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The first step to a heart transplant is being added to the list of people waiting for an organ donor. As part of this process, patients undergo a complete evaluation and maintain routine office visits with their physician. The patient and physician must keep the United Network for Organ Sharing (UNOS) aware of any changes that may affect the patient’s transplant status. Preliminary tests will include:
- Blood tests. Tests that determine the amount of any given substance in the blood and identify abnormally high or low levels that may affect normal body functions.
- Chest x-ray. An image of the chest on film or fluorescent screens. It is produced by using low doses of radiation and shows the general size, shape and structure of the heart and lungs.
- Electrocardiogram (EKG). A recording of the heart's electrical activity as a graph on a moving strip of paper or video monitor. The highly sensitive electrocardiograph machine helps detect heart irregularities, disease and damage by measuring the heart's rhythms and electrical impulses.
- Cardiac catheterization. A minimally invasive test that offers clear, accurate information about the heart chambers, the coronary arteries located on the surface of the heart and (depending on whether another test is done) the aorta.
- Echocardiogram. This ultrasound technique allows comprehensive evaluation of the structure and function of the heart muscle and valves. Patients who are candidates for heart transplantation usually have severely depressed pumping function. The technique can also detect some reversible causes of heart failure such as valvular heart disease that can be surgically corrected.
- Noninvasive evaluation of myocardial viability. Coronary artery disease is the underlying source of heart dysfunction in the majority of patients who require heart transplantation. Coronary artery disease impairs heart function by inducing scarring of the heart tissues due to shortage of oxygen-rich blood in the heart muscles. However, in some patients heart dysfunction may be reversible in the presence of viable tissues. Techniques such as dobutamine stress echocardiography and positron emission tomography (PET) can differentiate a scar from viable tissue. These tests can identify patients who may benefit from the restoration of blood supply to the heart through coronary artery bypass or angioplasty (revascularization procedures). Patients with mostly scar tissues are considered for transplant whereas those who may improve with revascularization may not require transplantation.
Other tests may be conducted depending on the conditions or symptoms present, and tests may be repeated periodically. Patients who have life-threatening illnesses unrelated to the heart (e.g., kidney failure, liver failure) are generally not candidates for a heart transplant.
The waiting period during which a patient is registered and awaiting delivery of a heart may be the most difficult part of the transplant process. The median wait time for a new heart is currently more than 200 days and is dependent on factors such as blood type, weight and health status.
Support groups and therapy are available to help people cope with the process. Most heart transplant teams have a social worker and/or a mental health professional available to help patients work through the emotional, medical and lifestyle changes that will likely accompany the procedure. In the meantime, the physician will continue medical therapies that can provide short-term relief of the heart condition.
In some cases, a ventricular assist device (VAD) or left ventricular assist device (LVAD) may be used to as a "bridge to transplant." A VAD helps one of the lower chambers of the heart (the ventricles) pump blood. The device may also be used after the transplant while the patient recovers from surgery. Some researchers hope that either the ventricular assist device or the total artificial heart will one day be used as a permanent solution to the problem of severe heart disease.
Heart transplant teams will do everything they can to help, but patients have the responsibility to make lifestyle changes that improve their situation in the short-term, including:
- Quitting smoking. Many heart conditions are caused or aggravated by smoking. To prepare for a heart transplant, the use of all tobacco products must be stopped at least six months before the procedure. Use of such products not only continues a health risk for those awaiting a heart, it also endangers any chance of receiving a donated organ. Traces of tobacco products during random testing by the physician can lead to removal of a patient from the transplant registry.
- Avoiding the use of alcohol and other controlled substances. These are forbidden for people who are on the waiting list. If an organ suddenly becomes available, these substances cannot be present in the patient’s system. This is because many of the drugs taken after the transplant are broken down (metabolized) in the liver. It is therefore important that the liver not be involved in metabolizing other substances, such as alcohol. Alcohol is not only broken down in the liver, but can cause liver damage. As a result, potential benefits of medications will be lost.
- Eating a heart-healthy diet. It is important to adopt healthy dietary habits as soon as possible that will remain with the patient after a new heart has been received. For example, too much sodium in the diet can cause fluid buildup in the body, which, in turn, can make the heart work harder. Fluid retention can also be caused by medication. Transplant patients should also be aware that some of their medications can increase the appetite and raise glucose (blood sugar) levels. Just as excess fluid strains the heart, so does being overweight. Nutritionists typically are part of the transplant team, and will work with patients regarding a proper balance of foods as well as what foods to limit or avoid.
- Getting regular exercise, under the direction of one’s physician. The patient needs to maintain strength for the surgery or will be removed from the waiting list.
- Controlling diabetes and high blood pressure (hypertension). These conditions must be under control to reduce the risk of serious complications during surgery.
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