The excitement generated the by first successful heart transplant, performed by Christian Barnard in South Africa in 1967, remains a landmark in medical history. However, until the development of the immunosuppressive drug cyclosporin in 1982 (Oyer et al, 1982), transplantation was plagued with insurmountable immunological problems of organ rejection.
In the wake of this development, there was a proliferation of transplant centres worldwide which, in turn, generated an increase in the number of potential recipients. Initially this increase was matched by an increase in the supply of donor hearts. This continued until 1990, when the number of cardiac donors reached a plateau at about 3,500 a year worldwide. The number of patients listed for cardiac transplantation now far outstrips the supply of donor organs.
There are now eight centres in the UK performing 250-300 heart transplants a year (Anyanwu, 1999). The improved life expectancy and improvement in quality of life of carefully selected heart transplant recipients has been documented and published around the world (United Network for Organ Sharing, 2000; Hosenpud, 2000).
Heart transplant surgery
When a donor becomes available the prospective recipient is rushed to hospital as an emergency and prepared for theatre. There follows an anxious period, waiting to hear whether the donor heart is suitable. If it is acceptable, the patient is transferred to theatre and given an anaesthetic, intubated, and has lines inserted.
The operation is performed via a median sternotomy. Cardiopulmonary bypass is instituted once the donor heart is 15 minutes from the hospital and the diseased heart explanted. Implantation begins with anastomosing the left atrium, followed by the pulmonary artery, then the aorta. The heart is de-aired and right atria anastomosis is then completed. The patient is then weaned from cardiopulmonary bypass, with the heart paced at 100-120 beats per minute, the chest is closed and the patient moved to intensive care supported with inotropic infusions.
In the immediate postoperative period - until haemostasis and haemodynamic stability are achieved - the patient will be nursed in a designated cardiac ICU. Extubation is usually rapid, and done once arterial blood gases are found to be satisfactory. Management of the patient usually includes monitoring intra-arterial blood pressure, central venous pressure (CVP), left atrial pressure (LAP) and pulmonary artery pressures (PAP).
Intravenous infusions may include inotropic support, fluid and volume replacement, anti-rejection therapy and analgesia. Mediastinal drains and a urinary catheter will also be in situ.
A prolonged stay in ICU may be necessary if the patient has complications such as bleeding, right-sided cardiac dysfunction or bi-ventricular failure requiring multiple inotrope therapy, an intra-aortic balloon pump or ventricular-assist device.
Patients will be transferred to the transplant unit when extubated six to 24 hours after surgery, where they will usually remain until discharge.
Following transfer, ECG monitoring and routine observations will be sustained. In addition, invasive blood pressure and CVP monitoring will continue for a day or two. Mediastinal drains are usually removed soon after transfer when drainage is minimal.
Maintenance of a heart rate of 100-110bpm is an important aspect of early postoperative care (Kuo, 2001) that enables optimal cardiac output and adequate renal perfusion to be achieved. In addition, reduction of pulmonary vascular resistance is beneficial for right ventricular function. Isoprenaline is administered to achieve both of these, although temporary pacing via epicardial wires may be required. Additional inotropes/vasodilators such as milrinone/adrenaline or glyceryl trinitrate may be used, depending on the patient.
If the patient's cardiac function is satisfactory and adequate hydration is achieved, maintaining adequate blood pressure is not usually a problem in the early postoperative period. Hypertension is common following cardiac transplant; this is often drug-induced and generally caused by anti-rejection therapy: ACE inhibitors and calcium channel blockers are common treatments.
Life-threatening arrhythmias are rare postoperatively, even during acute rejection episodes (Forni et al, 1996). Atrial flutter/fibrillation is occasionally seen in patients and, if problematic, can be treated with overdrive atrial pacing, amiodarone or, more rarely, DC cardioversion.
Patients rarely experience respiratory problems. Intense physiotherapy, observation of respiratory rate, oxygen saturations, and regular chest X-rays will allow early identification of pulmonary atelectasis. Precise fluid management will help prevent pulmonary oedema. Oxygen therapy will be weaned as the patient's clinical condition allows.
Fluid balance/renal function
The assessment and management of a patient's fluid balance following heart transplant can be challenging. It is essential to keep a fluid balance record, to check the patient's weight daily, as well as make regular checks of their urea and electrolyte levels, and do clinical examinations. Patients are often oedematous, and this is caused by a combination of fluid overload and having low albumin levels preoperatively. Diuretics are frequently used but care must be taken not to cause hypovolaemia.
Most patients will present with renal dysfunction at the time of transplant, secondary to heart failure. The insult of surgery, potential hypotensive episodes perioperatively and nephrotoxic anti-rejection therapy usually worsens renal function in the early days.
Regular monitoring of urea and electrolyte levels, maintenance of optimal fluid balance and avoidance of unnecessary nephrotoxic drugs will help. Dialysis may, occasionally, be necessary. Renal-dose dopamine is no longer used routinely for all patients, as many studies have questioned its value (Kellum et al, 2001).
Rejection following cardiac transplant is most common in the first six to 12 weeks, although it can occur at any time. Triple therapy anti-rejection treatment consisting of cyclosporin, azathioprine and prednisolone is most commonly administered postoperatively, but the drug regimen will vary from centre to centre. Agents such as tacrolimus, and mycophenolate mofetil can also be used.
All anti-rejection therapy has side-effects that include:
- Abnormal liver function;
- Bone-marrow suppression;
- Post-transplant lymphoproliferative disease;
- Increased incidence of skin cancer/malignancies;
- Acne/moon face/facial hair;
Non-compliance (see Post-operative psychological issues below) is also often associated with drug side-effects, and should not be underestimated.
Signs and symptoms of rejection may include:
- Weight gain;
- Low grade temperature;
- Lethargy/general malaise;
- Shortness of breath;
- Soft heart sounds/S3 gallop.
Balancing the dose of anti-rejection drugs is crucial both to minimise rejection and avoid a high level of side-effects.
The most accurate way of determining rejection remains endomyocardial biopsy (Caves, 1974; Billingham, 1990). This is initially carried out at weekly intervals and gradually reduced in frequency, according to individual need. Biopsy specimens are examined and graded according to the International Society of Heart and Lung Transplantation guidelines as described by Hakim (1997). Forty per cent of patients will require treatment for rejection in the first six weeks, through intravenous administration of methyl prednisolone 10mg/kg for three days.
Patients taking immunosuppressive drugs are inevitably at risk of infection. All patients are initially nursed in cubicles with restricted visiting. The focus of care to minimise infection risk is early extubation, the removal of lines and ambulation. Antibiotic therapy of flucloxacillin 500mg four times a day is given for 48 hours. In addition, short-term anti-infective treatment will include nystatin suspension (antifungal mouthwash); acyclovir 200mg three times a day (antiviral); and sulfamethoxazole trimethoprim 480mg once a day (to prevent Pneumocystis carinii infection).
Any signs and symptoms of infection including pyrexia and raised white-cell count will be investigated and, where possible, an organism identified before further antibiotics are commenced; broad-spectrum antibiotics are rarely used. Patients are taught to take their own temperature and recognise signs and symptoms of common infections.
Good pain control is essential to aid recovery from transplant and facilitate cooperation with physiotherapy (Coleman and Bucker-Milburn, 1996). Although all patients are assessed individually, patient-controlled analgesia (morphine) is commonly used, followed by oral dihydrocodeine and paracetamol. Patients are encouraged to express their needs. Referral to the specialist pain team can be made, if necessary.
All patients are assessed for the risk of deep-vein thrombosis and will usually be prescribed low molecular weight anticoagulants once a day until they are mobile. Patients who develop thromboembolic problems may require formal anticoagulation therapy.
Mobility and independence are encouraged as the patient's condition and confidence improve: they are encouraged to sit out of bed on day two, start walking around at four to five days postoperatively and attend the gym on day eight, following a satisfactory cardiac biopsy result. Each patient will require an individual exercise plan tailored to his or her needs (Thompson, 1995).
Nutrition and hydration
As soon as adequate gastrointestinal function is established, patients are encouraged to eat and drink, and intravenous fluids are discontinued. A good fluid intake of 2L in 24 hours is optimal. In the early postoperative period, a diet high in protein and calories is encouraged to aid recovery and tissue repair (Verity, 1996).
Early dietetic input is established, as patients may require advice on low-potassium, low-sugar or high-magnesium needs. Long-term advice will recommend patients adhere to a low-saturated fat diet, to prevent obesity and raised lipid levels. Constipation will be treated with basic interventions.
Patients will usually be mobile and independent about one week postoperatively, inotropes and monitoring will normally have been discontinued, and the focus of care will shift to education and rehabilitation. It is often around this time that a patient's emotional and psychosocial needs increase.
Postoperative psychological issues
Although successful transplantations have much to do with advances in surgical technique, physical management and immunosuppression, a patient's emotional and behavioural responses contribute significantly to long-term survival and progress following transplantation.
The education process starts as soon as the patient is able to cope with it (three to seven days postoperatively). This is a structured programme that covers self-medication, awareness of side-effects, self-monitoring of signs and symptoms of rejection and infection, checking temperature and weight, and general health advice. Teaching is relaxed and informal and continues in the outpatient clinic.
Transplantation support is family focused; lack of carer support has been identified as a cause for non-compliance and, therefore, poor recovery (Dew et al, 1996). It is, however, important that the transplant recipient takes responsibility for their recovery and well-being.
Both patient and family will initially feel euphoria following a successful transplant, and may have difficulty accepting potential complications in the postoperative period (Suszycki, 1990). As a result, if complications occur they can be devastating, owing to a growing realisation that the patient's lifespan is unpredictable (Mishel and Murdaugh, 1987).
The emotional and psychological trauma of transplantation cannot be underestimated. After the initial feelings of euphoria, the recipient may become depressed and irritable. It is an important aspect of the transplant nurse's role to help the patient and family through some of the difficulties. It is important that the nurse be aware of the feelings the patient may be experiencing.
It is the policy at our centre to discuss donor details such as age/sex/cause of death. Some patients have an overwhelming need to know about their donor, others may ask years later, and some never feel the need to discuss donor issues. Patients are supported through this time. Thank-you letters can be passed to donor families via the transplant coordinators.
The stress of waiting for a transplant and coming to terms with life afterwards, including changes in life expectancy, long-term complications, and a changing of roles (from sick to well).
Partners often put their life on hold until after the transplant and take on the main role in the family. After transplant it may be difficult to give up these acquired responsibilities, which can result in conflict between the patient and their partner (Mishel and Murdaugh, 1987). Relationship problems experienced pre-transplant can often be heightened rather than resolved after the operation.
Side-effects from medication
All patients will initially be started on a regimen of high-dose steroids which in themselves can result in depression even before the occurrence of side-effects such as obesity and excessive hair growth.
Body image and compliance
Changes in body image can affect the patient's recovery and subsequent drug compliance. Non-compliance with drug therapy/clinic attendance can result in transplant rejection, increased mortality and excessive health costs (DeGeest et al, 1996).
DeGeest et al also identify adolescents as a higher risk group for non-compliance than the over-forties. Younger recipients often perceive themselves as victims, whereas older recipients are grateful for a second chance (Mishel and Murdaugh, 1987). Many adolescents have difficulty in coping with the altered body image caused by the medication.
Multidisciplinary interventions used to improve compliance and patient recovery include:
- Thorough explanations of the need for medication and clinic visits (even when the patient feels well);
- The planning of medication regimens to fit into the person's lifestyle, through mutually acceptable times, (Cramer, 1991);
- The creation of opportunities to discuss emotional issues, for example, hospital helplines;
- Good rehabilitation (DeGeest et al, 1996).
Rehabilitation and outpatient care
Rehabilitation and education are ongoing processes following the operation, culminating in discharge into hospital accommodation or home within two to three weeks of transplantation.
Outpatient visits are frequent in the early postdischarge period, and medications, investigations and follow-up are adjusted on an individual basis. Within three months, the majority of patients will be able to lead a normal lifestyle and many consider returning to work.
In this time of surgical and medical miracles, it is important to recognise that for the well-being and long-term survival of transplant patients, the multidisciplinary input of transplant coordinators, nurses, social workers, psychologists, physiotherapists, chaplains and even ward domestics is paramount. Despite the worry and upheaval of having a transplant, the recipients see the process as worthwhile (Greaves, 1997).
Transplantation is a specialty that depends not only on the medical staff, but on the team as whole. Furthermore, none of this would be possible without the courage of the donor families and the dedication of the teams that support them.