Heart transplantation

Last updated
Heart transplantation
Heart transplant.jpg
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, 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).

Contents

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]

History

A beating heart awaiting transplant Transport bijiciho srdce.jpg
A beating heart awaiting transplant

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 would receive a heart-lung transplant, and their original heart would be transplanted into someone else. [27]

Worldwide, about 5,000 heart transplants are performed annually, an increase of 53 percent between 2011 and 2022. [28] The majority of these are performed in the United States (about 4,000 annually). [29] Vanderbilt University Medical Center in Nashville, Tennessee currently is the largest heart transplant center in the world, having performed a world-record 174 adult and pediatric transplants in 2024 alone. [30]

About 800,000 people have NYHA Class IV heart failure symptoms indicating advanced heart failure. [31] 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. [32] 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. [33]

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. [34]

Recently, Australian researchers found a way to give more time for a heart to survive prior to the transplant, almost double the time. [35] Heart transplantation using donation after circulatory death (DCD) was recently adopted and can help in reducing waitlist time while increasing transplant rate. [36] Critically ill patients that are unsuitable for heart transplantation can be rescued and optimized with mechanical circulatory support, and bridged successfully to heart transplantation afterwards with good outcomes. [37]

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. [38] [39] Bennett died two months later at University of Maryland Medical Center on March 8, 2022. [40] [41] On April 19, 2023 Stanford Medicine surgeons performed the first beating-heart transplants from cardiac death donors. [42]

On December 11, 2024, in Padua, Italy, the world's first heart transplant from a non-beating donor to a fully beating heart was performed. [43] [44]

Contraindications

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. [45]

Absolute contraindications:

Relative contraindications:

[47]

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).

Complications

Potential complications include: [48]

Rejection

Since the transplanted heart originates from another organism, the recipient's immune system will attempt to reject it regardless if the donor heart matches the recipient's blood type (unless if the donor is an isograft). Like other solid organ transplants, the risk of rejection never fully goes away, and the patient will be on immunosuppressive drugs for the rest of their life. Usage of these drugs may cause unwanted side effects, such as an increased likelihood of contracting secondary infections or develop certain types of cancer. 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. [51]

People who have had heart transplants are monitored in various ways to test for possible organ rejection. [52]

A 2022 pilot study [53] 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 greater organ rejections and other poor outcomes.

Prognosis

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: [54]

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. [55]

See also

Related Research Articles

<span class="mw-page-title-main">Christiaan Barnard</span> South African cardiac surgeon (1922–2001)

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, who regained full consciousness and was able to talk easily with his wife, before dying 18 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.

<span class="mw-page-title-main">Organ transplantation</span> Medical procedure in which an organ is removed from one body and placed in the body of a recipient

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.

<span class="mw-page-title-main">Liver transplantation</span> Type of organ transplantation

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. Liver transplantation is highly regulated, and only performed at designated transplant medical centers by highly trained transplant physicians. Favorable outcomes require careful screening for eligible recipients, as well as a well-calibrated live or deceased donor match.

<span class="mw-page-title-main">Transplant rejection</span> Rejection of transplanted tissue by the recipients immune system

Transplant rejection occurs when transplanted tissue is rejected by the recipient's immune system, which destroys the transplanted tissue. Transplant rejection can be lessened by determining the molecular similitude between donor and recipient and by use of immunosuppressant drugs after transplant.

Prior to the introduction of brain death into law in the mid to late 1970s, all organ transplants from cadaveric donors came from non-heart-beating donors (NHBDs).

<span class="mw-page-title-main">Xenotransplantation</span> Transplantation of cells or tissue across species

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 because 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.

<span class="mw-page-title-main">Kidney transplantation</span> Medical procedure

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. The first successful kidney transplant was performed in 1954 by a team including Joseph Murray, the recipient's surgeon, and Hartwell Harrison, surgeon for the donor. Murray was awarded a Nobel Prize in Physiology or Medicine in 1990 for this and other work. In 2018, an estimated 95,479 kidney transplants were performed worldwide, 36% of which came from living donors.

<span class="mw-page-title-main">Lung transplantation</span> Surgical procedure in which a patients diseased lungs are partially or totally replaced

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.

The Organ Care System (OCS) is a medical device designed by Transmedics to allow donor organs to be maintained for longer periods of time prior to transplant. The system mimics the elements of human physiology and keeps organs in an environment and temperature similar to the human body. The system allows for organ preservation that last longer than the standard organ preservation method of putting organs on ice, static cold storage, which can cause cold ischemia. When put on ice, organs begin to deteriorate about three to four hours after retrieval. On the other hand, the Paragonix SherpaPak Cardiac Transport System can offer uniform cooling by suspending the donor heart in a preservation solution, and provides continuous temperature monitoring.

Organ procurement is a surgical procedure that removes organs or tissues for reuse, typically for organ transplantation.

Sean Patrick Pinney is an American cardiologist and the Director of both the Advanced Heart Failure and Cardiac Transplant Program and the Pulmonary Hypertension Program at Mount Sinai Medical Center in New York City.

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.

ABO-incompatible (ABOi) transplantation is a method of allocation in organ transplantation that permits more efficient use of available organs regardless of ABO blood type, which would otherwise be unavailable due to hyperacute rejection. Primarily in use in infants and young toddlers, research is ongoing to allow for increased use of this capability in adult transplants. Normal ABO-compatibility rules may be observed for all recipients. This means that anyone may receive a transplant of a type-O organ, and consequently, type-O recipients are one of the biggest beneficiaries of ABO-incompatible transplants. While focus has been on infant heart transplants, the principles generally apply to other forms of solid organ transplantation.

<span class="mw-page-title-main">Paolo Brenner</span> German cardiac surgeon

Paolo Brenner is a German physician and a professor of cardiac surgery at the Department of Cardiac Surgery, Klinikum Großhadern of the Ludwig Maximilian University of Munich (LMU). He is known for his work in the fields of xenotransplantation, the advancement of artificial hearts, extracorporeal membrane oxygenation (ECMO) and lung transplantation.

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.

<span class="mw-page-title-main">Bruno Reichart</span> German cardiothoracic surgeon

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.

<span class="mw-page-title-main">Keith Reemtsma</span> American surgeon

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.

<span class="mw-page-title-main">Cardiac allograft vasculopathy</span> Medical condition

Cardiac allograft vasculopathy (CAV) is a progressive type of coronary artery disease in people who have had a heart transplant. As the donor heart has lost its nerve supply there is typically no chest pain, and CAV is usually detected on routine testing. It may present with symptoms such as tiredness and breathlessness.

References

  1. ↑ Kilic A, Emani S, Sai-Sudhakar CB, Higgins RS, Whitson BA, et al. (2014). "Donor selection in heart transplantation". Journal of Thoracic Disease. 6 (8): 1097–1104. doi:10.3978/j.issn.2072-1439.2014.03.23. PMC   4133543 . PMID   25132976.
  2. 1 2 Cook JA, Shah KB, Quader MA, et al. (2015). "The total artificial heart". Journal of Thoracic Disease. 7 (12): 2172–80. doi:10.3978/j.issn.2072-1439.2015.10.70. PMC   4703693 . PMID   26793338.
  3. 1 2 Till Lehmann (director) (2007). The Heart-Makers: The Future of Transplant Medicine (documentary film). Germany: LOOKS film and television.
  4. ↑ Burch M.; Aurora P. (2004). "Current status of paediatric heart, lung, and heart-lung transplantation". Archives of Disease in Childhood. 89 (4): 386–89. doi:10.1136/adc.2002.017186. PMC   1719883 . PMID   15033856.
  5. ↑ May Transplant the Human Heart (.PDF), The New York Times , January 2, 1908.
  6. ↑ Hardy James D.; Chavez Carlos M.; Kurrus Fred D.; Neely William A.; Eraslan Sadan; Turner M. Don; Fabian Leonard W.; Labecki Thaddeus D. (1964). "Heart Transplantation in Man". JAMA. 188 (13). doi:10.1001/jama.1964.03060390034008.
  7. 1 2 Every Second Counts: The Race to Transplant the First Human Heart, Donald McRae, New York: Penguin (Berkley/Putnam), 2006, Ch. 7 "Mississippi Gambling", pp. 123–27. This source states the heartbeat for approximately one hour.
  8. ↑ James D. Hardy, 84, Dies; Paved Way for Transplants, Obituary, New York Times (Associated Press), Feb. 21, 2003. This source states the transplanted chimpanzee heartbeat for 90 minutes.
  9. ↑ Hardy James D (1963). "Lung Homotransplantation in Man". JAMA. 186 (12): 1065–74. doi:10.1001/jama.1963.63710120001010. PMID   14061414. See also Griscom NT (1963). "Lung Transplantation". JAMA. 186 (12): 1088. doi:10.1001/jama.1963.03710120070015. PMID   14061420. in same issue.
  10. ↑ Second Wind: Oral Histories of Lung Transplant Survivors, Mary Jo Festle, Palgrave MacMillan, 2012.
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  12. 1 2 Cooper DK (2012). "A brief history of cross-species organ transplantation". Proc (Bayl Univ Med Cent). 25 (1): 49–57. doi:10.1080/08998280.2012.11928783. PMC   3246856 . PMID   22275786. ' … the consent form for Hardy's operation –which, in view of the patient's semi-comatose condition, was signed by a close relative –stipulated that no heart transplant had ever been performed, but made no mention of the fact that an animal heart might be used for the procedure. Such was the medicolegal situation at that time that this "informed" consent was not considered in any way inadequate. . '
  13. ↑ Xenotransplantation: Law and Ethics, Sheila McLean, Laura Williamson, University of Glasgow, UK, Ashgate Publishing, 2005, p. 50.
  14. ↑ "Pig Heart Transplanted in Human". The Hindu. 2022-01-15. Retrieved 2022-01-16.
  15. ↑ "Man Gets Genetically Modified Pig Heart". BBC. 2022-01-15. Retrieved 2022-01-16.
  16. 1 2 3 4 McRae, D. (2006). Every Second Counts: The Race to Transplant the First Human Heart, New York: Penguin (Berkley/Putnam).
  17. ↑ Norman Shumway: Father of heart transplantation who also performed the world's first heart-lung transplant, Obituary, The Independent [UK], 16 Feb. 2006.
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  19. ↑ "Pneumonia Blamed in Transplant Patient's Death". The New York Times. 1967-12-21. Retrieved 2018-01-08.
  20. ↑ Lyons, Richard D. "Heart Transplant Fails to Save 2-Week-old Baby in Brooklyn; Heart Transplant Fails to Save Baby Infants' Surgery Harder Working Side by Side Gives Colleague Credit", The New York Times , December 7, 1967. Accessed November 19, 2008.
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  22. ↑ Tilli Tansey; Lois Reynolds, eds. (1999). Early heart transplant surgery in the UK. Wellcome Witnesses to Contemporary Medicine. History of Modern Biomedicine Research Group. ISBN   978-1-84129-007-2. OL   12568266M. Wikidata   Q29581627.
  23. ↑ Major Medical Milestones Leading Up To the First Human Heart Transplantation Archived 2016-07-14 at the Wayback Machine , Kate Elzinga, from Proceedings of the 18th Annual History of Medicine Days Conference 2009: The University of Calgary Faculty of Medicine, Alberta, Canada, Cambridge Scholars Publishing, 2011. " . . following Barnard's landmark heart transplantation on December 3, 1967, 107 human heart transplants were performed by 64 surgical teams in 24 countries in 1968. . "
  24. ↑ The Adrian Kantrowitz Papers, Replacing Hearts: Left Ventricle Assist Devices and Transplants, 1960–1970, National Institutes of Health, U.S. National Library of Medicine.
  25. ↑ Transplantation of the heart: An overview of 40 years' clinical and research experience at Groote Schuur Hospital and the University of Cape Town, South African Medical Journal, "Part I. Surgical experience and clinical studies." J Hassoulas, Vol. 102, No. 6 (2012).
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  38. ↑ "In 1st, US surgeons transplant pig heart into human patient". Associated Press. 2022-01-10. Retrieved 2022-01-10.
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  43. ↑ "In Padua, the world's first heart transplant from a non-beating donor to a fully beating heart". December 13, 2024. Retrieved December 13, 2024.
  44. ↑ Michela Nicolussi Moro (December 12, 2024). ""Così ho eseguito il primo trapianto a cuore battente: non si ferma mai, batte tra le mani del chirurgo mentre lo sposta da chi lo dona a chi lo riceve"" ["That's how I performed the first beating-heart transplant: it never stops, beating between the surgeon's hands as he moves it from donor to recipient."] (in Italian). Archived from the original on December 13, 2024. Retrieved December 13, 2024. In the usual transplantation, the heart is stopped at the time of retrieval from the donor, then transported up to the operating room at a temperature of 4 degrees and then transplanted, still stopped. After surgery is performed, it is restarted in the recipient. With the new technique, referred to as totally beating heart transplantation, we took the organ from the donor without stopping it and put it into the ex vivo perfusion machine, in which the heart continued to beat and never stopped, even when 'we reimplanted it into the recipient.
  45. ↑ de Jonge, N.; Kirkels, J. H.; Klöpping, C.; Lahpor, J. R.; Caliskan, K.; Maat, A. P. W. M.; Brügemann, J.; Erasmus, M. E.; Klautz, R. J. M.; Verwey, H. F.; Oomen, A.; Peels, C. H.; Golüke, A. E. J.; Nicastia, D.; Koole, M. A. C. (2008). "Guidelines for heart transplantation". Netherlands Heart Journal. 16 (3): 79–87. doi:10.1007/BF03086123. ISSN   1568-5888. PMC   2266869 . PMID   18345330.
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  53. ↑ Killian, Michael O.; Clifford, Stephanie; Lustria, Mia Liza A.; Skivington, Gage L.; Gupta, Dipankar (2022-04-18). "Directly observed therapy to promote medication adherence in adolescent heart transplant recipients". Pediatric Transplantation. 26 (5): e14288. doi: 10.1111/petr.14288 . ISSN   1397-3142. PMID   35436376. S2CID   248242427.
  54. ↑ Heart Disease and Stroke Statistics – 2012 Update The American Heart Association . Retrieved 27 November 2012.
  55. ↑ Weiss, E. S.; Allen, J. G.; Patel, N. D.; Russell, S. D.; Baumgartner, W. A.; Shah, A. S.; Conte, J. V. (2009). "The Impact of Donor-Recipient Sex Matching on Survival After Orthotopic Heart Transplantation: Analysis of 18 000 Transplants in the Modern Era". Circulation: Heart Failure. 2 (5): 401–08. doi: 10.1161/CIRCHEARTFAILURE.108.844183 . PMID   19808369.
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