On December 3, 1967, Christiaan Barnard transplanted a foreign heart for the first time at Groote Schuur Hospital in Cape Town. The patient died 18 days after the transplantation from pneumonia, which was initially misinterpreted as heart failure in the context of rejection. Due to unmanageable rejection and infection problems, many transplant programs were suspended. It was not until the discovery of cyclosporine, which is able to keep the body's own defenses against a foreign transplanted organ in check, that heart transplantation (HTPL) resumed worldwide.
The University Hospital Zurich started performing heart transplantations as early as 1969, but had to experience uncontrollable rejection and infection, as was the case worldwide. For this reason, the University Hospital Zurich was the first center in Switzerland to start performing heart transplants again only in 1985. Subsequently, heart transplants were also performed in Lausanne, Geneva and later in Bern and Basel. Currently, there are 3 centers in Switzerland: Lausanne, Bern and Zurich. By the end of 2020, a total of 497 heart transplants had been performed in Zurich. Just as important as surgery is lifelong, individualized care for patients after transplantation.
Today, mechanical support systems also play an important role in the therapy of advanced heart failure. Heart transplantation is considered one of several options in a comprehensive range of therapeutic approaches for heart failure. To address this complexity, the University Heart Center was established at the USZ to provide interdisciplinary care for all patients according to their needs.
Heart failure is a serious disease, which is still underestimated in its frequency and severity. Thanks to important advances in therapy, survival rates have improved in recent years. Nevertheless, many people still reach the stage of severe chronic heart failure. Once the possibilities with drugs and special pacemakers have been exhausted, the last alternative is heart transplantation. It is an established and very efficient therapeutic option that can restore normal performance and quality of life to patients. However, due to the shortage of organs, only (too) few patients benefit from this form of therapy.
Any form of severe heart disease in which severe symptoms (shortness of breath, impaired exercise capacity, heart pain, arrhythmias) persist despite fully exhausted comprehensive therapies and life expectancy is severely limited by the disease. Objective parameters, such as limited ejection fraction of the heart, exercise capacity measured by stress test and cardiac output determined by cardiac catheterization, help to identify suitable patients. Patients must want the transplantation and be motivated and positive about it, and the support of family members is extremely important.
Are there patients who are not suitable for heart transplantation?
Yes, especially older patients with many concomitant diseases may not be considered as recipients because the risk for the operation would be too high or concomitant diseases would be aggravated by the lifelong immunosuppression. For this reason, patients are examined in detail during a short hospitalization before a possible transplantation. Here we check whether, for example, a hidden tumor, another severe systemic disease, a severe lung or liver disease, an addictive disease or an uncontrollable infectious situation make a transplant impossible.
After all clarifications have been completed, the heart transplant team and the patient discuss the options together. If the patient is suitable, he or she can be placed on the national waiting list for a transplant. The length of the waiting period varies widely. Donor organs are provided by deceased organ donors. These are reported in Switzerland via Swisstransplant and allocated to recipients from there according to the Swiss guidelines.
Even during the time on the waiting list, patients are cared for very closely by the heart failure team.
Decisive for the successful transplantation of a foreign heart are the matching blood group as well as similar weight and height of donor and recipient.
A heart transplant is performed under general anesthesia. It takes about four to six hours: the sternum is opened, the blood circulation is connected to the heart-lung machine, the patient’s heart is removed and replaced by the donor’s heart.
At the end of the operation, the chest is closed with wires. This is followed by transfer to the intensive care unit.
When the cardiac, pulmonary and circulatory situation is stable, the patient is weaned off the ventilator. As soon as the patient’s state of health permits, he or she is transferred to the normal ward. This is followed by a rehabilitation phase of about 3 weeks.
The immune system, which normally protects the body from viruses and bacteria, is also able to distinguish foreign tissue from the body’s own tissue. The immune system will recognize the new heart as “foreign” and try to fight it. This defense reaction, called “rejection,” can be suppressed by a combination of different drugs (called immunosuppressants). These must be taken for the rest of the patient’s life.
Intensive and highly specialized care and follow-up with constant monitoring with regard to rejection reactions and infections is necessary for life.
After transplantation, follow-up care is provided in the transplant outpatient clinic by experienced nursing staff and specialized cardiologists at the USZ and in close cooperation with the patient’s family doctor, the referring cardiologist and the cardiac surgeons at the hospital.
Patients and their relatives take an active role in self-management after transplantation following comprehensive training and support by specialists from various disciplines.
Conscientious intake of medications, daily monitoring of symptoms, and timely contact with the treatment team are very important and can contribute greatly to the success of the transplant.
Rejection and immunosuppression
If a rejection reaction occurs despite taking immunosuppressants, treatment specifically adapted to the situation must be initiated. A rejection reaction often does not lead to symptoms. For this reason, tissue samples from the right heart (so-called endomyocardial biopsies) must be taken at regular intervals (see below) to be examined for a rejection reaction. An initial myocardial biopsy is required approximately one week after transplantation. In the early phase after transplantation, i.e., the first few months, myocardial biopsies are performed at regular intervals of one to four weeks. Later, biopsies are usually needed only every 6 months or not at all.
The prognosis depends crucially on close cooperation between the patient and the treating team. Three essential factors determine the course:
The prognosis is very good. Six months after surgery, most patients can resume a relatively normal life.