Heart Transplant Q&A
Companion article to our Winter 2015 cover story, Giving Heart
Sitaramesh Emani is assistant professor of medicine specializing in advanced heart failure and cardiac transplant at The Ohio State University Wexner Medical Center. Ayesha Hasan, an associate professor of clinical medicine, is medical director of the Cardiac Transplant Program and the director of the Heart Failure Devices Clinic at Wexner. We asked them to clarify a few things about heart transplants.
Though a heart transplant doesn’t solve everything and requires on going care and medical supervision, it is literally life-saving.
HI: On average, how long does a transplanted heart last?
Emani: The median survival after transplant is 11 years. Conditional survival, which is survival if they survive the first year, is 13 years. When you consider that the average age of adult transplant patients is around 60, 11-13 years of survival places them close to a natural life span.
HI: How does the transplant list work?
Hasan: There is national list maintained by the United Network for Organ Sharing (UNOS). The strategy is to maximize the potential for survival after transplant while minimizing the risk of dying on the wait list. In order to accomplish this, the sickest patients within the region are typically prioritized and are more likely to receive offers that are geographically close by. However, a very sick patient who is further away may be prioritized over a less sick patient who was closer to the donor depending on the balance of risk factors involved.
HI: What are the criteria that go into matching donors and recipients?
Emani: When matching a donor to a recipient, we try to find the best match possible to maximize the potential for a good outcome. Initial factors include matching the correct blood type and body size. Additional factors include the risk of rejection of the new heart based on blood tests.
Other factors sometimes considered include the distance that a donor heart would have to travel since longer travel times may increase the risk of the new heart not doing well. All these factors are balanced against the severity of the recipient’s illness and how much time that patient has to wait.
HI: What is the typical wait for a donor heart after someone goes on the list?
Emani: The typical wait time for someone on the wait list can vary greatly depending on his or her blood type, body size, predetermined risk of rejecting a heart based on testing, severity of illness, and even the region in which he or she lives. Sometimes wait times can be as short as a few days or weeks, other times wait times can exceed several years.
HI: Do transplant patients have to take anti-rejection drugs forever or does the body eventually accept the heart?
Hasan: Recipients have to take anti-rejection medications for the rest of their lives. Although the risk of rejection may go down in specific patients, the overall risk never goes away completely. Therefore, lifelong medication to control the risk of rejection is necessary.
HI: What are the side effects of the anti-rejection drugs?
Emani: Anti-rejection medications can have many side effects. One such side effect is an increased risk for infection since the body’s immune system is being suppressed. Other side effects include changes in kidney function, increased risk of certain cancers including skin cancer, and changes in blood counts. When steroids are used as part of the anti-rejection regimen, there is an increased risk of diabetes as well as weight gain.
Patients who have undergone a transplant have to be followed carefully by a transplant program to monitor for the side effects; medication adjustments and other treatments are often necessary to help minimize the overall side effects.
HI: Are there untoward consequences to heart transplants, especially for those who have transplants as children?
Hasan: Perhaps the biggest factor affecting the lives of transplant patients is the fact that they need to be followed carefully and are still treated as if they have a medical condition despite having a new heart.
Because of the highly specialized nature of anti-rejection medications, patients need to be monitored for the development of side effects. They also require routine follow-up and testing to check the function of the new heart.
Sometimes, when treating unrelated conditions, patients need to be evaluated more carefully. For example, medications used to treat other illnesses and conditions may interact with anti-rejection medications and would need to be avoided or adjusted. Similarly, patients undergoing surgery for unrelated conditions may need their anti-rejection medications adjusted to prevent complications.
For women who are of childbearing age, pregnancy can be extremely challenging because of the effects of anti-rejection medications on the fetus. For this reason, pregnancy is discouraged in patients who have undergone transplant.
HI: Are there things people with heart transplants can’t do, like be physically active?
Emani: All transplant patients are encouraged to be active and exercise regularly once cleared by their medical team. They do need to be extra careful about the risk of infection and vigilant about good hygiene and avoiding sick people from whom they may become sick themselves.
HI: Are there dietary restrictions?
Hasan: In general, transplant patients are encouraged to eat a healthy, balanced diet. Specific restrictions and instructions are also given, including avoiding raw or undercooked foods from which illnesses may be contracted.
HI: Is there any kind of regular maintenance or observation that must be done?
Emani: These patients require routine maintenance and follow-up with a transplant program. This includes regular blood work, imaging to check function, and biopsies to check for rejection. Some patients also require regular heart catheterizations to monitor for the development of heart disease. Non-cardiac follow-up can include regular skin exams as well as other general health exams as appropriate.