first several years, this procedure becomes quite routine, and a coronary angiography and heat biopsy are usually performed once yearly. Transplant-associated coronary disease is a dreaded complication and may require coronary stenting. Treatment with medications such statins can reduce the incidence of transplant-associated coronary disease. Careful management of the medications after heart transplantation can help patients live a very productive and healthy life.
