Heart transplantation surgical procedure

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Heart transplantation Microchapters


Patient Information


Historical Perspective




Epidemiology and Demographics

Risk Factors


Complications and Prognosis





Criteria for Cardiac Transplantation

Equitable Distribution of Donor Hearts to those Awaiting Transplantation and the Process of Being Listed for a Transplant


Medical Therapy



Electrocardiogram and Pacing After Cardiac Transplantation

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Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D.; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [1]Ifrah Fatima, M.B.B.S[2] Edzel Lorraine Co, DMD, MD[3]


Surgery is usually reserved for patients with advanced, irreversible heart failure with a severely limited life expectancy. Surgery is not the first-line treatment option for patients with heart failure. The mainstay of treatment for heart failure is medical/device therapy.


  • Surgery is the first-line treatment option for patients with either:

Systolic Heart Failure with a Left Ventricular Ejection Fraction less than 35%


  • Due to either:

Ischemic Coronary Artery Disease with Refractory Angina

  • Ischemia which is not amenable to percutaneous or surgical revascularization (coronary artery bypass graft surgery CABG) and is refractory to maximally tolerated medical and/or device therapy. [2]

Intractable life-threatening Arrhythmias


Congenital Heart Disease


Pre-operative Procedure

Heart transplantation needs a donor heart from a recently deceased or brain dead donor. The transplant patient is then thoroughly evaluated for the operation. The donor heart is also evaluated to check its suitability for transplantation.

Operative Procedure

Once the donor heart has passed its inspection, the patient is taken into the operating theatre and given a general anesthetic. Either an orthotopic or a heterotopic procedure is followed, depending on the condition of the patient and the donor heart. [5]

Orthotopic Procedure

In the orthotopic procedure a median sternotomy is done to expose the mediastinum. After opening the pericardium, the great vessels including the superior vena cava, inferior vena cava, pulmonary artery, pulmonary vein and aorta are dissected and cardiopulmonary bypass is attached. The diseased heart is taken out after transecting the great vessels and a part of the left atrium. The pulmonary veins are not transected; rather a circular portion of the left atrium containing the pulmonary veins is left in place. The donor heart is now fit onto the patient's remaining left atrium and great vessels. The transplanted heart is started after slowly weaning the patient from cardiopulmonary bypass. The procedure is completed by closing the chest cavity. [6] [7]

Heterotopic procedure

In the heterotopic procedure, the diseased heart is left in place and the donor heart is implanted. The donor heart is placed in a way to have the chambers and blood vessels of both hearts connected. This results in something to the effect of a 'double heart'. In this way, the patient's original heart can be given a chance to recover. Therefore, even if the donor heart fails, it is removed to allow the patient's original heart to start working again. Heterotopic procedure is advantageous when the donor heart is not strong enough to function independently. This may be due to various reasons such as disproportionate body size of the patient and donor, the donor heart being weak, or pulmonary hypertension in the patient.[8] [7]


Post-operatively the patient requires ICU care. The following are essential in a post-transplant patient:

Another post-operative change to expect is mild tachycardia of around 100 bpm because the vagus nerve is severed during transplantation.

Living organ transplant

  • In February 2006, at Bad Oeynhausen Clinic for Thorax and Cardiovascular Surgery, Germany, a 'beating heart' was transplanted into a patient.[9]
  • The donor heart is kept at body temperature and connected to a Organ Care System. This machine lets it to continue beating with oxygenated blood flowing through it. This ensures that the heart remains in a suitable condition for a longer time.


Absolute Contraindications


Relative Contraindications due to associated comorbidities


Cardiac Transplantation (DO NOT EDIT) [13][14][15][16]

Class I
"1. For selected patients with advanced HF despite GDMT, cardiac transplantation is indicated to improve survival and QOL. [17][18][19] (Level of Evidence: C-LD) "
Value Statement: Intermediate Value
"2. In [[patients] with stage D (advanced) HF despite GDMT, cardiac transplantation provides intermediate economic value. [20] (Level of Evidence: C-LD) "


  1. Mehra MR, Canter CE, Hannan MM, Semigran MJ, Uber PA, Baran DA; et al. (2016). "The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update". J Heart Lung Transplant. 35 (1): 1–23. doi:10.1016/j.healun.2015.10.023. PMID 26776864.
  2. Lund LH, Edwards LB, Dipchand AI, Goldfarb S, Kucheryavaya AY, Levvey BJ; et al. (2016). "The Registry of the International Society for Heart and Lung Transplantation: Thirty-third Adult Heart Transplantation Report-2016; Focus Theme: Primary Diagnostic Indications for Transplant". J Heart Lung Transplant. 35 (10): 1158–1169. doi:10.1016/j.healun.2016.08.017. PMID 27772668.
  3. 3.0 3.1 Alraies MC, Eckman P (2014). "Adult heart transplant: indications and outcomes". J Thorac Dis. 6 (8): 1120–8. doi:10.3978/j.issn.2072-1439.2014.06.44. PMC 4133547. PMID 25132979.
  4. Thrush PT, Hoffman TM (2014). "Pediatric heart transplantation-indications and outcomes in the current era". J Thorac Dis. 6 (8): 1080–96. doi:10.3978/j.issn.2072-1439.2014.06.16. PMC 4133537. PMID 25132975.
  5. Flécher E, Fouquet O, Ruggieri VG, Chabanne C, Lelong B, Leguerrier A (2013). "Heterotopic heart transplantation: where do we stand?". Eur J Cardiothorac Surg. 44 (2): 201–6. doi:10.1093/ejcts/ezt136. PMID 23487534.
  6. Jungschleger JGM, Boldyrev SY, Kaleda VI, Dark JH (2018). "Standard orthotopic heart transplantation". Ann Cardiothorac Surg. 7 (1): 169–171. doi:10.21037/acs.2018.01.18. PMC 5827120. PMID 29492395.
  7. 7.0 7.1 Baumgartner WA, Reitz BA, Oyer PE, Stinson EB, Shumway NE (1979). "Cardiac homotransplantation". Curr Probl Surg. 16 (9): 1–61. doi:10.1016/s0011-3840(79)80010-6. PMID 387341.
  8. Konertz W, Sheikhzadeh A, Weyand M, Friedl A, Bernhard A (1988). "Heterotopic heart transplantation: current indications for the procedure, with results in 10 patients". Tex Heart Inst J. 15 (3): 159–62. PMC 324818. PMID 15227245.
  9. "Bad Oeynhausen Clinic for Thorax- and Cardiovascular Surgery Announces First Successful Beating Human Heart Transplant". TransMedics. 23 February 2006. Retrieved 2007-05-14.
  10. Mancini, Donna; Lietz, Katherine (2010). "Selection of Cardiac Transplantation Candidates in 2010". Circulation. 122 (2): 173–183. doi:10.1161/CIRCULATIONAHA.109.858076. ISSN 0009-7322.
  11. Mehra, Mandeep R.; Canter, Charles E.; Hannan, Margaret M.; Semigran, Marc J.; Uber, Patricia A.; Baran, David A.; Danziger-Isakov, Lara; Kirklin, James K.; Kirk, Richard; Kushwaha, Sudhir S.; Lund, Lars H.; Potena, Luciano; Ross, Heather J.; Taylor, David O.; Verschuuren, Erik A.M.; Zuckermann, Andreas (2016). "The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update". The Journal of Heart and Lung Transplantation. 35 (1): 1–23. doi:10.1016/j.healun.2015.10.023. ISSN 1053-2498.
  12. Kellerman L, Neugut A, Burke B, Mancini D (2009). "Comparison of the incidence of de novo solid malignancies after heart transplantation to that in the general population". Am J Cardiol. 103 (4): 562–6. doi:10.1016/j.amjcard.2008.10.026. PMID 19195521.
  13. Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM; et al. (2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e876–e894. doi:10.1161/CIR.0000000000001062. PMID 35363500 Check |pmid= value (help).
  14. Yancy CW, Jessup M, Bozkurt B, Masoudi FA, Butler J, McBride PE; et al. (2013). "2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. doi:10.1016/j.jacc.2013.05.019. PMID 23747642.
  15. Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009)2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016.DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967
  16. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al. (2005) ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 112 (12):e154-235. DOI:10.1161/CIRCULATIONAHA.105.167586 PMID: 16160202
  17. Khush KK, Cherikh WS, Chambers DC, Harhay MO, Hayes D, Hsich E; et al. (2019). "The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: Thirty-sixth adult heart transplantation report - 2019; focus theme: Donor and recipient size match". J Heart Lung Transplant. 38 (10): 1056–1066. doi:10.1016/j.healun.2019.08.004. PMC 6816343 Check |pmc= value (help). PMID 31548031.
  18. Colvin M, Smith JM, Hadley N, Skeans MA, Uccellini K, Goff R; et al. (2020). "OPTN/SRTR 2018 Annual Data Report: Heart". Am J Transplant. 20 Suppl s1: 340–426. doi:10.1111/ajt.15676. PMID 31898418.
  19. Teuteberg JJ, Cleveland JC, Cowger J, Higgins RS, Goldstein DJ, Keebler M; et al. (2020). "The Society of Thoracic Surgeons Intermacs 2019 Annual Report: The Changing Landscape of Devices and Indications". Ann Thorac Surg. 109 (3): 649–660. doi:10.1016/j.athoracsur.2019.12.005. PMID 32115073 Check |pmid= value (help).
  20. Long EF, Swain GW, Mangi AA (2014). "Comparative survival and cost-effectiveness of advanced therapies for end-stage heart failure". Circ Heart Fail. 7 (3): 470–8. doi:10.1161/CIRCHEARTFAILURE.113.000807. PMID 24563450.

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