When diseases of the heart weaken the heart muscles and prevent the heart from pumping out blood to other organs in the body, and other medical and/ or surgical treatments fail, then patients are considered to be in end-stage heart failure and need a transplant.
Lung transplantation or pulmonary transplantation is a surgical procedure in which a patient’s diseased lungs are partially or totally replaced by lungs which come from a donor. Donor lungs can be retrieved from a living donor or a deceased donor. A living donor can only donate one lung lobe. With some lung diseases a recipient may only need to receive a single lung. With other lung diseases such as cystic fibrosis it is imperative that a recipient receive two lungs. While lung transplants carry certain associated risks, they can also extend life expectancy and enhance the quality of life for end-stage pulmonary patients.
Heart & Lung Transplant
Heart & Lung transplantation is the simultaneous surgical replacement of the heart and lungs in patients with end-stage cardiac and pulmonary disease. This procedure remains a viable therapeutic alternative for patients in specific disease states, though the frequency of application has substantially diminished in recent years.
Heart transplant is performed on patients with end-stage heart (cardiac) disease. This is usually due to the following reasons:
Usually lung transplants are performed for
Patients having end stage heart and lung diseases are given combined heart and lung transplants.
Symptoms of Heart failure
Most important symptoms of heart failure to watch out for are:
Other symptoms can be:
Symptoms of Lung Disease
Pre-operative work-up is extremely important for proper treatment and recovery.
Pre-operative support measures
Clinical condition is maintained optimally with the following:
In patients with severe cardiac failure, the following support can be used while waiting for a transplant:
A median sternotomy incision (the rib cage is split down the sternum) is made for initial inspection of the heart and lungs. Cardiopulmonary bypass is used.
The heart and lungs are removed, with care taken to preserve the phrenic nerves and to address the bronchial artery circulation so as to prevent postoperative bleeding complications.
Next, the new heart and lungs are inserted. The tracheal anastomosis is performed first. The right atrial anastomosis is performed next, followed by the aortic anastomosis. Care is taken to keep the donor trachea as short as possible because of the limited vascularity of the area.
Cardiac rejection is monitored by serial endomyocardial biopsies. Lung rejection is monitored by radiographic changes in the lung fields, and examination of the cellular content of the Broncho alveolar lavage fluid.
Even if there is a suspicion of rejection, anti rejection treatment with steroid pulses (methylprednisolone 500-1000 mg/day for 3-5 days), monoclonal antibody treatment, or polyclonal antibody therapy is instituted.
This is a transient and reversible deterioration in compliance, gas exchange, and pulmonary vascular resistance that occurs immediately after the operation and can last for a week. This is attributed to lymphatic disruption, ischemia-reperfusion injury, denervation, surgical trauma, fluid overload, and inadequate preservation.
Cytomegalovirus (CMV) infection – This may be a reactivation of recipient disease caused by the immunosuppression or a de novo infection arising from donor tissue, transfused blood, or other sources. The process proceeds rapidly to respiratory failure and death if aggressive treatment is not initiated. For prophylaxis, patients are generally started on ganciclovir 5 mg/kg/day; for treatment, the same drug and dosage are used.
Other viral, fungal, and bacterial infections can occur, depending on exposure and diagnosis and treatment should be immediate.
Early mobilization of the patient and aggressive chest physiotherapy and treatment can help prevent this complication. Bacteriologic culture of the donor and recipient trachea may demonstrate potential pathogens and guide appropriate prophylaxis. Diagnosis is confirmed by taking a careful history of the patient’s exposure and by obtaining a Broncho alveolar lavage specimen for culture.
Allograft vascular disease and bronchiolitis obliterans
A concentric myointimal hyperplasia develops in the coronary arteries, and squamous metaplasia and fibrous replacement of the bronchioles in the lungs and is the main causes of late graft failure and death.
Retransplantation is the only treatment.
Patient Education and Consent
A careful medical and psychosocial evaluation of the candidate is mandatory and the family is also involved in this process.
A written contract is negotiated between the transplant center and the patient, with the stipulation that noncompliance with the guidelines is grounds for removal from the program. Both patient and treating doctor must agree to these stipulations.
Patients are instructed to monitor temperature, blood pressure, and pulse oximetry after the procedure and to be alert for symptoms of rejection (which are carefully discussed with the treating doctor). At the first sign of an alteration in their usual state of health, they are to call the transplant centre. Patients are educated in detail about the immunosuppressive medications, their actions, and adverse effects.
Because heart-lung transplant patients are at risk for infection caused by their immunosuppressed state, patients should avoid being in crowds, and wear a mask, and avoid chemical sprays, noxious conditions, fires, and smoke.
Dietary discipline and modifications, viz low-sodium, low cholesterol diet, are taught to balance the adverse effects of immunosuppressant drugs.
Routine graded exercise is encouraged to maintain muscle tone.
Post surgery rehabilitation is instituted early to assist the patient in regaining normal functional status and good general health.
Monitoring and Follow-up
Care at home
Both the patient and the family should work together to ensure that post operative rehabilitation is successful.
A triple therapy of anti rejection drugs is used – Tacrolimus, Steroids and Azathioprine.
Doctors will undertake a thorough physical examination followed by detailed diagnostic tests. Imagining tests such as an MRI, CT Scan are also undertaken. A cardio pulmonary assessment is done to understand working of the heart & lungs.
Yes, a heart lung transplant surgery reduces the patient’s immunity as doctors will prescribe a lifetime of immunosuppressants to ensure that the body does not reject the donor organs. This makes the patient susceptible to several infections.
The patient will require regular doctor check-ups, diagnostic evaluations, physical assessments to ascertain the recovery & rehabilitation following a transplant. Post-transplant care is equally important for a successful outcome of the surgery.
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