You have been referred for a heart transplant by your doctor because he or she feels that your heart failure symptoms are getting worse and can no longer be managed effectively with medication or a less-invasive surgical procedure (e.g., special pacemaker).
Heart failure occurs as a result of one of the following:
- Coronary artery disease (blocked arteries)
- Hereditary condition
- Congenital heart disease
- High blood pressure
- Viral infection
- Side effects of medication
- History of alcohol use
Heart Transplant Workup
Your workup will include a number of tests to determine your eligibility for a heart transplant. An evaluation will determine whether you:
- Have a medical condition that would benefit from a heart transplant
- Would get greater benefit from other treatment options
- Are too healthy for a heart transplant
- Are too sick to have the surgery and post-transplant treatments
- Have any conditions that would not allow you to have a transplant
- Have a social habit (smoking, drinking and/or drugs) that you need to quit before you are accepted for a transplant
- Are willing to follow the steps required after a heart transplant (i.e., frequent follow-up appointments, blood work, tests and medication schedule)
- Have the emotional stamina and social support to deal with the wait time for a donor heart and the recovery after a heart transplant
Sometimes the evaluation can be done on an outpatient basis, but it is usually completed while you are in the hospital. It takes about seven days for the tests to be completed. You may have some or all of the following tests.
Extra tests are sometimes needed. Any extra tests will be explained to you.
To assess the following:
- Blood counts
- Kidney function
- Liver function
- Hepatitis B and C
- Prostate level (for men only)
- Thyroid function
- Virus status (cytomegalovirus, Epstein-Barr virus, human T-cell lymphotropic virus (HTLV))
- Tissue typing to determine whether you have any antibodies in your blood
- Blood group
- Urine and stool samples
- Chest X-ray
A number of other tests will be necessary for your evaluation, including:
- An echocardiogram is an ultrasound of your heart. It shows the four chambers of the heart and indicates how well the right and left ventricles and all of the valves are working. It can also reveal any clots in the chambers, which sometimes happen with heart failure. You do not need to prepare for the test. You will be asked to wear a patient gown and to remove only your top. Electrodes will be attached to your chest, and the technician will ask you to lie on your left side. A gel will be applied to your chest and pictures of your heart will be taken with a special probe.
- A MUGA (multiple-gated acquisition) scan provides an exact measurement of how well the left ventricle is working as a pump. For the test, you will be given an injection through an intravenous line, which will be inserted in your arm. The tracer material given during this injection will attach itself to the red blood cells circulating in your body. A camera will then take pictures of your heart chambers and the blood vessels leading to and from the heart. The test will show how much blood the heart pumps out (ejection fraction or EF) and how quickly it is pumped out.
- Right heart catheterization is a test in which the tip of a catheter is inserted into a vein in your neck and then advanced into your heart using a TV screen and X-rays. The catheter is moved around inside your heart and into the blood vessels going to your lungs. This test measures the pressure levels in your heart and indicates how well your heart is working. The procedure does not take very long and you can usually walk after the test. If the catheter is inserted through your leg, you will require bed rest afterward. The following picture shows how the catheter enters the heart and the path it follows.
- Left heart catheterization is performed if you have not had one in the past couple of years. A catheter is inserted in your groin and is advanced up to your heart. This is done with the assistance of TV and X-ray equipment. A dye is injected that shows how well the blood is flowing through the coronary arteries and whether there are any blockages present. This takes a little longer than a right heart catheterization, and you will require bed rest for about four hours afterward.
- A cardiopulmonary stress test measures how well your lungs work and shows how well your heart pumps blood to your muscles as you exercise. The stress test also assesses the electrical activity of your heart. An electrocardiogram (ECG) is performed while you exercise on a treadmill or stationary bike. During the test, you will be hooked up to electrodes that will record the rhythm of your heart. You will breathe into a breath analyzer, which measures the gas exchange in your lungs. A clip will be placed on your finger to determine the percentage of oxygen in your blood during the exercise. Your blood pressure and pulse will be taken at regular intervals.
SCANS AND OTHER TESTS
A CT (computerized tomography) scan will be done on your chest and abdomen. You may or may not be given a contrast dye prior to the test. During the test, you will lie on a motorized table that moves you through the CT scanner, which is shaped like a large doughnut.
A carotid Doppler ultrasound will be done to make sure there are no severe blockages of the arteries in your neck. A gel is applied to the left and right sides of your neck and pictures are taken with a special probe.
Arterial blood flow studies will be done on your legs to make sure there are no blockages. Cuffs similar to a blood pressure cuff will be wrapped around each leg and will be inflated and deflated to measure the flow of blood through the arteries.
A pulmonary function test will be done if needed. This test measures your lung function. You will be asked to blow into a mouthpiece both before and after using an inhaler.
A bone mineral density test measures the density of minerals (such as calcium) in your bones using a special X-ray. As we age, we do not build up the store of calcium in our bones as quickly as when we were young. We lose calcium and other minerals, making our bones more porous and sponge-like. Our bones become weaker and more at risk of breaking.
A tuberculin skin test will be done if you have a history that puts you at risk of having tuberculosis.
Referrals to Other Health Care Services
During the evaluation, you will be referred to different health care professionals who are part of the transplant team. These include:
- Social workers: There are two social workers at the Heart Institute who are assigned to heart transplant patients and their families. You will be referred to one of them during your evaluation. They can help you with information such as:
- Temporary living accommodations in Ottawa for you and your family
- Disability pensions and financial information
- Community resources and services to support lifestyle changes
- Drug benefit plans
- Dietitian: The dietitian will review your diet with you and help you learn more about healthy food choices for your heart condition.
- Physiotherapist: The physiotherapist will review exercise and energy conservation for people living with heart failure. The physiotherapist will also review the exercise routines that are recommended post-surgery.
Specialists in other areas may be consulted during your evaluation if appropriate. Some of these may include:
- Infectious Diseases
The information gathered from these tests and consultations is presented to a team of cardiologists, heart surgeons, other specialists, social workers, physiotherapists, dietitians and an advanced practice nurse. Your medical history, diagnostic test results, social history and the results of any consultations are reviewed to determine whether you are able to survive the heart transplant procedure and comply with the continuous care needed to live a long and healthy life.
Once the decision is made, your cardiologist will give you the results.
If the team finds that a heart transplant is not something you will benefit from, you will continue to be monitored by your cardiologist as an outpatient.
If the team determines that a heart transplant is something you will benefit from, the transplant advanced practice nurse will review with you and your family what is involved in the heart transplant process. Heart Transplant: A Guide for Patients and Families will provide you and your family with much of the information you will need to help you through the transplant experience.
Summary of the Process
The following diagram summarizes the transplant process and shows the time frame for the various stages: