Heart-lung transplant

A heart-lung transplant is a major and rarely performed surgical procedure.

Contents

Introduction

A heart-lung transplant is a major and rarely performed surgical procedure.

During a heart-lung transplant, a person's diseased heart and lungs are replaced with the heart and lungs of a recently deceased donor. As with any transplant there are risks, but the procedure aims to extend or improve quality of life in suitable candidates.

When is a heart-lung transplant needed?

A heart-lung transplant is the only treatment available for people who have combined heart and lung failure. It is a treatment that carries high risks but can offer benefits. For this reason it is only recommended when all other treatment options have failed.

In a healthy person, the heart and lungs work closely together. This means a problem in the lungs can damage the heart, or vice versa. If the damage is severe in both organs, replacing the heart or lungs alone may not be possible.

The conditions that most often require a heart-lung transplant are:

  • adult congenital heart disease (ACHD) – where an adult has one or more birth defects that affect their heart
  • pulmonary hypertension – where high blood pressure develops inside the blood vessels of the lungs, which can damage both the lungs and the heart

Occasionally, a heart-lung transplant may be used to treat cystic fibrosis, a condition where the lungs and digestive system become clogged up with sticky mucus.

How common are heart-lung transplants?

Heart-lung transplants are rarely carried out.

The main reason for this is the shortage of suitable organs available for donation and the priority given to heart transplants.

Limitations on organ availability

It is a complicated process to obtain a suitable organ and many things need to be correct before a transplant can be performed. Organs are initially matched based on blood group and size.

The heart and lungs are very delicate organs and the process of donation can make up to 70% of organs unusable.

The lung tissue rapidly deteriorates when it's removed from the body. A successful donation is usually only possible if the transplant is carried out within four to six hours of the lungs being removed from the donor. This usually means that a successful donation can only go ahead if the donor and recipient are in the same part of the country.

In addition, most donated hearts are from people who have been declared braindead. Although there is no activity in the brain, the heart can continue to beat spontaneously for many hours provided a ventilator is used to keep oxygen going into the bloodstream.

However, the prolonged use of a ventilator can damage the lungs, making them unsuitable for transplantation.

These factors mean there is a very low number of organs suitable for heart and lung transplants.

Read more about the transplant process.

Risks

A heart-lung transplant is a major procedure that carries a high risk of complications, some of which can be fatal.

This means the procedure is usually only carried out when all other treatment options have been exhausted and there is evidence to suggest that the potential benefits will outweigh the risks.

Read more about who can have a heart-lung transplant.

The main risks following a heart-lung transplant are your body rejecting the donated organs and immunosuppressant medication making you more vulnerable to infection.

Read more about the risks of having a heart-lung transplant.

Results

The outcomes of heart-lung transplants have improved significantly since the operation was first carried out in 1983. This is mainly because of the introduction of immunosuppressants, which help prevent the immune system rejecting donated organs.

However, it is important to realise that survival rates are a guide and cannot predict outcomes for each person. There are many factors that could influence your own predicted survival. One of these factors is your age, as the results are poorer in older people.

Your transplant team will be able to provide more detailed information for you.

Help and support

Finding out that you need to have a transplant, waiting for suitable donor organs to become available and actually having the transplant can be emotionally demanding for both you and your family. Most transplant teams are able to offer counselling for this.

Alternatively, your doctor should be able to refer you to a counsellor and provide you with information and advice about joining a support group in your area.

Recovery

Following a heart-lung transplant, you will need to stay in an intensive care unit (ICU) for a few days.

This is because:

  • you will need to be carefully monitored to make sure the organs are working
  • there is a risk that your body may suddenly reject the new organs, which would require emergency treatment
  • you will require assistance with breathing and feeding until you begin to recover

It is likely you will be in some pain after the transplant, so pain relief will be given as required.

You will usually be transferred to a general ward after three or four days, where your health will be monitored as you recover. Most people are well enough to leave hospital around three weeks after having a heart-lung transplant.

The recovery process

Recovering fully from a transplant can be a long and frustrating process. You may be referred to a physiotherapist or other rehabilitation specialist, who will teach you exercises specifically designed to strengthen your new heart and lungs. This is known as cardiopulmonary rehabilitation.

It may be up to six months before you are well enough to return to your normal daily activities.

During your recovery period, you will need frequent hospital visits and some admissions. You may need as many as three check-ups a week during the first few weeks after having the transplant. These appointments will become less frequent if you make good progress.

Even when you've made a full recovery, you will still need to have regular check-ups. Depending on your state of health, the timing of these appointments can range from once every three months to once a year.

Immunosuppressants

As the transplanted organs are foreign to your body, the immune system will try to defend itself by rejecting the organs. Rejection leads to injury of the transplanted organs, which, if not prevented, can cause organ failure. To prevent this, you will need to take life-long immunosuppressant medication.

Most patients will need a combination of three anti-rejection medications. If you are well, with time the dose of the immunosuppression can be reduced.

Immunosuppressants are powerful medications that can have a range of different side effects, including:

It is important to manage any complications to prevent long-term problems, which usually involves further medication. You may also experience other issues, such as:

While these side effects may be troublesome, you should never stop taking immunosuppressants or reduce the recommended dose. If you do, it could lead to your heart and lungs being rejected, which can be fatal.

Your transplant team may be able to provide you with additional treatments to help reduce any side effects that you experience after taking immunosuppressants.

How is it performed

If a heart-lung transplant is thought to be a potential treatment for you, it is likely that you will be invited to your local hospital for an initial assessment.

The purpose of the assessment is to check whether you are a suitable candidate for a heart-lung transplant. Read more about who can have a heart-lung transplant.

Following an initial assessment, it is likely you will be invited to your nearest transplant centre for a more in-depth assessment if you are thought to be a suitable candidate.

Further assessment

The purpose of a further assessment is to build up a more detailed picture of your current state of health and to check whether there are any underlying problems that could affect your suitability for having a transplant. In addition, it is designed for you to have the chance to hear details about the possible outcomes of a transplant.

Before visiting the transplant centre, you may find it useful to write a list of questions that you would like to ask the transplant team.

As part of your assessment, you may have some of the tests described below:

  • blood tests and urine tests to check for viral or bacterial infections and to assess the health of organs, such as your liver
  • chest X-rays
  • blood pressure tests
  • a lung function test, which uses a machine called a pulse oximeter to measure the amount of oxygen in your blood
  • computerised tomography (CT) scans and magnetic resonance imaging (MRI) scans, which can be used to check the health of certain organs, such as your lungs
  • an electrocardiogram (ECG), which is a test that can measure the electrical activity of your heart

The whole assessment process usually takes between two to four days to complete. If your child is being assessed, the transplant centre will be able to arrange accommodation for you if you need it.

The final decision about whether you or your child is suitable for a heart-lung transplant is not made by one person. An agreement is reached on each candidate by a number of members of the team during a formal meeting.

There are three possible outcomes from this assessment period. The team may:

  • think you will benefit from a transplant and offer you the opportunity to go on the transplant list
  • request further investigations or certain targets to be met before you are offered a place on the transplant list
  • not offer you a place on the transplant list if they feel there would be little benefit from a transplant

If it is decided that you or your child are not suitable for a heart-lung transplant, you will have the opportunity to discuss the treatment options that are suitable for you.

Once the decision has been made, you will have the opportunity to speak in person with a member of the transplant team.

Waiting for a suitable donor

It is impossible to say how long it will take for a suitable donor to be found. It may be several months or even years before a donated heart and lungs of the right size and blood group becomes available. The waiting times for a heart-lung transplant are very long and many people's conditions can deteriorate while waiting.

While you are on the list, you will be seen every few months to monitor your condition.

Your transplant centre will be able to offer any support, guidance and information you need while you are waiting for a suitable donor to be found. They will be fully aware that for many people this can be both a frustrating and frightening experience.

In some cases, a planned transplant might not go ahead. This may be because your health deteriorates to such an extent that a transplant is no longer considered to be a safe or effective treatment. Unfortunately, dying before a donated heart and lungs becomes available is also a possibility.

You should discuss both possibilities with the staff at your transplant centre and, if necessary, with your friends, family and loved ones.

The transplant operation

After a donated set of heart and lungs becomes available, your transplant team will contact you to arrange for transport to take you to the transplant centre as quickly as possible.

You will be taken to the operating theatre and given a general anaesthetic. A piece of equipment known as a heart-lung bypass machine will be attached to your body using tubes that are inserted into your blood vessels. The machine pumps oxygen-rich blood around your body until the operation is complete.

A cut will be made in your chest to enable the surgeon to remove your heart and lungs. The donated set of heart and lungs will be put in place and reconnected to the surrounding blood vessels. The incision in your chest will then be stitched up and you will be transferred to an intensive care unit (ICU), where your recovery will be closely monitored.

Because of the complexity of the procedure, a heart-lung transplantation usually takes several hours to complete.

Risks

After having a heart-lung transplant, one of the biggest risks is that your body will reject your new heart and lungs despite taking immunosuppressants.

There are two types of rejection:

  • acute rejection – where rejection occurs just after surgery
  • chronic rejection – where rejection occurs many months or years after surgery

Signs that your body may be rejecting your heart include:

  • fatigue (extreme tiredness)
  • swelling of your arms and legs
  • weight gain
  • a high temperature (fever) of 38°C (100.4°F) or above

Signs that your body may be rejecting your lungs include:

  • coughing
  • shortness of breath
  • breathing difficulties
  • a high temperature (fever) of 38°C (100.4°F) or above
  • swelling of your arms and legs
  • weight gain
  • heart palpitations (heartbeats that become more noticeable)

If you have any of these symptoms, you should contact your transplant centre as soon as possible. Rejection can usually be treated by increasing your dose of immunosuppressant medication.

Infection

Immunosuppressant medication will weaken your immune system and make you more vulnerable to infection. The three most common types of infection that affect people who have had heart-lung transplants are:

CMV is a common virus that is part of the herpes family of viruses.

Bacterial infection

A bacterial infection of the lungs (pneumonia) is common in the first few weeks after a transplant.

Symptoms of pneumonia include:

  • breathing difficulties
  • coughing up phlegm (thick mucus) that may be yellow, green, brown or blood-stained
  • wheezing
  • a rapid heartbeat (tachycardia)
  • a high temperature (fever) of 38°C (100.4°F) or above
  • feeling generally unwell
  • sweating and shivering
  • loss of appetite
  • pain in your chest

If you think that you may have pneumonia, you should contact your doctor or your transplant team. The condition will need to be treated with antibiotics.

To help prevent infection, you may also be given antibiotics to take for the first few weeks after your transplant.

Read more about treating pneumonia.

Fungal infections

Fungal infections are not as common as bacterial infections, but they can also sometimes develop in the first few weeks after having a transplant.

Less serious fungal infections can develop in the skin, nails, mouth, feet and vagina.

The symptoms of these types of fungal infection will depend on what part of your body is affected, although shared symptoms include:

  • scaling and redness of the skin
  • itchiness
  • a discharge of a thick white fluid from the vagina (in cases of vaginal infection)

More serious fungal infections can develop inside the body (invasive fungal infections), such as in the lungs (fungal pneumonia) or in the bloodstream.

Symptoms of an invasive fungal infection include:

  • a high temperature (fever) of 38°C (100.4°F) or above
  • shortness of breath
  • dizziness
  • chest pain
  • a change in mental behaviour, such as confusion or disorientation

You should contact your transplant centre as soon as possible if you think that you may have an invasive fungal infection.

Non-invasive fungal infections can be treated using antifungal creams and tablets. Invasive fungal infections may require admission to hospital and treatment with injections of antifungal medication (intravenous antifungals).

As a precaution against fungal infections, you may be given a course of antifungal medication to take for several months after your transplant.

Cytomegalovirus infection

Cytomegalovirus (CMV) infections are less common because of the introduction of antiviral treatment. It usually occurs after stopping this treatment between 6-12 months after the transplant.

Symptoms of a CMV infection include:

  • a high temperature (fever) of 38°C (100.4°F) or above
  • shortness of breath
  • the appearance of large, painful ulcers in your mouth
  • visual disturbances, such as blind spots, blurring and floaters (tiny black or shadowy dots or lines that appear to be floating in your field of vision)

If you think that you have a CMV infection, you should contact your transplant centre as soon as possible.

CMV infections can be treated with antiviral medication.

As a precaution against CMV, you may be given a course of antiviral medication to take for several months after your transplant.

Read more about treating cytomegalovirus infections.

Preventing long-term infection

After having a heart-lung transplant, it is likely you will need to take immunosuppressants for the rest of your life because you will be more vulnerable to infection. This means you will have to take extra precautions, including:

  • avoiding crowds (if this is unavoidable you should wear a face mask, particularly during the first year after your transplant)
  • avoiding close contact with anyone who is known to have an infection
  • avoiding anything that could damage your lungs and make them more vulnerable to infection, such as smoke, chemical sprays or chemical fumes
  • keeping your house very clean to prevent the spread of infection

Who can use it

The total number of available donor hearts and lungs is very small, so the assessment process used to decide who can have a heart-lung transplant is much stricter than for most medical treatments.

In addition, the operation places a major strain on the body, which means that in many cases the risks associated with transplantation may outweigh the potential benefits.

A person is therefore usually only considered to be a suitable candidate for having a heart-lung transplant if they are in relatively good health and have no other serious medical problems.

When a heart-lung transplant is not suitable

You will usually be considered unsuitable for having a heart-lung transplant if you:

  • are over 55 years of age and have another serious health condition, such as type 2 diabetes
  • have blood poisoning (sepsis)
  • have active cancer
  • are currently misusing alcohol or drugs
  • are currently smoking
  • have a long-term mental health condition, such as schizophrenia (an inability to tell the difference between reality and imagination), which means it is highly unlikely you will be able to comply with the treatment needed during the recovery period

In addition, you will usually not be offered a heart-lung transplant if you have any of the conditions listed below (although occasionally exceptions are made in special circumstances):

  • HIV and AIDS – the medications you need to take after donation will lower your immunity, which could be extremely dangerous if you have HIV or AIDS
  • hepatitis B and hepatitis C (two blood-borne viruses that can damage the liver)
  • obesity – being very overweight with a body mass index (BMI) of 30 or above
  • severe diabetes that has damaged your organs
  • osteoporosis (brittle bones) – many of the medications used during the recovery period can weaken your bones
  • any other long-term condition that results in poor survival
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