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What is a heart transplant and artificial heart support systems program?

The heart transplant and artificial heart support systems program is a team organization where specialists from many different fields work together before and after the heart transplant. In addition to a heart transplant surgeon and cardiologist for heart failure, the team includes organ transplant coordinators, specialists from chest diseases, infectious diseases, nephrology, psychology/psychiatry, pathology, and dentistry, and experienced organ transplant nurses, specialists from social services, physiotherapists, and dieticians.

What is heart failure?
Heart is a vital organ that enables blood circulation in the body. The oxygen-poor blood returned from body to the heart is pumped by the right ventricle of the heart to the lungs. The blood is oxygenated in the lungs and returned to the left atrium of the heart then pumped to the whole body.

Heart failure occurs when the right, left or both of the ventricles fail to function. Heart failure is a progressive disease and the power of the heart gradually decreases in time. Heart becomes dysfunctional to pump the required volume of blood by the body. Tissues and cells have difficulty in getting the oxygen and nutrients.

Heart failure may occur at any age depending on the underlying cause. However, it occurs in 2.5% of people older than 45 years old and in 10% of those older than 65 years old. It is the primary cause of hospitalization and mortality in the world and in Turkey. In the end stage heart failure, more than half of the patients die in 1 year after diagnosis.

What are diseases causing heart failure?
  1. •    Coronary Artery Disease: The most common heart disease. Coronary arteries supplying the heart are narrowed and/or obstructed thus the myocardium is unable to get the required oxygen and nutrients and injured even dies (infarction), resulting in decreased power to contract.
  2. •    Complex Heart Valve Disease: Congenital or acquired aortic and mitral valve disorders increase the work load of the heart, resulting in heart failure due to a dilated or stressed heart. 
  3. •    Dilated Kardiomyopathy: The heart is dilated and enlarged leading to heart failure associated with inadequate contraction of myocardium due to structural defect of heart muscle. 
  4. •    Myocarditis: A disease resulting from decrease power of heart contraction due to a viral infection. Dysfunction of heart contraction might totally disappear after viral infection is healed, or might become permanent, resulting in heart failure. 

What is the treatment of heart failure?

For treatment of heart failure, medications, diet, devices to rectify arrhythmia, and corrective surgeries (coronary bypass, valve surgeries, etc.) for the disease causing heart failure can be used. However, the most effective methods in the treatment of end stage heart failure are the heart transplant and support devices for artificial heart.

What is a heart transplant?

A heart transplant is to replace the dysfunctional ill heart with a healthy heart. When a healthy individual dies who donated their organs (donor), their kidneys, liver, heart, etc. are prepared for transplant to patients (receiver) for who a decision to transplant an organ has been previously taken.

Who can undergo a heart transplant?

Cardiac patients younger than 65 years old are candidates for a heart transplant, who are in end stage (Stage-D) of heart failure with a life expectancy less than 1 year. The older patients (65 to 72 years old) are carefully evaluated for their physical characteristics rather than their chronological age and they will be included in the program if they are appropriate.  There two common causes for a heart transplant.
The first one is the coronary artery disease. Such patients are impossible to cure by a coronary bypass surgery or balloon-stent procedure. Irreversible myocardial serious or major damage may occur caused by previous attack and/or attacks associated with blocked coronary arteries. 

The other one is congenital or acquired weakness related to bacteria, viruses, etc. of the heart which is called cardiomyopathy. This may require a heart transplant when the contraction power of myocardium is largely reduced. 

The other rare causes include rheumatic fever, hypertension, valve diseases resulted in myocardium damage, congenital heart anomalies impossible to correct surgically, and cardiac tumors.

The patients are also candidates for a heart transplant, who have a severe arrhythmia associated with various diseases and are impossible to stop despite any medications or pacemakers.

To be included and voluntarily participate in a heart transplant program, the patients and family members should be aware and sure that

  1. •    All known treatment methods have been considered, applied, and tried for their heart disease,
  2. •    They will lose their life if they do not undergo a heart transplant,
  3. •    They will be able to have the will to adapt the changes in their life and some applications that will be necessary for a life time or for some time before but particularly after the transplant procedure.  

The patients will be evaluated by specialists in the heart transplant team for the above medical, psychological, and social characteristics to be included in the program.

What is an artificial heart support device?

An artificial heart support device is a state-of-the-art technology device that assumes pumping function of the heart in patients of end stage heart failure. Temporary artificial heart support systems are available used until heart failure is healed, or until a heart transplant as well as permanent artificial heart support systems used for a life time. 

Who can use an artificial heart support devices?

Heart support devices are used in patients with end-stage heart failure developed instantly or in time for mainly four purposes.

  1. •    For bridging (short-term use) to avoid dysfunctions of other organs in patients developed instant heart failure and to keep the patient alive until a permanent heart support system is activated.
  2. •    For bridging to recovery to keep the patient alive when the disease shows severe progression, e.g. diseases that lead to sudden heart failure resulting in myocarditis (inflammation of myocardium by viruses, etc.) but are completely healed after a pharmacotherapy.
  3. •    For bridging to heart transplant in patients who are in the waiting list but with a progressed heart failure when waiting for a heart.
  4. •    For use of a life time to improve time and quality of life of patients who are unable to have a heart transplant for various reasons (advanced age, severe renal or liver disease, etc.).

Who performs the surgeries for heart transplant and artificial heart support devices?

Surgeries for heart transplant and artificial heart support devices are performed by fully equipped hospitals authorized by T.R. Ministry of Health which have experienced teams in organ transplant and artificial heart systems and carry out heart transplant programs.

How will I be included in a program for heart transplant and artificial heart support devices?

The cardiologist, who is informed about the patient’s medical history and monitors the patient, will resort to the council of heart transplant and artificial heart support systems when they consider a heart transplant is required to cure the disease. Patient’s medical history, condition, tests, physical capacity, and other details are discussed for pre-evaluation. The condition of the patient is evaluated in detail by the committee that regularly meets and consists of a heart transplant surgeon, cardiologist, anesthesiologist, pulmonologist, infectious disease specialist, and heart transplant coordinator and secretary. Other necessary tests and consultations (psychiatry, endocrinology, nephrology, dentistry, etc.) are planned. If the council of heart transplant and artificial heart support systems deems the patient appropriate for a heart transplant following the evaluation, the patient will be included in the program and registered in the waiting list of organs.

What happens during waiting period for a heart transplant?

The patients, who are included in the waiting list by the council of heart transplant and artificial heart support systems and who are in a good condition to be able to live at home, wait for the suitable heart at home and come for regular checks while the others with severe heart failure are hospitalized to wait for the suitable heart. The place of the patient in the waiting list is determined by patient’s medical condition, blood type, comparison of body sizes of donor and receiver, and waiting period for the organ. Naturally, the patients with more severe failure have priority. The patients whose medical condition worsens during waiting period will be kept alive by artificial heart support systems until an organ is found.

What should I be careful with during waiting period for a heart?

Patients waiting for a heart transplant should be both mentally and physically prepared for an immediate transplant surgery. They should take their drug in complete and on time. Such patients should avoid busy environments, pay attention to personal hygiene, and appear for regular checks as they are prone to an infection. The patient and relatives must be accessible by phone at all times because it is not possible to make a surgery appointment in advance for heart transplant, and be prepared to immediately come to the hospital after phone call.

What happens when an appropriate heart is found to transplant?

When a healthy individual dies who donated their organs, some of their organs, e.g. the heart, liver, and kidneys, continue to function for a while. When the anesthesiologist, neurologist, and cardiologist announce such persons to be dead, their relative will be asked to approve for organ donation. The persons approved for organ donation after their death are announced as an organ donor for organ transplant coordination centers managed by T.R. Ministry of Health to be matched with a suitable receiver.

The patients with heart failure in the waiting list who has been matched with a suitable donor are immediately called to come to the hospital if they are monitored at home. The necessary preparations will be started immediately for patients, who have been hospitalized for a heart transplant and matched with a suitable donor. After completion of all preparations, some part of heart transplant team goes to the relevant center to prepare the heart of donor. The other part of the team prepares the receiver for transplant surgery. Heart transplant surgery will be performed when the receiver and donor are both ready.

How is a heart transplant surgery performed? What happens after the surgery?

A heart transplant surgery takes approx 5-6 hours if no complications occur. The patients are transferred to intensive care after completion of surgery. They will be disconnected from ventilator when all vital signs get back to normal. Patients need to stay in postop ICU for 2-3 days then are transferred to a special patient room when a family member will stay with them. The duration of hospital stay is about 15-20 days postop. A biopsy is performed for tissue rejection and patient is discharged.

What is a cardiac biopsy? When is it performed?

A cardiac biopsy is still the most effective method for tissue rejection after a heart transplant. The heart is accessed by a wire guided through inguinal or neck veins to collect some sample from heart tissue. The samples are delivered to pathology to investigate for tissue rejection and its level if any.

The cardiac biopsy is performed on the 15th day after the transplant. It is performed for 4 to 6 times in the first year after the transplant under the supervision of medical team that has monitored the patient. The frequency of biopsy is reduced in years but can be increased when necessary.

What is tissue rejection?

Tissue rejection is the immune response of receiver to the heart of donor. There are three levels, mild, moderate and severe. The content and dose of immunosuppressive treatment is adjusted by the level of response.

Will the patients be able to return to their normal life after a heart transplant?

The patients should be able to gain strength soon to perform any physical activities after a heart transplant, particularly at the end of 2nd month when the tissue is largely healed. The patients will surely require physical therapy and rehabilitation since their arm and leg muscles have been weaken by heart failure for years.  You should be able to return your business life for a part-time or full time in 1 year after the transplant.

How is surgery for artificial heart support device performed? What happens after the surgery?

Artificial heart support devices are categorized in two groups, implantable, miniature, and paracorporeal. Which one to implant will depend on the severity of heart failure and patient’s general condition. Although the surgery for artificial heart support device varies by the type of device, it approx takes 3-6 hours if no complications occur. The patients will come out of anesthesia in the private transfer room in ICU and be disconnected from ventilator when vital signs back to normal. The patients stay in ICU for 2-3 days after the surgery and then are transferred to their private room where they will stay with a family member. The duration of hospital stay is 20-25 days. These patients need to take blood diluents and have periodic blood tests during the whole period they live with a device, and consult with their doctor for dose of the medicines.

 Who can have a total artificial heart?
A total artificial heart is a device replaced with the ill heart and implanted in the body. There are two types for two purposes. The first and mostly used one is Syncardia Cardiowest total artificial heart to keep the patient alive temporarily, i.e. until heart is transplanted. It is the latest version of the artificial heart developed by Dr. Kolff and Dr. Jarvik around 50 year ago. It has been used with a success rate higher than 90% in hundreds of patients. This is the most commonly used total artificial heart. The other one is the permanent intracorporeal electric motor AbioCor TAH.

Are the cost of surgeries for heart transplant and artificial heart support devices compensated by the state?
A limited number of healthcare organizations is licensed and audited by the state to carry out programs for heart transplant and artificial heart support devices. There is a packet payment systems available by Social Security Institution (SSI), which includes the costs for surgeries of heart transplant and artificial heart support devices, care and treatments during preparation, ICU, and hospitalization for patients under SSI.