Heart-lung transplant for Pulmonary Hypertension

Overview
Heart-lung transplant may be an option for some people with end-stage heart and lung disease due to pulmonary hypertension (PH). However, heart-lung transplant also poses significant risk for serious complications. Heart-lung transplant is an extremely rare surgery. Most transplant surgeries for PH are lung transplants only.

In any type of transplantation, the donor must be a good genetic match to avoid organ rejection. Travel distance between the donor and recipient is also an important factor.

There are extensive criteria for becoming a candidate for heart-lung transplant in addition to the severity of your disease. Most heart-lung transplant candidates have experienced decline in their conditions despite closely following a medical regimen, participating in pulmonary rehabilitation, and undergoing other surgical interventions. Ideal candidates are under 65 years of age, in good cardiovascular and general health, have a healthy weight, and do not smoke or have a drug or alcohol addiction. Candidates must be mentally stable and committed to working toward recovery after the transplant. Preference is given to those with family members and community who will help support them during recovery.

What does it involve?
In order to evaluate your candidacy, your doctor will perform several exams such as breathing tests, blood tests, heart function tests, cancer screenings, and imaging scans. Your psychological status may also be evaluated. Do not be afraid to ask questions about any aspect of the surgery or recovery.

Once you are approved as a candidate for heart-lung transplant, you may be enrolled in a comprehensive preoperative pulmonary rehabilitation program to prepare you for the surgery, speed your recovery and avoid complications. While you are on the waiting list, follow the diet plan, exercise recommendations, and drug regimen give to you by your transplant team. Do not smoke, and limit your consumption of alcoholic beverages to one or two per day. Being in top condition for surgery will make recovery easier. Remember, you never know when organs may become available.

When the transplant team notifies you that a heart and lungs have become available, you will be given instructions to stop eating a few hours before surgery. When you arrive at the hospital, vital signs will be taken, blood will be drawn for testing, and other tests may be performed on your heart and lungs. Be sure to let your transplant team know every type of medicine and supplement you have been taking, even over-the-counter medications. Also tell them if you have been drinking alcohol. When it is time for the surgery, you will receive an intravenous (IV) line and anesthetic medication to make you sleep.

The surgeon will make an incision down the sternum (breastbone) and spread the chest apart with rib spreaders. During the surgery, you will be ventilated via cardiopulmonary bypass – a machine that breathes and pumps your blood for you.

When the donor heart and lungs arrive and are deemed healthy, your diseased heart and lungs will be removed. The new organs will be attached to your body via the airways and blood vessels. Once the new organs are attached, blood flow will be restored. Finally, the surgeon will close the chest and incisions.

When you wake up after surgery, you will likely be attached to several tubes. You may have one or more tubes in your chest to drain fluids as you heal. You will have a breathing tube, an IV for fluids and medicines, and possibly an epidural in your spine to deliver pain medication. You will have a catheter to drain your bladder. The breathing tube may be removed when you awaken, but the other tubes will likely remain in place for one or more days as you recover. You should be able to get out of bed and walk after four or five days. You can expect to spend one to three weeks in the hospital recovering from heart-lung transplant surgery. The first few days of your stay may be spent in the intensive care unit.

A nurse or doctor will explain how to care for your wound or wounds before you leave the hospital. It may take as long as six months to recover fully from heart-lung transplant surgery. The transplant team may ask you to remain close to the hospital for three months after surgery for frequent checkups. You can expect to continue regular checkups with blood tests and x-rays for the rest of your life in order to monitor your condition.

Intended Outcomes
In the right candidate, a heart-lung transplant can prolong life and improve breathing, lung function, and quality of life.

Results
The survival rate for heart-lung transplant recipients is 71 percent at three months, 63 percent at one year, and 44 percent at five years, and 31 percent at 10 years.

Constraints
Wait time for a lung transplant is often two to three years. It is even more challenging to find a suitable donor with both heart and lungs, so the wait for a heart-lung transplant can be even longer.

Any surgery carries risks including blood clots, blood loss, infection, breathing problems, reactions to medication, and heart attack or stroke during the surgery.

Possible complications of lung transplant surgery include rejection, diabetes, high blood pressure, and bronchiolitis obliterans syndrome (BOS). BOS, which damages and destroys the small airways in the lung, occurs in 50 percent of lung transplants within five years of surgery, and can be fatal. BOS is also known as chronic rejection.

Apart from rejection, possible complications of heart transplant surgery include hardening of the coronary arteries leading to a condition called cardiac allograft vasculopathy (CAV). CAV can cause heart attacks, heart failure, arrhythmias, or sudden cardiac death.

You will need to take immunosuppressants for the rest of your life to prevent your body from rejecting the lung transplant. This medication also causes many side effects including suppression of the immune system, raising your risk for developing cancer and contracting serious infections.

Heart-lung transplant surgery can be painful, and you will most likely need pain medication for some weeks during recovery. Conversely, some nerves may be cut during surgery, causing loss of sensation.

Call your doctor immediately if you notice signs of infection such as swelling, redness, increased pain, or bleeding from the surgical wound.

For more details about this treatment, visit:

Heart-lung transplantation: adult indications and outcomes – Journal of Thoracic Disease
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC41...

What to Know About Pulmonary Hypertension and Lung Transplants – Pulmonary Hypertension News
https://pulmonaryhypertensionnews.com/2017/05/2...

Heart-lung transplantation – UpToDate
http://www.uptodate.com/contents/heart-lung-tra...

Lung Transplantation in Patients with Pulmonary Hypertension – Pulmonary Hypertension Association Online University
http://www.phaonlineuniv.org/DiagnosisTreatment...

Heart transplant - Risks – Mayo Clinic
http://www.mayoclinic.org/tests-procedures/hear...