Heart Transplantation

01 Overview

Heart transplantation replaces an irreversibly failing heart with a donor heart and is reserved for selected patients with advanced heart failure refractory to medical and device therapy.

02 Anatomy

The recipient's heart is excised, typically preserving the posterior walls of the atria, and the donor heart is anastomosed at the atrial or bicaval level, along with the pulmonary artery and aorta.

03 Physiology

The denervated transplanted heart lacks direct autonomic innervation, relying instead on circulating catecholamines and its own intrinsic conduction — which alters resting heart rate and the response to exercise and certain cardiac medications.

04 Indications

Indications include:

• End-stage heart failure refractory to optimal therapy
• Refractory life-threatening arrhythmia
• Certain complex congenital heart disease
• Cardiogenic shock unresponsive to other support

05 Contraindications

Contraindications include:

• Fixed, severe pulmonary hypertension
• Active malignancy or infection
• Irreversible severe dysfunction of another major organ without a combined transplant plan
• Severe uncorrectable peripheral or cerebrovascular disease

06 Donor Assessment

Donor hearts are evaluated for size match, cardiac function on echocardiography, coronary risk factors, and time from procurement to implantation, to minimise ischaemic injury.

07 Recipient Assessment

Candidates undergo detailed haemodynamic assessment and pulmonary vascular resistance measurement, and are screened for comorbidities that could limit post-transplant survival, alongside psychosocial evaluation.

08 Surgical Technique (Summary)

Performed on cardiopulmonary bypass, the operation involves excision of the recipient heart and implantation of the donor heart with sequential anastomoses of the great vessels and atrial or bicaval connections.

09 Immunosuppression (Overview)

Induction and maintenance regimens typically combine a calcineurin inhibitor, an antiproliferative agent, and corticosteroids, with routine endomyocardial biopsy used to monitor for rejection in the early post-transplant period.

10 Complications

Recognised complications include:

• Acute cellular or antibody-mediated rejection
• Cardiac allograft vasculopathy
• Primary graft dysfunction
• Infection
• Post-transplant malignancy

11 Follow-up

Follow-up includes surveillance biopsies, echocardiography, and coronary angiography to detect allograft vasculopathy, together with monitoring of renal function and the metabolic effects of immunosuppression.