Frequently asked questions

The structure of a human heart

Human heart

A schematic representation of a human heart (front view): red painted structures are structures through which arterial (oxygenated) blood moves, blue painted - venous blood.

The human heart has four chambers separated by partition walls and valves. Blood from the top and the inferior vena cava flows into the right atrium, passes through the tricuspid valve (which consists of three petals) into the right ventricle. Then, through the pulmonary valve and the pulmonary trunk it enters the pulmonary artery, moves to the lungs where the gas exchange takes place and returns to the left atrium. Then through the mitral (two-folding) valve (which consists of two lobes) enters into the left ventricle, and then passes through the aortic valve into the aorta.

The right atrium contains vena cava, the left atrium - pulmonary vein. Pulmonary artery (pulmonary trunk) and the ascending aorta arise from the right and left ventricle respectively. The right ventricle and the left atrium close the pulmonary circulation, the left ventricle and the right atrium - a large circle. The heart is a part of the middle mediastinum, most of its front surface is covered with lungs. With flowing sections of hollow pulmonary veins, the aorta and pulmonary outgoing trunk it is covered with a shirt (bag-like membrane or pericardium). The pericardial cavity contains a small amount of serous fluid. In adults, its volume and weight is average for men - 783 cc and 332 g, for women - 560 cc and 253 g

From 7 000 to 10 000 liters of blood pass through a man's heart within 24 hours, about 3.15 million liters per year.

What happens in the case of heart failure?

Heart failure is a condition in which the heart for some reason loses its ability to provide the body with the necessary amount of blood, ie to carry out its core, pumping, function.

Unfortunately, chronic heart failure is quite common, especially among the elderly. The disease is diagnosed in 3-5% of people over 65 and one in ten over 70 years old.

Reasons

The cause of heart failure can be various heart diseases, including ischemic heart disease, cardiomyopathy, or postinfarction changes. At the same time the myocardium is unable to develop due diligence to expel blood from the left ventricle. There may also be a different situation when the myocardium is initially healthy, but there are obstacles in the path of blood ejected by the heart, such as narrowing of the large blood vessels, arterial hypertension, valvular disease, etc. In all these cases the expulsion of blood from the left ventricle is complicated, which leads to increased stress on the myocardium. To cope with the increased load, heart muscle hypertrophy (increase in volume, thickened), the heartstarts to beat faster, and for a while supportaa normal blood circulation. Then the compensatory possibilities of myocardial become depleted, which leads to irreversible changes in the replacement of muscle cells by connective tissue, which is not able to be reduced. It this very moment the clinical picture of chronic heart failure starts to develop.

Symptoms

- Shortness of breath from exersice, or (in advanced cases) at rest;

- Increased heart rate;

- Pale or bluish skin, especially in remote areas of the body from the heart (fingers, toes, lips);

- Edema (primarily - feet);

- Pain in the right upper quadrant, related to the overflows the liver veins;

- Fatigue.

In which cases the transplantation is required?

The most frequently cases for the performance of orthotopic heart transplantation is dilated cardiomyopathy (55%) and coronary heart disease (42%). Only in 3% of the cases, the indications for the surgery are evident in rheumatic heart disease and other diseases.

The indications for the heart transplant are the following:

• congestive heart failure NYHA ClassIII - IV,

• resistant to drug therapy.

• left ventricular ejection fraction is less than 25%

• of course - diastolic pressure in the left ventricle - 20 mm. Hg

Heart transplant is the only chance of survival for people with end-stage heart failure. It is a painful condition in which the disruption of all systems and organs in the body occurs, as the heart, increased in volume, cannot cope with the load.

Can there be complications after a heart transplant?

• After the surgery there can be complications and you should be aware of the likelihood of the possible risk, which is as follows:
• after a heart transplantation acute or chronic transplant rejection may develop
• there is an increased risk of developing a variety of infectious diseases
• development of steroid diabetes
• occurrence of acute ulcers in the stomach
• increased risk of developing tumors
• bone disease
• overweight
• coronary artery disease

What examination should I undergo and where?

Before you get the necessary consultation from your doctor, you must pass a preliminary examination in the place of residence.

Typical tests include:

• General blood analysis. General urine analysis

• Biochemical blood assay: the study of electrolyte metabolism, the concentration of urea, creatinine, bilirubin, protein, sugar, ALT, AST blood HDL and low density, triglycerides.

• deployed coagulogram

• HBS - antigen, RW blood for antibodies to HIV

• Determination of antibodies to cytomegalovirus, Herpes simplex, Herpes zoster

• X-ray of the chest

• electrocardiography (ECG), Echo - cardiography

• gastroscopy

• ultrasound of the kidneys, adrenal glands, pancreas, liver, gall bladder

• gynecological examination (for women).

• dental exam

• otolaryngologist

If you are admitted to the transplant center, you will be assigned to the full range of necessary studies prior to the surgery.

What is a "waiting list" and how it is made?

The "waiting list" is a list of patients that are in need of organ transplants. It is made of patients who have no contraindications to transplantation. In the "waiting list" survey many of the indications of a patient are specified, the main of which are the tissue typing of HLA system (human leukocyte antigens, antigens of class I, antigens class II, minor (non-principal) histocompatibility antigens). It is the computer that selects the pair of "recipient - donor."

Will there be any other surgerical interventions prior to the heart transplantation?

Yes. You will need to undergo coronary angiography and intubation of the right heart and the pulmonary artery. This is necessary in order to detect the presence (or degree) of damage to the coronary vessels and to measure systolic blood pressure in the pulmonary artery

Are there any contraindications to heart transplantation, and which ones?

Yes, there are. Absolute contraindications are:

• persistent pulmonary hypertension

• active infection

• irreversible multiple organ pathology

• malignant neoplasms

• systemic diseases

• mental illness, alcoholism, drug addiction

Relative contraindications (reversible) are:

• diabetes

• infectious pneumonia

• gastric ulcer and duodenal ulcer

• cerebrovascular accident

• atherosclerosis of the coronary arteries.

A special role in the determination of contraindications to heart transplantation is played by preoperative assessment of pulmonary hypertension.

What is tissue typing?

Tissue typing includes blood tests that show blood proteins called antigens. A set of antigens is inherited from each parent, and is present in all cells of the body. HLA study reveals leukocytic antigens, according to which the donor for you is chosen.

Cross-match is the measuring of the level of antibodies in your blood and antigens located on the surface of the potential donor cells. A negative cross-match means that there are no antibodies to the heart that will be transplanted to you. A positive cross-match is the detection of antibodies against the potential donor heart and a greater likelihood of a crisis of rejection.

Antibodies are a protein substance produced by the reaction of an organism to foreign antigens. Such antigens can come through blood transfusion, transplantation of the heart, diseases, during which your own heart tissue becomes foreign to the body.

Blood type. Besides the histocompatibility antigens between a donor and a recipient there should be matching blood types. If a patient has the first blood group 0 (I), it is possible to transplant the donor's heart who also has the first group. If the recipient has blood group A (II), then he or she can be transplanted a heart from a donor with the first or second blood group. If the recipient has blood group B (III), he or she can be transplanted a heart from a donor with the first or the third blood group. If the recipient has blood group AB (IV), then the heart can be transplanted from a donor with any blood type.

How long will I wait for a surgery?

No guarantees can be provided in regard to the possible waiting period.

All the information about your type is entered into the computer. The waiting time for a heart transplantation can vary from several weeks to several years. A lot depends on the blood type, the presence of antibodies and immunological reactivity. But the main problem today is the shortage of donor organs. This problem is faced not only in Russia but also worldwide.

What do I need to take to the hospital?

You can take a change of clothes - tracksuit, bathrobe, pajamas, slippers, personal hygiene (shaver is required). You can take the necessary utensils: cup, spoon, plate. Expensive items, jewelry are best to leave at home. Upon hospitalization it is necessary to have an identity card.

What should I do before admission?

If you are called for a heart transplant, you must not consume any food and water. Preferably, at home wash and shave the hair (especially in the area of the surgical field (for men).

I was called for the operation. My actions.

Most importantly - do not worry, brace yourself to be in full confidence that everything will be fine. Your actions should not be hasty. Before the surgery, a complete blood analysis will be taken, or, perhaps, the necessary additional analysis will be performed, and you will be given medications that you should be taken before the surgery. After a cleansing enema, and after the examination by the anesthesiologist you will be transferred to the operating room.

How long does the operation last?

The duration of the operation on average is six hours.

What is the crisis of rejection of the transplanted heart, and what are its symptoms?

The reason for the rejection of the transplanted heart is antigenic differences between the donor and the recipient. There are several types of rejection:

• hyperacute rejection which developswithin the first minute and up to an hour after the restoration of the blood flow, and is caused bythe pre-existing antibodies to blood group antibodies, HLA or endothelial
• acute cellular rejectioncan occur at any time after the transplant, but more often within the first 3 - 6 months. This T - cell response with infiltration of lymphocytes and macrophages, ending with miotsitolizom. The diagnosis is made based on the results of endomyocardial biopsy, the severity is measured against a standard scale from mild to moderate to severe.
• acute humoral (vascular) - develops within the first days - weeks after the heart transplantation, and antibodiesplay a more crucial part in its occurance than T cells, in particular alloantibodies directed against HLA antigens or endothelial cell donor.
• chronic rejection developes months after heart transplantation. Its mechanism is not fully understood, but it is a consequence of the humoral and cellular processes of allorecognition. It is manifested by diffuse atherosclerosis of the coronary arteries.

The signs of rejection are:

• in the period of such rejection shortness of breath with minimal exercise and at rest can be felt
• weakness, palpitations, and oftena sense of fear
• upon examination by the doctor swollen jugular veins, enlarged liver, swelling in the legsmay be noticed
• at auscultation muffled tones, systolic heart murmurs over the apex of the heartare heard
• defined hypotension (low blood pressure)
• decreased urine output (urine moves badly)
• ever, even up to 38 - 39 degrees
• weight on the left side of the chestcan be felt
• feeling becomes similar to the onewhich was before the transplant

What is a biopsy of the heart?

Endomyocardial biopsy of the heart (EMB) is currently the only objective method of diagnosing transplant rejection. The biopsy gives the opportunity to explore the morphological manifestations of immune conflict in order to reliably estimate its severity and the effectiveness of immunosuppressive therapy. Also biopsy tests for the presence of infections and viruses. Biopsy is performed under local anesthesia through the right internal jugular vein. It is aimed to obtain biopsies from the top of the right ventricle and the interventricular septum. The access can be obtained through the subclavian or femoral vein. After a biopsy it is necessary to remain at bed rest, especially if it is performed through the femoral vein.

How is the rejection treated?

The treatment of rejection usually starts with methylprednisolone pulse therapy, which is administered intravenously in the dose of 500 - 1000 mg for three days. In addition, the base immunosuppression can be increased. In the 80 - 90% of the cases, the crisis comes off successfully.

The main thing is to keep calm. And it should always be rememberedthat if the condition has worsened in any way, it is necessary to urgently seek medical advice. Do not hope for the best. The earlier the treatment starts, the more chances there are to save the organ.

Can I have visitors in the postoperative period?

In the early postoperative period it is not recommended to have visitors, since you will be taking immunosuppressive therapy and, in order to avoid infection, you should be taken precautions.

In the late postoperative period, visitors can be alowed, but with caution. You will need to wear a face mask, and not only you but all the comers.

Do I need to be on a special diet after the transplantation?

Yes, a strict diet is necessary, especially in the early postoperative period. For your normal state of health the diet should be followed for the rest of the time as well. The body weight should be watched. First you need to eliminate all fat, flour, sweet, salty, spicy food, as well as grapefruit. The food should be diverse in terms of vitamins. The diet after the heart transplantation is similar to the one that is recommended for patients with coronary artery disease.

When will I be discharged from the hospital?

Everything will depend on your condition. On average, in a month.

What should I know before returning back home?

The most important thing is to learn to take care of yourself and to take seriously the medication that you take, to study their properties, dosage, hours of taking the pills. You must be able to measure the blood pressure, to control the amount of consumed and egested, measure temperature and know all the signs of rejection. Remember, you have had the surgery, so that you can live. Live a fullаilled life, but be prudent.