Heart transplantation | |
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![]() land illustrating the placement of a donor heart in an orthotopic procedure. Notice how the back of the patient's left atrium and great vessels are left in place. | |
Specialty | cardiology |
ICD-9-CM | 37.51 |
MeSH | D016027 |
MedlinePlus | 003003 |
A heart transplant, or a cardiac transplant, is a surgical transplant procedure performed on patients with end-stage heart failure or severe coronary artery disease when other medical or surgical treatments have failed. As of 2018 [update] , the most common procedure is to take a functioning heart, with or without both lungs, from a recently deceased organ donor (brain death is the standard [1] ) and implant it into the patient. The patient's own heart is either removed and replaced with the donor heart (orthotopic procedure) or, much less commonly, the recipient's diseased heart is left in place to support the donor heart (heterotopic, or "piggyback", transplant procedure).
Approximately 3,500 heart transplants are performed each year worldwide, more than half of which are in the US. [2] Post-operative survival periods average 15 years. [3] Heart transplantation is not considered to be a cure for heart disease; rather it is a life-saving treatment intended to improve the quality and duration of life for a recipient. [4]
American medical researcher Simon Flexner was one of the first people to mention the possibility of heart transplantation. In 1907, he wrote the paper "Tendencies in Pathology," in which he said that it would be possible one day by surgery to replace diseased human organs – including arteries, stomach, kidneys and heart. [5]
Not having a human donor heart available, James D. Hardy of the University of Mississippi Medical Center transplanted the heart of a chimpanzee into the chest of dying Boyd Rush in the early morning of Jan. 24, 1964. Hardy used a defibrillator to shock the heart to restart beating. This heart did beat in Rush's chest for 60 to 90 minutes (sources differ), and then Rush died without regaining consciousness. [6] [7] [8] Although Hardy was a respected surgeon who had performed the world's first human-to-human lung transplant a year earlier, [9] [10] author Donald McRae states that Hardy could feel the "icy disdain" from fellow surgeons at the Sixth International Transplantation Conference several weeks after this attempt with the chimpanzee heart. [11] Hardy had been inspired by the limited success of Keith Reemtsma at Tulane University in transplanting chimpanzee kidneys into human patients with kidney failure. [12] The consent form Hardy asked Rush's stepsister to sign did not include the possibility that a chimpanzee heart might be used, although Hardy stated that he did include this in verbal discussions. [7] [12] [13] A xenotransplantation is the technical term for the transplant of an organ or tissue from one species to another.
Dr Dhaniram Baruah of Assam, India was the first heart surgeon to transplant a pig's heart in human body. [14] However the recipient died subsequently. The world's first successful pig-to-human heart transplant was performed in January 2022 by surgeon Bartley P. Griffith of USA. [15]
The world's first human-to-human heart transplant was performed by South African cardiac surgeon Christiaan Barnard utilizing the techniques developed by American surgeons Norman Shumway and Richard Lower. [16] [17] Patient Louis Washkansky received this transplant on December 3, 1967, at the Groote Schuur Hospital in Cape Town, South Africa. Washkansky, however, died 18 days later from pneumonia. [16] [18] [19]
On December 6, 1967, at Maimonides Hospital in Brooklyn, New York, Adrian Kantrowitz performed the world's first pediatric heart transplant. [16] [20] The infant's new heart stopped beating after 7 hours and could not be restarted. At a following press conference, Kantrowitz emphasized that he did not consider the operation a success. [21]
Norman Shumway performed the first adult heart transplant in the United States on January 6, 1968, at the Stanford University Hospital. [16] A team led by Donald Ross performed the first heart transplant in the United Kingdom on May 3, 1968. [22] These were allotransplants, the technical term for a transplant from a non-genetically identical individual of the same species. Brain death is the current ethical standard for when a heart donation can be allowed.
Worldwide, more than 100 transplants were performed by various doctors during 1968. [23] Only a third of these patients lived longer than three months. [24]
The next big breakthrough came in 1983 when cyclosporine entered widespread usage. This drug enabled much smaller amounts of corticosteroids to be used to prevent many cases of rejection (the "corticosteroid-sparing" effect of cyclosporine). [25]
On June 9, 1984, "JP" Lovette IV of Denver, Colorado, became the world's first successful pediatric heart transplant. Columbia-Presbyterian Medical Center surgeons transplanted the heart of 4-year-old John Nathan Ford of Harlem into 4-year-old JP a day after the Harlem child died of injuries received in a fall from a fire escape at his home. JP was born with multiple heart defects. The transplant was done by a surgical team led by Dr. Eric A. Rose, director of cardiac transplantation at New York–Presbyterian Hospital. Drs. Keith Reemtsma and Fred Bowman also were members of the team for the six-hour operation. [26]
In 1988, the first "domino" heart transplant was performed, in which a patient in need of a lung transplant with a healthy heart will receive a heart-lung transplant, and their original heart will be transplanted into someone else. [27]
Worldwide, about 3,500 heart transplants are performed annually. The vast majority of these are performed in the United States (2,000–2,300 annually). [2] Cedars-Sinai Medical Center in Los Angeles, California, currently is the largest heart transplant center in the world, having performed 132 adult transplants in 2015 alone. [28] About 800,000 people have NYHA Class IV heart failure symptoms indicating advanced heart failure. [29] The great disparity between the number of patients needing transplants and the number of procedures being performed spurred research into the transplantation of non-human hearts into humans after 1993. Xenografts from other species and artificial hearts are two less successful alternatives to allografts. [3]
The ability of medical teams to perform transplants continues to expand. For example, Sri Lanka's first heart transplant was successfully performed at the Kandy General Hospital on July 7, 2017. [30] In recent years, donor heart preservation has improved and Organ Care System is being used in some centers in order to reduce the harmful effect of cold storage. [31]
During heart transplant, the vagus nerve is severed, thus removing parasympathetic influence over the myocardium. However, some limited return of sympathetic nerves has been demonstrated in humans. [32]
Recently, Australian researchers found a way to give more time for a heart to survive prior to the transplant, almost double the time. [33]
On January 7, 2022, David Bennett, aged 57, of Maryland became the first person to receive a gene-edited pig heart in a transplant at the University of Maryland Medical Center. Before the transplant, David was unable to receive a human heart due to the patient's past conditions with heart failure and an irregular heartbeat, causing surgeons to use the pig heart that was genetically modified. [34] [35] Bennett died two months later at University of Maryland Medical Center on March 8, 2022. [36] [37]
Some patients are less suitable for a heart transplant, especially if they have other circulatory conditions related to their heart condition. The following conditions in a patient increase the chances of complications.[ citation needed ]
Absolute contraindications:
Relative contraindications:
Patients who are in need of a heart transplant but do not qualify may be candidates for an artificial heart [2] or a left ventricular assist device (LVAD).
Potential complications include: [40]
Since the transplanted heart originates from another organism, the recipient's immune system typically attempts to reject it. The risk of rejection never fully goes away, and the patient will be on immunosuppressive drugs for the rest of their life. These drugs may cause unwanted side effects, such as an increased likelihood of infections or the development of certain cancers. Recipients can acquire kidney disease from a heart transplant due to the side effects of immunosuppressant medications. Many recent advances in reducing complications due to tissue rejection stem from mouse heart transplant procedures. [43]
People who have had heart transplants are monitored in various ways to test for the development of rejection. [44]
A 2022 pilot study [45] examining the acceptability and feasibility of using video directly observed therapy to increase medication adherence in adolescent heart transplant patients showed promising results of 90.1% medication adherence compared to 40-60% typically. Higher medication variability levels can lead to fewer organ rejections and other poor outcomes.
The prognosis for heart transplant patients following the orthotopic procedure has improved over the past 20 years, and as of June 5, 2009 the survival rates were: [46]
In 2007, researchers from the Johns Hopkins University School of Medicine discovered that "men receiving female hearts had a 15% increase in the risk of adjusted cumulative mortality" over five years compared to men receiving male hearts. Survival rates for women did not significantly differ based on male or female donors. [47]
Christiaan Neethling Barnard was a South African cardiac surgeon who performed the world's first human-to-human heart transplant operation. On 3 December 1967, Barnard transplanted the heart of accident victim Denise Darvall into the chest of 54-year-old Louis Washkansky, with Washkansky regaining full consciousness and being able to talk easily with his wife, before dying eighteen days later of pneumonia, largely brought on by the anti-rejection drugs that suppressed his immune system. Barnard had told Mr. and Mrs. Washkansky that the operation had an 80% chance of success, an assessment which has been criticised as misleading. Barnard's second transplant patient, Philip Blaiberg, whose operation was performed at the beginning of 1968, returned home from the hospital and lived for a year and a half.
Organ transplantation is a medical procedure in which an organ is removed from one body and placed in the body of a recipient, to replace a damaged or missing organ. The donor and recipient may be at the same location, or organs may be transported from a donor site to another location. Organs and/or tissues that are transplanted within the same person's body are called autografts. Transplants that are recently performed between two subjects of the same species are called allografts. Allografts can either be from a living or cadaveric source.
Liver transplantation or hepatic transplantation is the replacement of a diseased liver with the healthy liver from another person (allograft). Liver transplantation is a treatment option for end-stage liver disease and acute liver failure, although availability of donor organs is a major limitation. The most common technique is orthotopic transplantation, in which the native liver is removed and replaced by the donor organ in the same anatomic position as the original liver. The surgical procedure is complex, requiring careful harvest of the donor organ and meticulous implantation into the recipient. Liver transplantation is highly regulated, and only performed at designated transplant medical centers by highly trained transplant physicians and supporting medical team. The duration of the surgery ranges from 4 to 18 hours depending on outcome. Favorable outcomes require careful screening for eligible recipient, as well as a well-calibrated live or cadaveric donor match.
Xenotransplantation, or heterologous transplant, is the transplantation of living cells, tissues or organs from one species to another. Such cells, tissues or organs are called xenografts or xenotransplants. It is contrasted with allotransplantation, syngeneic transplantation or isotransplantation and autotransplantation. Xenotransplantation is an artificial method of creating an animal-human chimera, that is, a human with a subset of animal cells. In contrast, an individual where each cell contains genetic material from a human and an animal is called a human–animal hybrid.
A heart–lung transplant is a procedure carried out to replace both failing heart and lungs in a single operation. Due to a shortage of suitable donors and due to the fact that both heart and lung have to be transplanted together, it is a rare procedure; only about a hundred such transplants are performed each year in the United States.
Cardiac surgery, or cardiovascular surgery, is surgery on the heart or great vessels performed by cardiac surgeons. It is often used to treat complications of ischemic heart disease ; to correct congenital heart disease; or to treat valvular heart disease from various causes, including endocarditis, rheumatic heart disease, and atherosclerosis. It also includes heart transplantation.
Kidney transplant or renal transplant is the organ transplant of a kidney into a patient with end-stage kidney disease (ESRD). Kidney transplant is typically classified as deceased-donor or living-donor transplantation depending on the source of the donor organ. Living-donor kidney transplants are further characterized as genetically related (living-related) or non-related (living-unrelated) transplants, depending on whether a biological relationship exists between the donor and recipient.
Lung transplantation, or pulmonary transplantation, is a surgical procedure in which one or both lungs are replaced by lungs from a donor. Donor lungs can be retrieved from a living or deceased donor. A living donor can only donate one lung lobe. With some lung diseases, a recipient may only need to receive a single lung. With other lung diseases such as cystic fibrosis, it is imperative that a recipient receive two lungs. While lung transplants carry certain associated risks, they can also extend life expectancy and enhance the quality of life for those with end stage pulmonary disease.
A uterine transplant is a surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased. As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile. This phenomenon is known as absolute uterine factor infertility (AUFI). Uterine transplant is a potential treatment for this form of infertility.
Adrian Kantrowitz was an American cardiac surgeon whose team performed the world's second heart transplant attempt at Maimonides Medical Center in Brooklyn, New York on December 6, 1967. The infant lived for only six hours. At a press conference afterwards, Kantrowitz emphasized that he considered the operation to have been a failure.
Transplantable organs and tissues may refer to both organs and tissues that are relatively often transplanted, as well as organs and tissues which are relatively seldom transplanted. In addition to this it may also refer to possible-transplants which are still in the experimental stage.
Stephanie Fae Beauclair, better known as Baby Fae, was an American infant born in 1984 with hypoplastic left heart syndrome. She became the first infant subject of a xenotransplant procedure and first successful infant heart transplant, receiving the heart of a baboon. Though she died within a month of the procedure, she lived weeks longer than any previous recipient of a non-human heart.
Norman Edward Shumway was a pioneer of heart surgery at Stanford University. He was the 67th president of the American Association for Thoracic Surgery and the first to perform an adult human to human heart transplantation in the United States.
Richard Rowland Lower was an American pioneer of cardiac surgery, particularly in the field of heart transplantation. Lower was born in Detroit, attended Amherst College, and received his medical degree from Cornell University in 1955. Lower and Norman Shumway developed many of the techniques required to conduct successful heart transplantation, including the use of hypothermia and the orthotopic technique, which became the standard technique for cardiac transplantation.
Prafulla Kumar Sen MD was an Indian vascular and cardiothoracic surgeon, who led the first human heart transplant procedure in India in 1968 and became the fourth surgeon in the world to carry out this operation. It was also the sixth attempt at this procedure in the world.
Jack Greene Copeland is an American cardiothoracic surgeon, who has established procedures in heart transplantation including repeat heart transplantation, the implantation of total artificial hearts (TAH) to bridge the time to heart transplant, innovations in left ventricular assist devices (LVAD) and the technique of "piggybacking" a second heart in a person, while leaving them the original.
Edward B. Stinson is an American retired cardiothoracic surgeon living in Los Altos, United States, who assisted Norman Shumway in America's first adult human-to-human heart transplantation on 6 January 1968 at Stanford University.
Bruno Reichart is a retired German cardiothoracic surgeon who performed Germany's first successful heart transplant in 1981 and its first combined heart–lung transplant in 1983.
Keith Reemtsma was an American transplant surgeon, best known for the cross-species kidney transplantation operation from chimpanzee to human in 1964. With only the early immunosuppressants and no long-term dialysis, the female recipient survived nine months, long enough to return to work.
Bartley P. Griffith is an American heart surgeon.