Surgery

I have been diagnosed as having heart failure. Will I be able to have a heart transplant?

If your heart muscle is very weak and your activity remains very limited in spite of optimal medical treatment, transplantation is the best option available to give you a better quality and length of life. You must be aged less than 60 years and you will need to be mentally strong and have support and help available. Some people will not be suitable because of other serious illnesses or problems.

What does a heart transplant involve?

If you have been placed on a waiting list, you must be available within 2-3 hours of being called because the donor heart can only be transplanted within 6 hours of the death of the donor. You will usually be given a beeper or mobile phone. The donor heart should be of the same blood group and match yours, as well as matching your immune system. The race and sex of the donor and recipient do not matter but the size of the heart should be similar to yours, although it does not need to be exactly the same.

The operation is performed on the bypass machine. The diseased heart is removed by separating it from all the vessels connected to it but the back walls of the right and left atria are left in place. The new heart is then stitched onto the vessels and the atria, and the bypass is discontinued to allow the new heart to take over (see Figure 5.2).

After the transplant, which is a straightforward procedure, you will stay in hospital for 2-3 weeks whilst drugs are used to suppress rejection of the new heart. Biopsies via a small catheter are taken from the heart to look for signs of rejection. This is a simple, painless procedure performed under a local anaesthetic and uses a vein in the neck. You will remain on drugs always to keep rejection at bay, and you need to watch your lifestyle carefully: hardening of the arteries in the new heart is a particular problem and is checked for at regular

Figure 5.2 Heart transplant operation. (a) Heart being removed, with cuts at A, B and C; (b) no heart in place; (c) new heart stitched on.

intervals by your transplant doctor. A transplant that is successful will transform your life. After 1 year, 8 out of 10 patients will still be alive, and 6 out of 10 will live beyond 5 years.

I've heard about an operation to reduce the size of the heart by cutting out a piece of heart muscle. It is claimed to help heart failure. Should I consider this before a transplant?

This is a debated operation. In many of the cases, a new mitral valve is also put in, so that it is difficult to sort out which part of the operation has been successful. It must remain a part of a careful evaluation programme before it is widely used. We need to know the risk of death at the time of the operation and if the operation works - for how long and what evidence there is for improved quality of life. It is still in its early phase of evaluation when caution should replace over-enthusiasm.

My doctor has mentioned cardiomyoplasty but was not very enthusiastic about it. What is this operation?

This was an idea for surgery for the failing heart. A large muscle taken from a patient's back was loosened and then wrapped around the heart. A pacemaker was used to stimulate the muscle to squeeze the heart and give it more power. Initial enthusiasm has been replaced with disappointment as any benefit did not last long.

Is an artificial heart another option for me?

It may be a short-term help, if the heart is severely inflamed by a virus, when it might buy time for recovery. It might also buy time for a transplant donor to be found. At present, it does not offer a long-term solution, but it acts as a bridge to definitive therapy.

Can pacemakers be used to treat heart failure?

Pacemakers are usually used if there is an electrical fault with the heart (see the section How your heart works in Chapter 1). However, a special pacing technique has been developed for heart failure, which can be used even if the electrical connections are intact. It is used in more severe cases but is not suitable for everyone. Results have been very encouraging and it is certainly a treatment to consider. It is called resynchronisation therapy.

My cardiologist has advised a defibrillator as well as a pacemaker. Why both?

It is one combined unit. The pacemaker improves the heart's efflciency and the defibrillator stops dangerous, life-threatening changes in heart rhythm by giving the heart a shock. It is recommended when heart failure is more severe or when dangerous rhythms have already occurred. It is inserted by cardiologists who specialise in electrical events affecting the heart, and regular follow-up checks are needed.