Introduction
 


Heart-lung transplant



 

A heart-lung transplant is a major and rarely performed surgical procedure where a person's diseased heart and lungs are replaced with those of a recently deceased donor.

On average, only six heart-lung transplants are performed in the UK each year.

This is because there are very few suitable donor organs available and priority is generally given to people who only need a heart transplant.

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 when all other treatment options have failed.

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



congenital heart disease – birth defects of the heart that impact the lungs



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.

Who can have one?

The total number of available donor hearts and lungs is very small and the transplant operation places a major strain on the body. This means a heart-lung transplant will only be recommended after very careful consideration and an in-depth assessment of your physical and mental health.

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

For example, a heart-lung transplant may not be recommended if you are elderly, have cancer, misuse alcohol or drugs, smoke, are obese, or have a long-term mental health condition.

Specific criteria for people requiring a heart-lung transplant are currently being developed. For now, recommendations are made after consultation with a panel of transplant experts and members of your transplant team.

The heart-lung transplant process

If it's thought you might benefit from a heart-lung transplant, you'll be asked to have an assessment in hospital to check whether you are a suitable candidate for the procedure.

This will involve a number of tests, which may include blood tests, urine tests, blood pressure tests, lung and heart function tests, X-rays and scans.

If a heart-lung transplant is recommended after your assessment, you'll go on the transplant list to wait until suitable donor organs become available. The length of time spent on the waiting list can vary, but it can be several months or even years.

When a set of donor heart and lungs becomes available, you'll be admitted to hospital for the operation, which usually takes several hours to complete. Most people need to stay in hospital for around three weeks after the procedure.

What are the risks?

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

This is why the procedure is usually only carried out when all other treatment options have been exhausted and it's thought the potential benefits will outweigh the risks.

The main risk after a heart-lung transplant is your immune system recognising the donated organs as not belonging to you and attacking them, which can stop the organs working properly.

This can often be avoided by taking medication to suppress your immune system. However, these medications themselves can cause side effects, such as high blood pressure and increased vulnerability to infections.

Results

The outcomes of heart-lung transplants have improved significantly since the operation was first carried out in the early 1980s, mainly because of the introduction of immunosuppressant medication.

In the UK, around 85% of people who have a heart-lung transplant are still alive after one year. For those who survive to one year, the outlook is generally quite good, with most people surviving for at least 10 years and some people potentially living for 25 years or more.

However, it's 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, such as your age.

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

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 GP may be able to refer you to a counsellor and provide you with information and advice about joining a support group in your area.

There are a number of support groups, charities and other organisations that offer support and advice. These include:



British Heart Foundation – a charity for people affected by heart disease



British Lung Foundation – a charity for people affected by lung disease 



Children's Heart Foundation – a charity for people affected by congenital heart disease  



Little Hearts Matter – a charity that supports children with serious heart defects




Because of the limited availability of suitable organs, there is a need for members of the public to join Organ Donor Register.

You can join the Organ Donor Register by completing a simple online form or calling  Donor Line on 0300 123 23 23.

What happens before and during a heart-lung transplant 

If a heart-lung transplant is thought to be a potential treatment for you, you'll be asked to have an assessment before potentially being placed on the transplant waiting list.

The purpose of the assessment is to check whether you're a suitable candidate for a heart-lung transplant.

Assessment

An in-depth assessment will be carried out at your nearest transplant centre to build up a detailed picture of your current state of health. This will also check whether there are any underlying problems that could affect your suitability for having a transplant.

You'll also have the chance to hear details about the transplant. Before visiting the transplant centre, you may find it useful to write a list of questions you would like to ask the transplant team.

Tests

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



blood tests and urine tests to check for infections and assess the health of your organs, such as your liver



chest X-rays



blood pressure tests



tests to find out how well your heart and lungs work, such as measuring how much air you can exhale and the level 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



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

Making the decision

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

After your assessment is complete, 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



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

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

Waiting for a suitable donor

It's 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 become available. The waiting times for a heart-lung transplant are often very long and your condition could deteriorate while you wait.

While you're on the waiting list, you'll be seen regularly to monitor your condition. Your transplant centre will be able to offer any support, guidance and information you need while you're waiting for a suitable donor to be found. They're 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

When 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 so you're asleep while the procedure is carried out.

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 (incision) 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 transplant procedure usually takes several hours to complete.

Recovering from a heart-lung transplant 

Following a heart-lung transplant, you'll probably need to stay in a hospital intensive care unit (ICU) for a few days.

This is because:



you'll need to be carefully monitored to make sure the organs are working



there's a risk your body may suddenly reject the new organs, which would require emergency treatment



you'll require assistance with breathing and feeding until you begin to recover



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

You'll usually be transferred to a general ward after a few days, where your health will be monitored as you recover. Most people are well enough to leave hospital after a few weeks.

The recovery process

Recovering fully from a transplant can be a long and frustrating process. You may be referred to a physiotherapist or another 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 several months before you are well enough to gradually start to return to your normal daily activities.

During your recovery period, you will need frequent hospital visits and some admissions. You may need several check-ups a week during the first few weeks, but 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, your immune system will try to attack them. This is known as rejection. This leads to injury of the transplanted organs, which – if not prevented – can cause organ failure. To prevent this, you will need to take immunosuppressant medication for the rest of your life.

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



high blood pressure



diabetes



high cholesterol



kidney problems



increased vulnerability to infection



increased risk of certain types of cancer



weakened bones (osteoporosis)



nausea and vomiting



stomach ulcers



blurred vision



insomnia



weight gain



mood swings



shaking of the hands



acne



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 while taking immunosuppressants.

Risks of a heart-lung transplant 

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

There is also a chance your new heart and lungs won't work properly, or you could develop serious infections because your immunosuppressant medication will weaken your immune system.

Rejection

Rejection can occur soon after transplant surgery, or several months or years later.

It doesn't always cause any obvious symptoms, but possible symptoms can include:



fatigue (extreme tiredness)



swelling of your arms and legs



weight gain



a high temperature (fever) of 38C (100.4F) or above



heart palpitations (heartbeats that become more noticeable)



shortness of breath



coughing and wheezing



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

Bronchiolitis obliterans syndrome

Bronchiolitis obliterans syndrome (BOS) is a relatively common form of lung rejection that can occur in the years after a heart-lung transplant. In BOS, the immune system causes the airways inside the lungs to become inflamed, which blocks the flow of oxygen through the lungs.

Symptoms include:



shortness of breath



dry cough



wheezing



It may be treated by giving you additional immunosuppressant medication.

Narrowing of the heart arteries

Although generally uncommon after a heart-lung transplant, sometimes the blood vessels connected to the donor heart can become narrowed and hardened. This is known as cardiac allograft vasculopathy or coronary artery vasculopathy (CAV).

CAV is potentially serious as it can restrict the supply of blood to the heart, which can sometimes trigger a heart attack or lead to heart failure. Because of this risk, you may have regular check-ups after your transplant to check whether your heart is receiving enough blood.

Treatment options for CAV include statins and calcium channel blockers (medication to help widen blood vessels).

Infections

Immunosuppressant medication will weaken your immune system and make you more vulnerable to infection, including bacterial, fungal andcytomegalovirus (CMV) infections.

Signs of a possible infection can include:



a high temperature (fever) of 38C (100.4F) or above



shortness of breath, wheezing or breathing difficulties



generally feeling unwell



sweating and shivering



loss of appetite



diarrhoea



chest pain



coughing up thick mucus that may be yellow, green, brown or bloodstained



a rapid heartbeat



dizziness



a change in mental behaviour, such as confusion or disorientation



If you think you may have an infection, contact your GP or transplant team. Depending on the type of infection you have, you may need treatment with antibiotics, antifungals or antivirals.

Preventing infections

As a precaution, you may be given antibiotic, antifungal or antiviral medication for a few months after your transplant to protect you from serious infections.

You should also do what you can to reduce your risk of picking up an infection, particularly in the early stages of recovery. You should try to:



avoid crowds



avoid close contact with anyone you know who has an infection



avoid anything that could damage your lungs and make them more vulnerable to infection, such as smoke, chemical sprays or chemical fumes



practise good personal hygiene and ensure your house is kept clean