Heart Transplant | Surgery and Hospital Stay

Heart transplant surgery

A donor heart can become available at any time of the day or night. Timing is critical. The child will need to be ready to go to the operating room within one to two hours upon arrival at the hospital.

The child will be admitted to the cardiac floor or cardiac intensive care unit (CICU) and be prepared for surgery. An electrocardiogram (EKG), chest x-ray and blood tests will be done. The child will be seen by the surgeons, anesthesiologists and cardiologists to discuss the upcoming procedure.

While the child is being prepared for the operating room, a surgical team is leaving to obtain the donor heart. The time of operation is planned to match the team’s arrival back at Boston Children’s Hospital.

The heart can’t live long outside the body, so it is important to remove the heart, transport it to our hospital and then transplant the heart within a few hours.

The transplant operation involves removing the damaged heart from the child’s body and attaching the new heart. The transplant operation takes about four to six hours. For children with complex congenital heart disease, the operation can be more involved because of the abnormal anatomy and the scar tissue from previous operations.

Parents can wait in the CICU waiting room at night or in the main surgical waiting area during the day. We provide progress reports every few hours during the operation.

Care after surgery is very similar to other open-heart surgeries. The child will return from the operating room on a breathing machine (ventilator) with a breathing tube in the nose or mouth. The child will be on a cardiac monitor, have several IVs and other tubes and equipment and will be in a private room in the CICU to protect from infection.

The average hospital stay is two to four weeks. Half the time is spent in the CICU and the other half on the cardiac floor. Patients go to a private room on the cardiac floor when they leave the CICU, where they continue recovery, are monitored for rejection and other problems, and have medications adjusted.

Possible complications after heart transplant

Rejection

Rejection is a normal reaction of the body to a foreign object. When a new heart is placed in a child’s body, the body sees the transplanted organ as a threat and tries to attack it.

The immune system is responsible for the body’s defense against infection (such as bacteria or viruses) or foreign tissues (such as transplanted organs). A heart transplant is viewed by the body’s immune system as foreign, which means the body mounts an attack against the transplanted heart by sending cells from the immune system to destroy it. This attack is called rejection.

We can identify that rejection is occurring by looking at the cells in small pieces of the heart muscle (biopsy) under a microscope. We see swelling or inflammation around the heart’s muscle cells.

Following transplantation, immunosuppressive medications are used to prevent the immune system from rejecting the new heart. These medications are taken multiple times per day. Medicine to prevent rejection will be needed for the rest of a child’s life. Rejection of a transplanted organ will occur at unpredictable times following transplant. It is not a complication of the operation.

The chance of rejection is highest in the first few months after the heart transplant. The first year following transplant is the time period when we are working to establish the best combination of anti-rejection medications. A child may experience rejection but have no observable symptoms. However, there is often some evidence of rejection if a child experiences at least some the following symptoms:

  • fatigue
  • irritability
  • shortness of breath
  • difficulty breathing
  • fast heartbeat
  • irregular heartbeat
  • poor eating
  • decreased appetite
  • nausea
  • vomiting
  • abdominal pain
  • diarrhea
  • fever

We often treat rejection episodes in the first few months after transplant with hospitalization and high IV doses of immunosuppressive medication. Rejection episodes later in the transplant course may be treated with an increase in a child’s Prograf or CellCept or a course of oral prednisone for several days.

If the rejection is recurrent or more severe, additional immunosuppression may be necessary. We monitor children closely during rejection episodes. Cardiac biopsy will always be repeated following a rejection episode to see if the treatment was successful or if more treatment is needed.

Our goal is to give children adequate immunosuppression to prevent rejection but use the lowest doses possible to prevent side effects. Using drugs in combination allows us to use lower doses for each drug than if only one drug was used, so we generally take this approach to suppress a child’s immune response. Since every patient is different, finding a good balance takes some time, and many medication adjustments may be needed in the first few months.

Infection

Since children who undergo a heart transplant require medications that decrease their body’s immune system, they are at higher risk for infection. To some degree, a child will always be at higher risk of infection. However, a child will be at the highest risk early after transplant while on the highest doses of immunosuppressive medications.

The signs of an infection are similar to rejection. A child may develop:

  • fever
  • cough
  • irritability
  • diarrhea
  • vomiting

In addition, the wound from surgery may be red, swollen and draining.

Treatment is based on severity of symptoms and the cause of infection. Early post-transplant patients are often admitted to the hospital for both the evaluation of infection and treatment.

Going home after a heart transplant

Families will be taught their child’s current medication schedule, proper administration of the medication and how to monitor for side effects and complications from the transplant.

In the beginning, the child will require frequent follow-up (once to twice per week). Families who live more than two hours from Boston are usually requested to stay in the local area for a period of time (six to 12 weeks) after discharge. Accommodations and length of stay after discharge will be determined on an individual basis.

Our goal after transplant is to return the child and their family to as normal a routine as possible. This will take time but will always remain our goal.