Heart transplant

Heart failure is not a single disease but the end point of many. The muscle may have been damaged by a heart attack, weakened by a cardiomyopathy, strained for decades by a faulty valve, or malformed from birth. Whatever the cause, the result is a pump that can no longer deliver enough blood for the body to function, and a person whose breathlessness, exhaustion and fluid retention worsen despite good treatment.

Modern heart failure care is genuinely effective, and most people never approach transplantation. Medication combinations have improved substantially, implanted defibrillators prevent sudden death, and resynchronisation devices help hearts whose chambers have fallen out of step. Transplantation is considered only when that entire ladder has been climbed and the person is still deteriorating.

What a transplant offers, when it works, is not an incremental improvement but a different life: someone who could not climb a flight of stairs may return to work, to exercise and to ordinary independence. That is why the operation is undertaken at all despite its difficulty.

One clarification worth making early, because it causes real confusion. A heart transplant is not the same as heart surgery in general. Bypass grafting, valve replacement and congenital repairs are major operations on a person's own heart, and they are widely available to international patients. Transplantation is categorically different, because it requires an organ that only a national system can allocate.

Almost every heart transplant performed today is orthotopic: the diseased heart is removed and the donor heart placed in its position. Within that, surgeons use one of two joining techniques. The bicaval method connects the two vena cavae separately and is now standard in most centres; the older biatrial method joins cuffs of the recipient's own atria. The bicaval approach tends to preserve the geometry of the atria better and is associated with less need for a permanent pacemaker.

Heterotopic transplantation, in which the donor heart is placed alongside the recipient's own and works in parallel, is now very rare. It survives as an option in unusual circumstances, such as severe fixed pulmonary hypertension where a donor right ventricle would fail immediately, or a donor heart considerably smaller than the recipient needs.

Alongside transplantation sits mechanical circulatory support, and understanding the relationship matters. A left ventricular assist device is a pump implanted to take over the work of the failing left ventricle, driven by an external controller and battery. It is used in two quite different ways. As an LVAD bridge to transplant, it keeps somebody alive and often improves their condition while they wait. As destination therapy, it is the long-term treatment itself for a person who is not a transplant candidate.

For an international reader, this distinction is the practical one. Mechanical support is a device and an operation, and unlike an organ it can in principle be provided wherever a programme exists and is willing to take the case. That is a genuine avenue where transplantation is not.

Heart transplant eligibility rests on two things assessed in parallel: whether the heart failure is severe enough that a transplant is justified, and whether the rest of the body can survive the operation and the immunosuppression that follows. Both have to be true. Somebody can be too well to benefit and too unwell to survive, and the window between those is what assessment is trying to find.

The conditions that most often lead to transplantation are dilated cardiomyopathy, ischaemic cardiomyopathy following one or more heart attacks, and congenital heart disease that has reached the limit of what repair can achieve. Less commonly, restrictive and hypertrophic cardiomyopathies, cardiac amyloidosis and sarcoidosis, valve disease that has damaged the muscle beyond recovery, and intractable arrhythmias that cannot be controlled by any other means.

Severity is not judged by symptoms alone. Programmes use objective measures: how far the person can walk, what their peak oxygen uptake is on formal exercise testing, whether they are dependent on intravenous inotropes or mechanical support, how often they are readmitted, and what their kidney and liver function show about the effect of poor circulation on other organs.

One measurement carries particular weight, and it surprises people. A right heart catheterisation measures the pressure and resistance in the lung circulation. If pulmonary vascular resistance is high and does not fall when vasodilators are given, a normal donor right ventricle will fail acutely when asked to pump against it. That finding can rule out an isolated heart transplant and redirect the discussion towards mechanical support first, or towards heart-lung transplantation.

A donor heart is accepted or declined by the receiving team on the basis of a detailed assessment made in the hours after death is determined. The donor's age, the reason they died, their cardiac history, an echocardiogram, sometimes a coronary angiogram, the doses of drugs supporting their circulation, and their infection and cancer screening all feed into that decision. A substantial proportion of offered hearts are declined, and declining is often the right answer.

Matching is less elaborate than people expect. Blood group compatibility is required. Size matching matters, because a heart too small for the recipient cannot meet their circulation's demands — this is judged by body weight and increasingly by predicted heart mass rather than height alone. Tissue typing is not routinely used to select a heart the way it is for a kidney, because the organ cannot wait long enough for it.

Sensitisation is the complication that most affects waiting. Somebody who has developed antibodies against human tissue — through pregnancy, transfusion, a previous transplant or a ventricular assist device — will be incompatible with a larger share of donors. Programmes measure this and may treat it, but a highly sensitised person generally waits longer.

The blunt point, and the reason this section exists on a page about a procedure rather than about donation, is that none of this is within a patient's control or a hospital's gift. There is no relative who can step forward, no arrangement that can be made, and no version of this pathway in which willingness to pay alters the outcome.

A heart transplant is among the largest operations in medicine, performed on people who are already critically unwell. The risks are correspondingly serious, and a programme that does not set them out plainly is not preparing you properly.

In the first hours and days, the principal danger is that the new heart does not work well enough immediately. Primary graft dysfunction — a donor heart that is stunned and cannot support the circulation on its own — is the leading early cause of death, and it is managed with drugs and, where necessary, temporary mechanical support while the organ recovers. Right ventricular failure is a specific version of this, and it is the reason lung pressures are measured so carefully beforehand.

Rejection is the risk that continues. The immune system recognises the new heart as foreign, and acute cellular rejection is common enough in the first year that programmes look for it routinely rather than waiting for symptoms — usually by taking small biopsies of the heart muscle through a neck vein. Antibody-mediated rejection is less common and harder to treat. Most episodes found early are treated successfully with adjusted immunosuppression.

Infection is the mirror image of rejection, and the two are managed against each other. Suppressing the immune system enough to protect the graft leaves a person more vulnerable to bacteria, viruses and fungi, particularly in the first months when doses are highest. Prophylactic drugs are given for that period, and fever after a transplant is always treated as urgent.

Over years, two problems dominate. Cardiac allograft vasculopathy is a diffuse narrowing of the coronary arteries of the transplanted heart that is distinct from ordinary coronary disease; because the heart is denervated it usually causes no chest pain, which is why programmes look for it with periodic imaging rather than waiting for symptoms. Malignancy — particularly skin cancers and post-transplant lymphoproliferative disorder — occurs more often under long-term immunosuppression, which is why skin surveillance and screening become part of routine care.

None of this is a reason to refuse a transplant when it is indicated. It is the reason transplantation is reserved for people who will otherwise die of their heart failure, and the reason follow-up is lifelong.

Assessment for a heart transplant is thorough and takes weeks rather than days. It is carried out by a multidisciplinary team — cardiologists, surgeons, anaesthetists, specialist nurses, a psychologist or psychiatrist, a pharmacist, a dietitian and a social worker — and the decision to list is taken collectively, not by one doctor.

The cardiac work-up establishes how severe the failure is and whether anything reversible remains: echocardiography, cardiopulmonary exercise testing to measure peak oxygen uptake, right heart catheterisation to measure lung pressures and their reversibility, coronary imaging, and rhythm monitoring. If a treatable cause is found, it is treated first.

The general work-up asks whether the rest of the body can withstand what is coming: kidney and liver function, lung function, vascular imaging, screening for infection including hepatitis and tuberculosis, dental assessment, age-appropriate cancer screening, bone density, and immunisation status. Vaccines are brought up to date before transplantation, because live vaccines cannot be given afterwards.

When the team agrees, the person joins the heart transplant waiting list with a status reflecting how urgently they need an organ, and that status is reviewed as their condition changes. Waiting is the hardest part of the process and the least predictable: it may be days if the person is critically ill and easily matched, or years if they are stable, large, or highly sensitised. During that time the person remains under active care, and deterioration may bring inotropes, a temporary device or an assist device as a bridge.

Once a heart is accepted, two operations run against a clock in different hospitals. A retrieval team travels to the donor, examines the heart directly, and only then confirms the offer. The recipient is prepared in parallel, but the chest is not opened until that confirmation arrives — because an offer can still be declined at the donor's bedside.

Heart transplant surgery begins, for the recipient, with a median sternotomy. In someone who has had previous cardiac surgery or carries an assist device, freeing the heart from scar tissue can take hours on its own, and this is often the longest and most hazardous part of the procedure.

The patient is placed on cardiopulmonary bypass, which takes over the work of the heart and lungs. The diseased heart is removed, leaving cuffs of tissue to which the new heart will be joined. The donor heart is then sewn in — in the bicaval technique, the left atrium, the two vena cavae, the pulmonary artery and the aorta are each connected in turn.

When the joins are complete, the clamp is released and blood flows into the new heart. It often begins to beat spontaneously; sometimes it needs a shock. Coming off bypass is the moment the operation is judged: the new heart must take over the circulation with drug support, and the right ventricle in particular must cope with the recipient's lung pressures. If it cannot, temporary mechanical support is used while it recovers.

The whole procedure typically takes somewhere between four and six hours, longer where scarring or a device complicates the dissection. Pacing wires and drains are placed, the sternum is wired closed, and the patient goes to intensive care still ventilated and supported.

One feature of the operation has consequences for the rest of the recipient's life. The transplanted heart is denervated — its connections to the nervous system are cut and only partially regrow. It responds to exercise more slowly, through circulating hormones rather than nerve signals, so warming up and cooling down matter. And because the heart cannot send pain signals in the usual way, angina is an unreliable warning, which is why later coronary narrowing is looked for by imaging rather than waited for.

Heart transplantation has better results today than at any point in its history, and the honest framing of a heart transplant survival rate is a curve rather than a number. The highest risk is concentrated in the first weeks — around the operation itself and primary graft dysfunction — after which the risk of dying falls sharply and then declines slowly year on year.

The registry that publishes international figures is maintained by the International Society for Heart and Lung Transplantation, which collects data from programmes worldwide and reports survival by era, age group and diagnosis. Reading those reports is more useful than reading a single headline figure, because survival differs substantially between a young person with a dilated cardiomyopathy and an older person transplanted from mechanical support.

Three things move an individual's numbers away from any average. The first is what condition they were in when transplanted: somebody supported on multiple inotropes or ECMO enters the operation with less reserve than somebody who walked in. The second is the donor heart itself — its age, its ischaemic time, and how well it was functioning. The third is what happens afterwards, and specifically whether the recipient takes their medication exactly as prescribed. Non-adherence is a leading cause of late graft loss, and it is the one variable entirely within a patient's control.

The first stop after theatre is intensive care, still ventilated and supported with drugs that help the new heart pump. Most people are woken and taken off the ventilator within a day or two if the graft is working well. Drains, pacing wires and lines are removed over the following days.

The first weeks on the ward are spent stabilising immunosuppression, monitoring for rejection and infection, and learning. Education is a substantial part of this stay: recognising the drugs by sight, knowing what each does, understanding which symptoms mean "phone now", learning to take a temperature and blood pressure, and understanding food safety.

Discharge for an uncomplicated recovery is commonly somewhere between two and four weeks after surgery, though complications extend that considerably. Discharge is not the end of intensive follow-up: clinic visits are frequent at first, often weekly, with blood tests, drug levels, echocardiograms and rejection surveillance.

The sternum takes six to twelve weeks to heal, and that dictates the physical restrictions of the early months: no heavy lifting, no pushing or pulling with the arms, and no driving until the centre agrees. Cardiac rehabilitation, structured and supervised, is one of the strongest predictors of how well somebody does, and should be started as soon as it is offered.

By around three months most people are substantially more independent, and by six months many have returned to work and normal activity. The denervated heart changes how exercise feels: the pulse rises more slowly at the start and falls more slowly afterwards, so warming up and cooling down properly is not advice but necessity.

Life after a heart transplant settles into a rhythm built around three things: medication, surveillance, and sensible precautions. None of them is dramatic, and together they are what makes the graft last.

Immunosuppression is taken every day for as long as the heart works. Most regimens combine a calcineurin inhibitor with an antiproliferative agent and, initially, a steroid, with doses adjusted by blood levels. Timing matters — these drugs are taken at fixed hours, and blood tests are taken before the morning dose, not after. Many recipients find a pill organiser and a phone alarm more useful than any amount of willpower.

Interactions are a genuine hazard rather than a caution. Grapefruit, some antibiotics and antifungals, certain heart drugs, anti-epileptics and St John's wort all shift immunosuppressant levels substantially, in both directions. Any new medicine — including anything bought over the counter or recommended by a pharmacist who does not know your history — should be checked with the transplant team first.

The long-term reality should also be said plainly: a transplanted heart does not last forever, and some recipients are eventually assessed for a second transplant. That is a difficult conversation, but knowing it from the start is better than discovering it later. What extends a graft's life more than anything else available today is exact adherence to medication and attendance at surveillance.

Any figures shown here come from the price registry, where each is recorded with the source that verified it and the date. Where nothing appears, no current verified figure exists — which is more honest than an estimate written once and left to age quietly.

Heart transplantation is carried out only in accredited centres attached to a national donation and allocation system, because that is the only way a heart can lawfully reach an operating theatre. Any hospital listed on this platform is recorded from a public reference rather than a marketing claim, and a hospital appearing here is not an indication that it can accept an international patient for transplantation.

Availability for heart transplantation means something narrower than it does elsewhere on this platform. A country may have excellent programmes and still be entirely closed to a non-resident seeking a transplant, because the constraint is not surgical capability but the law governing who may join a national waiting list.

Most systems allocate deceased-donor organs to residents. Some permit non-resident listing under defined conditions, often within a quota and usually requiring residency, insurance or a formal agreement between health authorities. Others prohibit it outright. These rules change, and they are set by health ministries rather than by hospitals, so a hospital's willingness to assess you says nothing about whether you could be listed.