Who was the first to perform a human heart transplant? Reasons for heart transplant. Specific indications and conditions for heart transplantation

Heart transplantation has become an established treatment for end-stage heart failure. Candidates for heart transplantation are patients in whom conservative therapy is ineffective, while others surgical methods correction of heart disease is not indicated due to insufficient myocardial function.

Key considerations in heart transplantation are evaluation and selection of recipients, as well as postoperative management and immunosuppression. Consistent implementation of these steps in accordance with heart transplant protocols is the key to the success of the operation.

History of heart transplant

The first successful human heart transplant was performed by Christian Barnard in South Africa in 1967. Early research in this area was carried out by scientists in various countries: Frank Mann, Marcus Wong in the USA, V.P. Demikhov in the USSR. Success early operations was limited by the imperfection of technology and equipment for artificial blood circulation, and insufficient knowledge in immunology.

A new era in transplantology began in 1983 with the clinical application cyclosporine. This increased survival rates, and heart transplants began to be performed in various centers around the world. In Belarus, the first heart transplant was performed in 2009. The main limitation to transplantation worldwide is the number of donor organs.

A heart transplant is an operation to replace the heart of a patient with end-stage heart failure with a heart from a suitable donor. This operation is performed on patients with a survival prognosis of less than one year.

In the United States, the annual heart transplant rate for patients with heart failure is about 1%.

Diseases for which heart transplants are performed:

• Dilated cardiomyopathy – 54%

• Ischemic cardiomyopathy with coronary disease hearts - 45%

• Congenital heart pathology and other diseases – 1%

Pathophysiology of heart transplantation

Pathophysiological changes in the heart in patients requiring heart transplantation depend on the cause of the disease. Chronic ischemia causes damage to cardiomyocytes. In this case, a progressive increase in the size of cardiomyocytes, their necrosis and scar formation develops. The pathophysiological process of coronary heart disease can be influenced by selected therapy (cardioprotective, antiplatelet, hypolipidemic), performing coronary artery bypass grafting and angioplasty with stenting. In this case, it is possible to slow down the progressive loss of heart muscle tissue. There are also cases of damage to the distal coronary bed; in these cases surgical treatment ineffective, the function of the heart muscle gradually decreases, and the cavities of the heart expand.

The pathological process underlying dilated cardiomyopathy has not yet been studied. Apparently, the deterioration of myocardial function is influenced by mechanical enlargement of cardiomyocytes, dilation of the heart cavities and depletion of energy reserves.

Pathophysiological changes in a transplanted heart have their own characteristics. Denervation of the heart during transplantation leads to the fact that the heart rate is regulated only humoral factors. As a result of reduced innervation, some myocardial hypertrophy develops. The function of the right heart in the postoperative period directly depends on the time of graft ischemia (from cross-clamping of the aorta during donor heart collection to reimplantation and reperfusion) and the adequacy of protection (perfusion of the preservative solution, temperature in the container). The right ventricle is very sensitive to damaging factors and in the early postoperative period may remain passive and not perform any work. Within a few days, its function may be restored.

Pathophysiological changes include rejection processes: cellular and humoral rejection. Cellular rejection is characterized by perivascular lymphocytic infiltration and, in the absence of treatment, subsequent myocyte damage and necrosis. Humoral rejection is much more difficult to describe and diagnose. Humoral rejection is thought to be mediated by antibodies that deposit in the myocardium and cause cardiac dysfunction. The diagnosis of humoral rejection is mainly clinical and is a diagnosis of exclusion, since endomyocardial biopsy in these cases is not very informative.

A late process characteristic of cardiac allografts is atherosclerosis of the coronary arteries. The process is characterized by hyperplasia of the intima and smooth muscles of small and medium-sized vessels and is diffuse in nature. The reasons for this phenomenon often remain unknown, but it is believed that cytomegalovirus infection(CMV infection) and rejection reaction. This process is thought to depend on the release of growth factor into the allograft by circulating lymphocytes. There is currently no treatment for this condition other than a repeat heart transplant.

Clinical picture

Candidates for heart transplantation are patients with heart failure of classes III-IV according to the New York classification.

To determine tactics and select treatment functional assessment heart failure is often carried out according to the New York Heart Association (NYHA) system. This system takes into account symptoms depending on the patient's activity level and quality of life.

Indications

The general indication for heart transplantation is severe decline in cardiac function for which the prognosis for survival at one year is poor.

Specific indications and conditions for heart transplantation

• Dilated cardiomyopathy

• Ischemic cardiomyopathy

• Congenital heart disease with ineffectiveness or absence effective treatment(conservative or surgical)

• Ejection fraction less than 20%

• Intractable or malignant arrhythmias when other therapy is ineffective

• Pulmonary vascular resistance less than 2 Wood units (calculated as (PAP-CVD)/SV, where PAP is wedge pressure pulmonary artery, mmHg.; CVP – central venous pressure, mm Hg; CO – cardiac output, l/min)

• Age less than 65 years

• Willingness and ability to follow the plan further treatment and observations

Contraindications

• Age over 65 years; this is a relative contraindication and patients over 65 years of age are assessed individually
• Sustained pulmonary hypertension with pulmonary vascular resistance greater than 4 Wood units
• Active systemic infection
• Active systemic disease, such as collagenosis
• Active malignancy; Patients with a predicted survival of more than 3 or 5 years may be considered candidates; tumor type should also be taken into account
• Smoking, alcohol abuse, drug abuse
• Psychosocial instability
• Reluctance or inability to follow the plan for further treatment and diagnostic measures

Survey

Lab tests

General clinical examinations are performed: general analysis blood with counting formula and platelets, general urine analysis, biochemical analysis blood (enzymes, bilirubin, lipid spectrum, nitrogen metabolism indicators), coagulogram. The test results must be within normal limits. Pathological changes should be clarified and, if possible, corrected.

The blood type, a panel of reactive antibodies are determined, and tissue typing is performed. These tests form the basis of the immunological match between donor and recipient. A cross-match test with donor lymphocytes and recipient serum (cross-match) is also carried out (determination of anti-HLA antibodies).

Screening for infectious diseases

Examination for hepatitis B, C. For carriers of the disease and patients with an active process, as a rule, a heart transplant is not indicated (this is a relative contraindication). Hepatitis in recipients is treated differently in different centers around the world; until now consensus on this issue no.

HIV testing

A positive HIV test is considered a contraindication for heart transplantation.

Virological screening

Epstein-Barr virus, cytomegalovirus, herpes simplex virus. Exposure to these viruses in the past (IgG) and the presence/absence of an active process (IgM) are analyzed. A history of infection with these viruses indicates increased risk reactivation of the disease. After heart transplantation, these patients require appropriate prophylactic antiviral treatment.

It should be noted that active infectious diseases should be treated when preparing a patient for heart transplantation (ie, during observation and waitlisting). Patients with a negative test for cytomegalovirus infection are usually prescribed cytomegalovirus immunoglobulin (Cytogam). During the observation period before transplantation in America, it is recommended to immunize patients with negative tests for IgG to other viral agents.

Tuberculin skin test

Patients with positive breakdown require additional evaluation and treatment before being placed on the heart transplant waiting list.

Serological tests for fungal infections

Serological studies on fungal infections also help to anticipate an increased risk of reactivation of the process after surgery.

Screening for cancer

Screening for oncological diseases carried out before inclusion on the waiting list.

Prostate-specific antigen (PSA) test

Prostate-specific antigen (PSA) test. At positive analysis appropriate assessment and treatment is required.

Mammography

Women should have a mammogram. The condition for inclusion on the waiting list is the absence of pathology on the mammogram. In the presence of pathological formations, an oncological examination and, possibly, treatment are necessary before inclusion on the waiting list.

Cervical smear examination

The condition for inclusion on the waiting list is the absence of pathological changes. If pathology is present, an oncological examination and, possibly, treatment are necessary before inclusion on the waiting list.

Instrumental examinations

For cardiopathy, coronary angiography is performed. This study allows you to select patients who can undergo coronary artery bypass grafting (with correction of valve pathology), angioplasty with stenting.

Echocardiography is performed: ejection fraction is determined, cardiac function is monitored in patients on the waiting list for a heart transplant. An ejection fraction of less than 25% indicates a poor prognosis for long-term survival.

To exclude other pathologies of the chest organs, an x-ray of the chest organs is performed, possibly in two projections.

A function test may be used to assess lung function. external respiration. Severe uncorrectable chronic illness lungs is a contraindication to heart transplantation.

To assess global cardiac function, maximum oxygen consumption (MVO 2) is determined. This indicator is a good predictor of the severity of heart failure and correlates with survival. MVO 2 below 15 indicates poor prognosis one-year survival rate.

Diagnostic invasive procedures

An acute rejection reaction can manifest itself immediately after restoration of blood flow, as well as during the first week after surgery, despite immunosuppressive therapy.

The main problem in modern transplantology is infectious complications. To prevent infections, special organizational and pharmacological measures are taken. In the early postoperative period, bacterial infections often develop. The incidence of fungal infections increases with the presence of diabetes mellitus or excessive immunosuppression. Prevention of Pneumocystis pneumonia and cytomegalovirus infection is carried out.

The main method for diagnosing a rejection reaction is endomyocardial biopsy. Depending on the severity of the process, it is possible to intensify the immunosuppression regimen, increase the dose of steroid hormones, and use polyclonal or monoclonal antibodies.

The leading cause of death and allograft dysfunction in long term is a pathology of the coronary arteries. In the arteries of the heart, progressive concentric hyperplasia of smooth muscle and intima occurs. The reason for this process is unknown. Cytomegalovirus infection and rejection are thought to play a role in this process. Studies show that with severe initial ischemia and reperfusion injury of the donor organ and repeated episodes of rejection, the risk of coronary artery disease increases. The treatment for this condition is a repeat heart transplant. In some cases, stenting the affected artery is appropriate.

Outcome and prognosis

According to American estimates, survival after heart transplantation is estimated at 81.8%, 5-year survival rate is 69.8%. Many patients live 10 years or more after transplantation. Functional status recipients are usually good.

Prospects and problems of heart transplantation

The lack and impossibility of long-term storage of donor organs was the impetus for the development alternative techniques treatment of terminal heart failure. Various circulatory support systems (artificial ventricles of the heart) are being created, resynchronization therapy is being carried out, new drugs are being studied, research is being conducted in the field of genetic therapy, and in the use of xenografts. These developments have certainly reduced the need for heart transplants.

Prevention and treatment remain pressing challenges vascular pathology transplant. Solving this problem will further increase the survival rate of patients after heart transplantation.

The issues of selecting recipients and drawing up a waiting list remain problematic from a medical and ethical point of view. We also have to talk about the economic problems of transplantology: the high cost of organizational support for the process, postoperative therapy and patient monitoring.

Heart transplant in Belarus - European quality at a reasonable price

Heart transplantation is a complex, important and expensive procedure. Sometimes it's the only way save a person's life.

Many people have been waiting for a donor organ for many years due to the fact that there are not enough transplants for everyone. To get on the waiting list, you must consult a cardiologist and fill out special documents. Sometimes a patient can be moved to the top of the list, but only in case of serious pathologies, when there is no time to wait.

Information about first transplants

The first attempts were made in the middle of the last century, but most of them were unsuccessful: the recipients died. This was due to lack of equipment, immunosuppressive therapy, lack of experience and understanding of the problems.

The first successful transplant was registered in 1967, performed by Christian Barnard. This marked the beginning of a new phase in transplantation, and the introduction of cyclosporine in 1983 further accelerated the process.

The drug increased the chances of patients by improving the survival rate of the donor heart.

Despite the development of medicine, there is a large shortage of donor organs in modern transplantation. This is due to the principles of legislation and lack of public awareness of the importance of transplantation.

What is the procedure

Surgery allows you to remove the diseased, damaged heart and replace it with a new one. Basically, the procedure is carried out in the terminal stage of heart failure, the presence of disturbances in the functionality of the ventricles and myocardium.

Ventricular failure can develop when congenital defect heart, defect of one of the ventricles or valves.

The operation is quite complex and expensive; in addition, it can have many risks, since no one knows whether the organ will take root or not.

In general, the annual survival rate is 88%, 75% of patients remain viable for 5 years, only 56% of all operated patients survive for more than 10 years.

Repeated heart transplantation is also possible, but each time the likelihood of the donor organ surviving decreases. That is why it is rarely performed twice.

Indications for surgery

Basically, the procedure is prescribed to patients with severe heart failure stages 3-4. They experience weakness, tachycardia, and severe shortness of breath. Even with a slight load or at rest in the most advanced stages, the prognosis for survival is poor, so an urgent transplant is necessary.

In addition, the indications for transplantation are as follows:

• Dilated cardiomyopathy.
• Ischemic disease, myocardial dystrophy in serious condition.
• Development benign tumor in the organ area.
• Significant rhythm disturbances that do not respond to medical therapy.
• Congenital heart anomaly that cannot be corrected with plastic surgery.

Contraindications

Most often, transplantation is performed on patients under 65 years of age. A very important factor is the patient’s desire; if it is absent, the procedure is inappropriate.

• Increased pulmonary artery pressure exceeding 4 Wood units.
• Infectious diseases in the acute stage, sepsis.
• Connective tissue disease or autoimmune pathology, for example, rheumatism, ankylosing spondylitis, scleroderma, lupus.
• Malignant formation on the heart.
• Chronic pathologies in the stage of decompensation.
• Disease mental nature when contact with the patient before and after transplantation is impossible.
• Obesity.

Absolute contraindications include alcohol abuse, smoking, and any narcotic substances.

Preparing for transplant

Before registering or undergoing surgery, patients are required to undergo laboratory and instrumental examinations.

The recipient must undergo:

• Fluorography, radiography of the sternum.
• Mammography and cervical smear for women, PSA for men. These tests allow us to determine oncological pathologies.
• Ultrasound, ECG.
• Coronary angiography, through which the condition of the blood vessels can be assessed. If necessary, stenting or bypass surgery is performed.
• Catheterization right side heart, when the pressure in the vessels of the pulmonary circulation is determined.
• Taking blood tests for hepatitis, syphilis, HIV, coagulation, group and rhesus, general clinical.
• Analysis of urine.
• Examination by a cardiologist, gynecologist, ENT specialist and, if necessary, other specialists.

Very important analysis is immunological typing according to the HLA system, thanks to which it is possible to determine the most suitable donor heart. Before the transplant, a test is done with the donor's lymphocytes to determine the degree of match between the graft and the recipient.

Who can be a donor

Usually the implanted organ is taken from dead people in case of an accident, serious injury or brain death. The ideal is a transplant that is not affected by coronary disease and has no dysfunction.

It is desirable that the donor does not have heart disease and is under 65 years of age. It is very important that the transplanted organ is the right size.

Always pay attention to immunological compatibility, which shows the percentage of success of the procedure.

Immediately after the heart is removed from the donor, it is placed in a cold cardiac solution and transported to a thermally insulated container. It is important that transportation occurs as soon as possible (no more than 6 hours) after the organ is removed from the human body.

How long does it take to get a donor heart?

If a patient requires a transplant procedure, he is placed on a waiting list at the transplant center. This institution maintains contact with medical organizations, where donors can appear.

You can get a referral to get on the quota line from a cardiologist or cardiac surgeon after consultation and passing all examinations. It is unknown how long they will have to wait in line; some patients may not wait for a transplant and die if the pathology does not tolerate delay.

Most people only have 1-2 years to wait while their condition is maintained with medication. As soon as a suitable donor is found, the operation is immediately carried out either planned or emergency.

How is the wait for a donor heart going?

While waiting and preparing, cardiac pathologies are treated with medication. For chronic deficiency, beta blockers, glycosides, diuretics, ACE inhibitors and calcium antagonists are prescribed.

If the patient gets worse, he is taken to the transplant center for cardiac surgery. There they connect a special device to carry out blood flow through bypass routes. It is in this case that the patient may be moved to the top of the waiting list.

Types of surgery

The most common methods are heterotopic and orthotopic transplantation. In the first case, the native organs remain, and the graft is placed on the lower right. In the second case, the patient's heart is removed, and the donor's is fixed in the place where the recipient's heart was.

The most common is the orthotopic method.

How is the operation performed?

Immediately before the transplant, a blood test, blood pressure and sugar levels are checked. Heart transplantation is performed under general anesthesia and lasts on average from 6 to 10 hours. During this period, the process of artificial circulation should be well established.

First, the doctor treats the desired surface and makes a longitudinal incision, opening the chest. The patient is connected to a heart-lung machine through the vena cava.

Having gained access to the organ, its ventricles are removed, but the atrium is left and great vessels. The donor heart is sutured at this site. Since there are two types of transplantation, depending on the chosen one, the organs are secured.

In the heterotopic form, the native organ is left in place and the graft is placed to the lower right of the heart. Next, anastomoses are laid between the chambers and vessels. In this case, two organs can cause compression of the lungs. Basically, the operation is performed in patients with severe pulmonary hypertension.

Orthotopic transplantation involves suturing one's own atria to donor ones after removal of the ventricles. The vena cava can be sutured separately, this will reduce the load on the right ventricle.

Sometimes the procedure is combined with tricuspid valve repair to prevent the development of tricuspid valve insufficiency.

Transplant surgery in childhood

In children, the transplant is somewhat more difficult than when the operation is performed on an adult. Therefore, transplantation in children is extremely rare, only if the patient suffers end-stage heart disease with limited physical activity. In this case, if refused, the recipient is given no more than 6 months.

An absolute contraindication to surgery for children in early age is the presence of systemic pathologies or uncontrolled infection in an active form.

When a patient is put on the waiting list, the life prognosis is disappointing; he has to wait from 1 week to 1.5 years. 20-50% of these people die before receiving a transplant.

The five-year survival rate in children is about 45-65%; within one year this figure is slightly higher and amounts to 78%. No more than 72% live for about 3 years, and only 25% live longer than 11 years after transplantation.

A very serious problem in the treatment of children is high mortality. In addition, late rejection occurs more often, nephrotoxicity occurs with long-term use of cyclosporines, and coronary atherosclerosis develops faster.

When the operation is performed on a child within six months after birth, the one-year survival rate is no more than 66%. This is due to vascular inconsistency.

The most dangerous reconstruction of the aortic arch is when deep hypothermia and circulatory arrest are performed.

Scar after transplant

For a heart transplant patient, an incision is made from the neck to the middle of the navel. The scar remains for life, it is quite noticeable. To hide it, you have to wear closed clothes or use various means for skin correction in the damaged area. Some do not hide it and are even proud of it.

How long does rehabilitation take?

After transplantation, there are 4 stages of rehabilitation:

• The first is called the “reanimation period” and takes from 7 to 10 days.
• The second is called sick leave period, lasts up to 30 days.
• The post-hospital period extends to 12 months.
• And the fourth phase can go more than a year after transplantation.

At the first and second stages, a treatment regimen, immunosuppression and necessary research. In the third phase, the patient is transferred to a maintenance regimen of immunosuppression, but every month it is necessary to undergo hemodynamic assessment and immunological monitoring. At the fourth stage, the patient can already return to his usual labor activity, but some control measures still remain.

After the operation, the patient is left in the department intensive care for a few days. He may be given oxygen for the first 24 hours. During this period, continuous cardiac monitoring occurs to see how the donor heart is functioning. It is important to monitor the functioning of the kidneys, brain and lungs.

For several months after discharge, the patient must undergo special training 1-2 times a week. medical examinations to check for infection and complications in the graft.

Basic rules for recovery after surgery

After transplantation, vasoprotectors and cardiotonics are prescribed. The amount of ionized calcium must be checked to see how the heart works. In addition, it is measured acid-base balance, immunosuppressive therapy is prescribed to prevent organ rejection.

Immediately after awakening from anesthesia, the patient is disconnected from the machine, and the amount of cardiotonics is reduced. To assess the functionality of the graft, they resort to the method of myocardial biopsy.

In addition, the following may be carried out:

• Tests for the presence of infection.
• X-ray of the lungs.
• Electrocardiogram.
• Echocardiography.
• General biochemical blood test, as well as checking the functioning of the kidneys and liver.
• Blood pressure control.

Restrictions

In order to exclude serious consequences and complications, as well as to improve organ engraftment, it is necessary to follow a certain lifestyle:

• Take recommended medications: cytostatics and hormones that help weaken your own immunity so that foreign tissue can take root well.
• Observe restrictions on physical activity for several months. And on the recommendation of a doctor, you can perform the compiled gymnastics daily.
• Monitor your diet, excluding unhealthy foods, for example, fatty, fried, smoked foods.
• Protect yourself from infection. Life after surgery changes a lot; in the first months the patient should avoid crowded places and those suffering from infectious diseases. You should also wash your hands with soap and drink boiled water and eat processed foods. This is necessary because due to immunosuppressive therapy, your own immunity becomes weaker and even a minor infection can lead to serious complications.

The benefits of proper nutrition

After transplantation, it is important to stick to a daily routine and only consume healthy food without burdening the cardiovascular system with harmful foods and dishes.

Fractional nutrition means 5-6 meals during the day. This helps reduce stress and prevent obesity. Long intervals between meals should not be allowed.

The diet implies an exception:

• Sausage products.
• High-fat dairy products, including hard cheeses.
• Fatty meat.
• Smoked meats.
• Muffins.
• Meat by-products.
• Egg yolk.
• Semolina and rice cereals, pasta.

Alcohol and smoking are strictly prohibited. Carbonated drinks and energy drinks are very harmful. It is better to avoid sweet and salty foods. But if you can’t eat fresh food, then it’s better to switch to iodized salt, but not more than 5 g per day. For sweets, you can eat dried fruits.

It is useful to steam or boil foods. The last meal should take place no later than 2-3 hours before bedtime.

You need to include in your diet:

• Vegetables and fruits.
• Steamed fish.
• Low-fat kefir.
• Seafood.
• Persimmon.
• Nuts.
• Garlic.
• Tomatoes.
• Olive and corn oil.
• Barley, barley, buckwheat, oatmeal.
• Bran, rye bread.

Important in postoperative period reduce the calorie content of food to 2500 Kcal. Proteins should take up half of the diet, with 25% of them being plant origin. About 40% is allocated to fats daily menu, but they are exclusively plant-based. And carbohydrates remain 10%. Liquids can be no more than 1.5 liters per day.

Do they give disability

Typically, patients who need a transplant already have a disability of the corresponding group. Depending on how the operation went and how the patient feels after the transplant, the medical commission considers an extension or switch to another group.

There are no precisely regulated rules for establishing a group in this case, so everything is decided according to individual indicators patient.

Most often, group 2 is given with a review after 1-2 years, but they can also be given permanently.

Lifespan

After heart transplantation, survival after 1 year is 85%. Subsequently, some patients experience rejection, changes due to infectious diseases, and the percentage drops to 73.

Life expectancy of more than 10 years is observed in no more than half of all patients who have undergone a heart transplant.

Basically, a new heart functions properly from 5 to 7 years, but it is more susceptible to dystrophy than its own healthy organ.

Gradually, a person may feel a deterioration in their condition, but there are cases when a person, even after so much time, is in excellent health.

Complications after surgery

The most serious consequences Graft rejection is considered. This may not happen immediately, but after several months. To the early postoperative complications include bleeding and infection.

If the first happens, the wound is opened again and the bleeding vessel is sutured. To prevent the development of bacterial, viral or fungal infections, antibiotics and immunosuppression are prescribed.

In addition, an oncological disease in the form of lymphoma or myeloma may develop; immunosuppressants contribute to this, as they suppress the immune system. Ischemia may occur if the organ was not implanted immediately, but more than 4 hours after removal from the donor body.

In addition, after surgery you may experience:

• Increased pressure on the heart, this is due to the amount of fluid in the space around the organ.
• Irregular heartbeat.
• Decreased cardiac output.
• An increase or decrease in the volume of blood in the circulatory system.

Half of patients develop coronary artery disease within 1-5 years after surgery.

During the postoperative period, you can suspect that something went wrong when:

• Chest pain, shortness of breath.
• Severe cough.
• Swelling.
• Migraines and dizziness on a constant basis.
• High temperature.
• Arrhythmias combined with nausea and vomiting.
• Coordination problems.
• Increased or decreased blood pressure, deterioration of general health.

Heart transplantation is considered very complex operation. The main difficulty is the lack of a donor organ according to the quota, and half of the patients die without receiving one.

In addition, even if the patient is operated on in a timely manner, organ rejection or wound infection may occur, which can lead to death. However, a transplant is very often the only salvation for patients with severe heart pathologies. And if everything went well, then the recipient receives new page life spans from 1 year to 11 years, and sometimes more.

The famous heart surgeon Christian Barnard performed the first heart transplant, was also a writer and an ardent opponent of apartheid.

Today, heart transplantation has become a routine operation. People with donor hearts work, get married, and play sports. They bear and give birth to children.

The first human heart transplant occurred on December 3, 1967 - 48 years ago. The heart surgeon who decided to perform this operation is Christian Barnard. He also owns the phrase: “Even a transplanted heart is capable of love.”

Christine Barnard's first successful operation was a kidney transplant in October 1967. Inspired by his success, Barnard began looking for a patient who would agree to a heart transplant. We didn't have to wait long. 54-year-old Polish emigrant Louis Washkanski, who suffered from an incurable heart disease, accepted the professor’s offer to become the first heart transplant patient.

The patient had no other chance to survive. All that remained was to wait for a donor organ, and Washkansky received it. The heart was taken from a 23-year-old girl who died in a car accident. On December 3, 1967, at half past one in the morning, two teams of surgeons began the operation. After several hours of painstaking work, at half past five, the transplanted heart began to beat.

The next day, Barnard woke up famous, and the front pages of the newspapers were full of headlines reporting a sensation in the field of medicine. However, Dr. Barnard this moment I was only worried about how the body would behave in relation to someone else’s heart.

Fortunately, it continued to work, so well that after a few days the patient was allowed to get out of bed. But trouble came from the other side - powerful doses of immunosuppressants weakened Washkansky’s immunity. The patient fell ill with pneumonia, from which he could not recover. Eighteen days - exactly how long the first transplanted heart beat.

Soon, trouble came to the surgeon’s house: first his son died tragically, and then his wife left Christian. At the same time, Professor Barnard decided to leave surgery and began to pay more attention to the problem of slowing down aging.

Like Professor Preobrazhensky from Bulgakov’s novel, in his declining years Barnard took up issues of rejuvenation. He collaborated with a Swiss clinic where rejuvenation procedures were carried out. Barnard was also concerned about his own aging. There were secret reasons for this: he fell in love again.

In 1987, Christian married a beautiful fashion model who was 40 years younger than her famous husband. The couple had two children, but this marriage, the third in the surgeon’s life, turned out to be short-lived. However, life's adversities did not deprive the doctor of optimism. Thinking about the problem of conservation healthy heart, he came to the conclusion that his own life could serve as an illustration of how such a heart could be preserved. As a result, the book “50 Ways to a Healthy Heart” was born.

In it, the famous surgeon expressed an unconventional view of health, rejecting many common truths. This book, he said, was supposed to teach people to avoid heart disease and prolong a full life.

The book of the famous surgeon contains many valuable recommendations and is full of paradoxes. For example, "be careful with strict diets. After most weight loss courses, it's only your wallet that's thinner." Barnard urged people not to stress over trifles. He believed that people often create their own experiences. "Most things that cause stress are not worth it," he wrote. Nevertheless, Barnard believed that stress in itself is not dangerous. It tones, activates the brain, increases protective forces body.

IN last years Throughout his life, Barnard observed with alarm the changes taking place in medicine. He was outraged by the new type of technocratic doctors who treat using high technology, but forget the importance of the human relationship between doctor and patient.

Barnard achieved success not only in professional activity, but also as a writer. An ardent opponent of apartheid, he published a number of autobiographical books and wrote a novel about blood donation. Several publications immediately invited him to become the host of a column about a healthy lifestyle, and Barnard gladly shared his thoughts from the newspaper pages.

Christian Barnard died in September 2001 while on holiday in Cyprus. And how strange life is! A man who knew everything about the heart, more than once held this organ in his hand and saved thousands of heart patients from inevitable death, himself became a victim of a heart attack.

The world record for life expectancy with a transplanted heart is held by the American Tony Huseman: he lived with a transplanted heart for 32 years and died from a disease unrelated cardiovascular system. The first heart transplant in the USSR was performed on November 4, 1968 by a group of doctors led by Academician of the USSR Academy of Medical Sciences Alexander Aleksandrovich Vishnevsky. It ended unsuccessfully, and “the topic was closed.” The first successful operation of this kind took place on March 12, 1987, under the leadership of Academician Valery Ivanovich Shumakov.

Igor Chervyakov

Heart transplant: the essence and reality of the operation, indications, implementation, prognosis

Heart transplantation as a separate field of medicine arose at the intersection of cardiology and immunology - a science that deals with human immunity and has crucial in matters of graft engraftment and rejection(“planted” biomaterial).

The first research conducted in the field of heart transplantation began in the fifties of the last century. Successful operations were carried out by doctors in South Africa and the USA in the 80s. The first heart transplant in the USSR was performed in 1988 by V.I. Shumakov. Due to the fact that the immunological basis of graft-host reactions was previously insufficiently studied, the quality of life and its duration after surgery did not correspond to the desired results, and the prognosis was uncertain.

At the present stage, the level of knowledge makes it possible to carry out such operations with minimal risk development of complications and with sufficient life expectancy after heart transplantation (slightly less than half of patients live more than 10 years after surgery).

In some cases it is even possible repeated transplants, for example, one of richest people world, according to Forbes magazine, David Rockefeller, at the age of 99, underwent his sixth heart transplant.

Indications for surgery

Heart transplant surgery is one of the least common operations in cardiac surgery. This is due not only to large financial costs, but also to the following nuances:

• Limited number of donors - persons with confirmed brain death, but with a healthy heart,
• The long period of time required to select a donor according to waiting lists, especially for heart transplant surgery for a child,
• Problems of an ethical nature, including from a religious point of view (in particular, according to Christian ideas, a person is considered alive as long as his heart beats),
• Problems of postoperative management of patients associated with duration and high cost rehabilitation period,
• Short period of storage of the donor heart (up to six hours).

However, despite the problems of this kind, operations, although rare, are still carried out, and very successfully.

The main indication in which a heart transplant is needed is the terminal (final) stage (CHF), or 3 - 4 functional class(FC), which cannot be treated with medications, with a survival prognosis for this condition of less than a year.

It is the symptoms characteristic of the last stage (pronounced limitation of activity, significant swelling of the limbs or the whole body, appearance at rest) that, if conservative therapy is ineffective, may require a donor heart transplant.

Such severe heart failure can develop due to the following diseases:

In addition to the above indications, data taken into account objective methods studies (ultrasound of the heart and pulmonary artery catheterization):

• less than 20%,
• Lack of heavy

Certain conditions must also be met when planning an operation:

1. The age of the recipient (the person to whom the heart will be transplanted) is less than 65 years old,
2. The patient's diligence and desire to follow a further strict treatment and observation plan.

What should a donor's heart look like?

A person in a coma with confirmed death can become a heart donor brain, whose cardiac activity is supported by equipment in intensive care unit. As a rule, such severe patients are observed in the hospital after an accident or. That is in fact, the person is already dead, since the artificial lung ventilation device breathes for him, and the heart works with the help medications . But if such a heart is implanted into another person, it will work autonomously in the new organism. In order to remove the heart from the body of such a patient, the consent of relatives or the patient himself, written during his lifetime, is required. If there are no relatives, or the patient remains unidentified, his heart can be taken away without official documents.

After a commission of several people, including the chief physician of the clinic where the donor is located, the Required documents, a doctor arrives from the transplant center, always with an assisting nurse. Next, an operation is performed to collect a donor heart, which is placed in a container with a cardioplegic solution and transported to the center.

Below are the criteria for selecting donor hearts:

• The absence of cardiac pathology, confirmed by the results of cardiac ultrasound and (CAG, performed for donors over 45-50 years old),
• Absence of malignant tumors,
• Lack of HIV infection, viral hepatitis(B, C),
• donor and recipient according to the ABO system,
• Approximate sizes of the donor and recipient hearts, estimated according to the results.

How long should I wait for surgery?

In order for a patient to receive a new heart, a waiting list must be created at the transplant center. Such centers cooperate with medical institutions, where possible donors can potentially be observed - trauma hospitals, neurological hospitals, etc. Periodically, the center sends a request to hospitals about the availability of a possible heart donor, and then compares those in need of a transplant and available donors according to the above selection criteria. The patient receives a referral to the transplant center from the attending physician - a cardiologist and/or a cardiac surgeon.

After drawing up the waiting list, it may take sufficient quantity time, and if a suitable donor is never found, the patient may die of heart failure without waiting for surgery. If a donor is found, the operation will be carried out in the coming weeks.

Due to the fact that the main indication for CHF is the patient’s predicted survival of less than one year, it is necessary to look for a donor during these critical periods.

Cost of heart transplant surgery

A law has been passed around the world banning organ trafficking; only cadaveric and related transplants are allowed. Therefore, the heart itself is given to the patient free of charge. Only the cost of the operation, drug support before and after the transplant, as well as the cost of the rehabilitation period are paid. Generally amounts vary and range from 70 to 500 thousand dollars, with an average of about 250 thousand dollars. In Russia there is an opportunity free software population with high-tech types of assistance and payment for operations under quotas (in the compulsory medical insurance system), but in any case, the exact cost and possibility free operation should be checked with the attending physician - transplantologist.

In Russia there is only one single focal point who selects donors, operating in the territory of Moscow and the Moscow region. Direct heart transplantation is performed in:

• Federal Scientific Center for Transplantology and Artificial Organs named after. V. I. Shumakov in Moscow, (FSBI "FNTSTIO named after V. I. Shumakov"),
• Research Institute of Circulatory Pathology named after. E. N. Meshalkina in Novosibirsk,
• FSBI North-Western Federal Medical Research Center named after. V. A. Almazov" in St. Petersburg.

Due to the fact that in our country the legislative principles of organ donation have not been fully developed, heart transplant operations are rarely performed, for example, in 2014, only 200 operations were performed, while about 28 thousand transplant surgeries were performed in the United States. For the same reason (the ban on organ removal from patients under 18 years of age), children in need of a heart transplant required expensive treatment abroad (Italy and India). But in May 2015, a document was adopted on the procedure for ascertaining brain death in persons over 1 year of age, which makes it possible further development legislative framework in the field of child donation.

Contraindications for surgery

The operation may be contraindicated in the following cases:

Preparing for surgery

When a patient is referred to a transplant center and the decision is made to place him on the waiting list for a heart transplant, he is assigned an evaluation plan. Necessary tests include:

• Fluorography or x-ray of the chest organs,
• Blood tests for markers of HIV infection, viral hepatitis, syphilis,
• Clinical blood test, determination of coagulation system and blood group,
• General urine analysis,
• Ultrasound of the heart, ECG, if necessary - CAG,
• Examination by a cardiac surgeon,
• Examinations by an ENT doctor and dentist (to exclude foci of chronic infections in the nasopharynx and mouth),
• Examination by a gynecologist or urologist (for women and men, respectively).

In order to be admitted to the transplant center for surgery if a donor is found, the patient must always have originals and copies of the following documents on hand:

1. Passport, medical policy, SNILS,
2. An extract from the sending institution with the results of the examination,
3. Referral from a medical institution at the patient’s place of permanent residence.

How is the operation performed?

Heart transplantation begins with removing the organ from the donor’s body and placing it in a cardioplegic solution for a period of no longer than 4-6 hours. At this time it is going preoperative preparation recipient (administration of sedative and analgesic drugs - premedication). Next, in an operating room under general anesthesia, an incision is made in the anterior chest wall of the recipient, large vessels are connected to a cardiopulmonary bypass machine (ACB), which performs the functions of “ artificial heart"during surgery.

After this, the right and left ventricles of the heart are cut off, while the atria are preserved. While maintaining the own atria, the sinus node remains active, setting the rhythm of heart contractions and being the pacemaker.

After the donor's atria have been sutured to the recipient's atria, a temporary pacemaker is installed to ensure adequate heart contractions after surgery. Rib cage sutured, applied aseptic dressing. The operation takes several hours, sometimes no more than six.

The next stage of heart transplantation is immunosuppressive and cardiotonic (supporting cardiac activity) therapy. Immune suppression (mainly with the help of cyclosporine) is necessary to prevent transplant rejection reactions and improve its engraftment.

Recipient heart removal and transplantation scheme:

Video: progress of heart replacement surgery (18+)

Complications

Complications in the early postoperative period include bleeding from surgical wound and infectious complications. The first can be quite successfully treated by reopening the wound and suturing the source of bleeding. Prevention of infectious (bacterial, fungal and viral) complications is the prescription of antibiotics and adequate immunosuppression regimens.

In the long-term postoperative period, the development of transplant rejection and dysfunction of the coronary arteries with the development of myocardial ischemia of the donor heart is possible.

Forecast

The prognosis after surgery is favorable - more than 90% of patients survive the first year safely, about 60% survive the first five years, and slightly less than half of those operated on (45%) live with a donor heart for more than 10 years.

Lifestyle after surgery

Lifestyle after heart transplant surgery consists of the following components:

1. Taking medications. This part of the patient's life after surgery is perhaps the most important. The patient must carefully monitor the timing of medications and strictly follow the dosage prescribed by the doctor. Mostly we're talking about about taking cytostatics and hormonal drugs, suppressing one’s own immunity directed against foreign heart tissue.
2. Physical activity. During the first month, the patient must adhere to a strict restrictive regimen, but normal daily activities should still be present. Within a couple of months the patient can start driving a car again, and after a few more months he can start easy physical exercises (gymnastics, walking, etc.).
3. Nutrition. It is necessary to lead healthy image life, completely eliminate alcohol consumption, smoking and follow a diet excluding unhealthy foods (fatty, fried, smoked, etc.).
4. Protection against infections. The patient should avoid visiting crowded places in the first months after surgery, avoid contact with infectious diseases in the future, wash hands thoroughly before eating, consume only boiled water and thermally well-processed food. This is because immunosuppression can lead to an increased incidence of bacterial, fungal and viral diseases after the initiation of immunosuppressive therapy.

In general, it can be noted that life after surgery undoubtedly changes a lot, but the quality of life without shortness of breath, palpitations and swelling changes for the better.

Heart transplant from the perspective of religion

Previously, when transplantation was just beginning to develop, representatives of various faiths had an ambiguous point of view on heart transplantation. In particular, representatives of Christianity considered such an operation not a godly act, because in fact, a person’s still “living” heart is taken away, and a person can come out of a coma even after several months (casuistic cases in medicine). However, due to the fact that doctors clearly distinguish between the concepts of “coma” and “brain death”, in recent years more and more clergy are talking about serving after their death to save another human life - true purpose Christian, because at the heart of this teaching is the concept of sacrifice. Isn’t sacrificing your heart a benefit for another person?

Video: Channel 1 report on heart transplant

Unfortunately, not all diseases of the heart and blood vessels can be treated drug therapy. In some cases, the question arises of carrying out such a labor-intensive surgery like a heart transplant. However, there are many contraindications to its use, and life expectancy is still not very long.

First experiments

The first heart transplant was performed in the mid-20th century - in 1964 - by James Hardy. He used a Chimpanzee as an organ donor, and the patient lived after that for only 1.5 hours.

The first successful transplant of the main “motor” of the human body in the world was carried out a little later - in 1967 by Christian Barnard in Cape Town, South Africa. The recipient was 55-year-old Louis Vashkansky, who suffered incurable disease heart, and the donor was 25-year-old Denise Darval, who died in a car accident. It was believed that the operation was performed perfectly, but the patient died from its complications on the 18th day.

Unfortunately, the success of early operations was reduced to zero due to the imperfection of technology and equipment for artificial blood circulation, as well as insufficient knowledge in the field of immunology. With development new era cyclosporine in 1983, the survival rate of recipients was significantly increased.

Transplantation of the body's main "pump" has become a routine operation performed in a variety of centers around the world. The only problem remains the small number of donor organs, because the heart can be removed only under certain conditions: recorded brain death, absence of pathologies and age under 65 years.

At the current level of development of transplantology, transplantation of the heart and other organs from the body of one biological species to the body of another biological species is not carried out, but scientists do not give up attempts to obtain material for transplants, for example, heart valves, tendons, from xenogeneic tissues of animals, in particular pigs. cartilage

Work continues to change the genome of pigs, which will reduce to zero the risk of rejection of a foreign organ by the human defense system. Japanese scientists are trying to grow human organs in the body of pigs and claim that very soon it will be possible to obtain a pancreatic gland from the patient’s skin tissue and successfully treat diabetes mellitus.

Who is indicated for surgery?

A heart transplant is indicated if the following pathologies are present on the face:

• ejection fraction less than 20%;
• atherosclerotic changes in large quantities coronary arteries;
• dilated or hypertrophic form of cardiomyopathy;
• congenital defects of the main “motor” of the body and valves;
• irregular rhythm that cannot be treated;
• cardiac ischemia.

When evaluating a transplant candidate, doctors first evaluate heart failure according to the NYHA system. It takes into account symptoms depending on the patient’s level of activity and quality of life.

The operation is indicated for minimal physical activity, when even short walking causes shortness of breath, palpitations and weakness. The same applies to people whose heart failure develops at rest, and any action is fraught with discomfort. The indication for surgery is also a poor prognosis for survival without surgery, which is less than a year.

The patient’s desire and ability to be examined and follow the subsequent treatment plan is taken into account. The recommended age for transplantation should not exceed 65 years.

Contraindications

Heart transplantation is contraindicated in the following cases:

1. The operation is not performed on persons over 65 years of age, but doctors evaluate this factor individually.
2. Sustained pulmonary hypertension, which is characterized by vascular wall resistance of more than 4 Wood units.
3. Systemic infections or diseases in active form.
4. Oncology, but at the same time taking into account predicted survival and tumor type.
5. Smoking, alcoholism or drug addiction.
6. Psychosocial instability.
7. Reluctance and inability to comply with the plan of therapeutic and diagnostic measures.
8. Positive test for HIV.
9. Hepatitis B and C, but this is determined on an individual basis.

How it all happens

It must be said that the process of preparation and examination is quite lengthy and complicated. All necessary tests are taken from the future recipient, examined for infectious and viral diseases, HIV, hepatitis, etc. Conduct instrumental studies and diagnostic procedures with invasion.

While waiting for a donor organ, the patient is constantly monitored and monitored for signs of deterioration in heart function. Preoperative management of the candidate is carried out with the participation of qualified personnel, relatives of the patient and in direct contact with the transplant center.

The examination procedure and potential donors are not neglected. Heart transplantation is possible with good ejection fraction, satisfactory condition valve structures, absence of left ventricular enlargement. If the potential recipient is in critical condition, then he can be transplanted with an “imperfect” heart.

The final verdict on the suitability of the donor organ is made by an experienced surgeon after direct examination of the organ and sternotomy. After surgery, immunosuppressive therapy is carried out, vasopressors and cardiotonics are prescribed. The patient will be required to attend coronary angiography annually.

Many people are interested in how long do people live after such an operation? If you believe the statistics, the life expectancy of such patients ranges from 10 years or more. The world record was broken by Tony Huseman, who lived with a transplanted heart for more than 30 years and died of skin cancer.

The main problem remains organ rejection by one’s own immune system, but when it comes to children, parents, without hesitation, agree to the operation in the hope of a normal future life for their child.

To the most possible complications include pneumonia, bleeding and the formation of blood clots, damage to organs such as kidneys, decreased brain function, and cancer. Of course, the recovery period is long and difficult, but is this an obstacle for a person who wants to live?