Heart Transplant

APPLICATION OF HEART TRANSPLANTATION AND ARTIFICIAL HEART SUPPORT DEVICES

Heart transplantation and the use of artificial heart support devices involve a team-based organization where specialists from various disciplines work together.

Heart Failure

The heart is a vital organ that ensures blood circulation in the body. Oxygen-poor blood returning from the body is pumped to the lungs by the right ventricle of the heart. Once oxygenated in the lungs, the blood returns to the left ventricle and is then pumped throughout the body. Heart failure occurs when one or both ventricles of the heart are unable to function properly. It is a progressive condition, and over time the heart’s strength diminishes, eventually becoming unable to pump enough blood to meet the body’s needs. This results in tissues and cells struggling to receive the necessary oxygen and nutrients.

In developed countries, heart failure is among the leading causes of death. Each year, 10% of heart failure patients progress to end-stage heart failure. Half of these patients in the terminal phase die within a year. It is estimated that there are around 800,000 heart failure patients in Turkey, of which 3,000 are in the end-stage phase. In 2010, the number of heart transplants per million people was 1.1 in Turkey, compared to 5.2 in Spain, 4.8 in Germany, and 2.0 in the UK. While the global need for heart transplants has doubled in the last decade, the number of donors has not increased proportionally, resulting in longer waiting lists for heart transplants. More than half of patients with end-stage heart failure die within one year of diagnosis.

Diseases Leading to Heart Failure

  • Coronary Artery Disease: The most common heart disease. Narrowing or blockage of coronary arteries reduces oxygen and nutrient delivery to the heart muscle, causing damage or infarction, and decreasing the heart’s pumping ability.
  • Complex Heart Valve Diseases: Congenital or acquired disorders of the aortic and mitral valves increase the heart’s workload, causing it to enlarge and eventually fail.
  • Cardiomyopathy: A heart muscle disease that can cause heart failure. The heart muscle enlarges and loses its contractile ability, failing to pump blood effectively. This leads to fluid buildup in the lungs, liver, abdomen, and legs, damaging other organs over time.

Causes of Cardiomyopathy:

    1. Dilated cardiomyopathy (may result from):
      • Viral infections
      • Postpartum period
      • Chronic alcoholism
      • Drug use
      • Unknown reasons
    2. Ischemic cardiomyopathy due to coronary artery disease or post-infarction damage.
    3. Congenital cardiomyopathy present from birth.
    4. Stiffened and thick-walled cardiomyopathies:
      • Hypertrophic
      • Restrictive
  • Myocarditis: A viral infection of the heart muscle that reduces its contractile strength. It can resolve completely or lead to permanent heart failure.

“The most effective treatments for heart failure are heart transplantation and artificial heart support devices.”

HEART TRANSPLANTATION

Heart transplantation is the surgical replacement of a failing heart with a healthy donor heart. Donor hearts are retrieved from individuals declared brain-dead who have consented to organ donation, and are transplanted into recipients selected for heart transplant programs.

Heart Transplantation Team:

  • Coordinator: Facilitates communication between the patient, family, and transplant team.
  • Infectious Disease Specialist: Prevents and treats infections.
  • Pathologist: Evaluates biopsies to detect rejection.
  • Cardiothoracic Surgeon: Evaluates and performs the surgery.
  • Cardiologist: Assesses heart and other conditions pre- and post-transplant.
  • Nurse: Assists in treatment and patient care.
  • Physiotherapist: Provides lung and muscle exercises.
  • Dietitian: Advises on ideal weight and dietary restrictions.

Patient Selection Criteria:

  • End-stage heart failure unresponsive to medication, with no other treatment options.
  • Contraindications include:
    • Pulmonary hypertension
    • Cancer
    • Irreversible liver, kidney, or lung dysfunction
    • Active infections
    • Age above 65–70
    • Severe diabetes with vascular damage
    • Advanced cerebrovascular disease
    • Extreme obesity or underweight
    • Substance abuse
    • Severe neurological impairment

ARTIFICIAL HEART SUPPORT DEVICES

These are high-tech devices that assist or take over the pumping function of the failing heart. Some are used temporarily until recovery or transplantation, while others are permanent. As technology advances, both device and patient longevity increase, with fewer complications and better outcomes.

  • 1st-generation devices: ~50% 1-year survival.
  • 2nd-generation: 68–86%.
  • 3rd-generation: 85–91%.

Used For:

  1. Bridge to Decision: Temporarily supporting life while assessing long-term options.
  2. Bridge to Recovery: In acute cases like myocarditis.
  3. Bridge to Transplant: For patients deteriorating while waiting for a donor.
  4. Destination Therapy: Permanent solution for non-transplant candidates.

Surgery:

  • Devices can be implantable (miniaturized) or paracorporeal (external).
  • Surgery typically lasts 4–6 hours.
  • Post-op, patients stay in ICU and are later discharged with anticoagulant medication and regular check-ups.

Short-term devices: Abiomed BVS 5000, Levitronix CentriMag, TandemHeart, Impella, ECMO
Long-term devices: Heartware, Heartmate II, Berlin Heart, Micromed DeBakey
Total Artificial Heart: Cardiowest TAH

TOTAL ARTIFICIAL HEART

This replaces the diseased heart entirely and temporarily sustains life until a transplant is available.

ENROLLMENT IN HEART TRANSPLANTATION AND ARTIFICIAL HEART DEVICE PROGRAMS

When a cardiologist determines the need for transplantation, they refer the patient to a multidisciplinary transplant council. If approved, the patient is added to the waiting list.

WAITING PERIOD

Patients with stable conditions stay at home with regular follow-ups. Severely ill patients are hospitalized. If a patient’s condition worsens, a support device may be implanted while awaiting a donor.

Patients must be physically and mentally prepared at all times. Medication adherence, infection prevention, and regular check-ups are vital. Since transplants cannot be scheduled, patients must be reachable 24/7 and ready to travel to the hospital immediately.

DONOR SHORTAGE

Donor shortages, as in many countries, are a major issue. The increasing gap between transplant candidates and available organs limits transplant feasibility. In Turkey, the number of people on the waiting list grows by 10% annually, with 7% dying while waiting.

PATIENTS SUPPORTED BY ARTIFICIAL DEVICES

Organs of deceased donors continue to function for a limited time. After death is confirmed by specialists, consent from next of kin is sought. Approved donors are registered with the national organ transplant coordination center and matched with recipients.

Once matched, the patient is called to the hospital for immediate preparation and transplant. The surgery lasts 5–6 hours. Post-op recovery in ICU is followed by a hospital stay of 15–30 days. Before discharge, biopsies are performed to assess rejection risk.

Heart transplant and artificial heart support programs are conducted in certified and regulated centers. All procedures and care are covered by SGK (Social Security Institution) for eligible patients in Turkey.