Heart Transplant Evaluation
- The Evaluation
- Roadblocks To Transplant
Once you and your cardiologist agree that a donor heart is an option for you, you must find out whether the rest of your body is up to it. The heart transplant procedure includes an open-heart surgery and a lifetime of taking multiple drugs. There can be a lot of mental and emotional stress from the demands of constant medical treatment and follow-up. The reality of that intensive medical care begins now - with your transplant evaluation.
These procedures may be slightly different than what you will face, since each transplant center sets its own testing procedures. Your medical insurance coverage for heart transplant expenses must be verified before your evaluation. Expect evaluation to last from 3 to 7 days.
- Skin tests
- You will have sterile antigens prepared from certain germs (like mumps) placed just under your skin, probably on your arm(s) in a series of "pricks." Each location will be circled and numbered on your arm. This test may take up to a 4-day period, during which you cannot wash off those numbers/circles. At 15 minutes, 6 hours, 24 hours, 48 hours and 72 hours after the "prick" you will have those locations on your arm checked. The size and type of reaction will be recorded. Redness and swelling may occur. This provides information about how your immune system reacts to certain germs. This will include a skin test to see how your body reacts to tuberculosis, since high reactivity can become serious with extended prednisone use
- Chest x-ray
- checks for respiratory tract problems and shows heart size. Quick and painless
- 24-hour Holter monitor
- checks for repeated heart arrhythmia. Annoying but painless
- Electrocardiogram (EKG or ECG)
- checks heart rhythm. Quick and painless
- Treadmill (stress) test
- checks your heart's ability to function under stress (exercise). A regular stress test can be difficult but is usually only painful if you have angina on exertion. If you have a Vo2max treadmill test, it will be harder
- Pulmonary function test
- checks lung function. You breathe into a tube with all the force you can muster for as long as possible. They say this won't collapse your lungs, but when doing it, you start to wonder <g>
- Arterial blood gases test
- checks amount of oxygen in your blood. A small needle is inserted into an artery - usually in your wrist - and blood is drawn. Unlike veins, arteries are deep beneath your skin, so the technician is trying to hit an artery he cannot see. This one may hurt
- Right heart cath
- measures pressures in pulmonary arteries and allows for biopsy - described here
- allows precise measurement of heart function and blood circulation, including locating blockages - described here
- measures heart function, checks for valve damage, and more - described here
- Dental exam
- all dental repairs must be completed before you are placed on the transplant waiting list
- CAT scan
- checks for tumors. Any cancer disqualifies you
- Blood testing
- drawing blood to test for:
- Typing identify your blood type for blood needs during and after surgery
- HIV/AIDS check for HIV infection
- Hepatitis B check for Hepatitis B surface antigen
- Thyroid check thyroid function
- Calcium check for calcium deficiencies: Low levels mean prednisone therapy will require lots of calcium supplementation
- Phosphorus measures your blood phosphorus level
- WBC or White Blood Cell counts white blood cells: High level means you have an infection. Low level means you may not be able to fight off infections
Normal = 4500 to 11,000/cu mm
- HCT or hematocrit counts oxygen-carrying red blood cells: High level can thicken your blood causing clots. Low level makes you anemic
Normal = 36 to 46%
- PLT or platelets counts blood cells that make your blood clot: High level makes your blood too thick, requiring blood thinners. Low level means you bleed easily
Normal = 150,000 to 350,000 cu mm
- K+ or Potassium measures potassium level in your blood: High level suggests high blood acid level and causes arrhythmia. Low level causes arrhythmia
Normal = 3.5 to 5 mEq/L
- CO2 or Carbon Dioxide reflects the acid balance in your blood: Low level means your blood is too acid and makes you tired and short of breath
Normal = 24 to 30 mEq/L
- BUN or Blood Urea Nitrogen and Cr or Creatinine checks kidney function: High level means your kidneys are not functioning properly
Normal BUN = 7 to 22 mg/dl
Normal Cr = 0.5 to 2 mEq/L
- Mg or Magnesium measures how much magnesium is in your blood: Low level may cause muscle weakness, sleepiness, and arrhythmia
Normal = 1.3 to 2 mEq/L
- Total Bilirubin and Direct Bilirubin checks liver function: High level means your liver is not functioning properly
Normal Total = 2 to 1.2 mg/dl
Normal Direct = 0 to 0.4 mg/dl
- Enzymes check liver function: High level means liver is not functioning properly
- AST or SGOT: Normal = 0 to 35 IU/L
- ALT or SGPT: Normal = 0 to 31 IU/L
- Alk. Phosph.: Normal = 30 to 120 IU/L
- GGT: Normal = 8 to 51 IU/L
- LDH: Normal = 0 to 220 IU/L
- PT or PTT or Pro-thrombin Time tests ability of your blood to clot (INR is often used now):
- Fasting Glucose or blood sugar measures diabetes control:
Normal = 70 to 115 mg/dl
- LDL/HDL or Cholesterol measures low-density liptoproteins (bad cholesterol) and high-density liptoproteins (good cholesterol)
- HCV or Hepatitis C Virus tests for hepatitis C antibodies
- CMV or Cytomegalovirus antibody and titer checks for the presence of this virus, which is harmless in most people but can seriously endanger heart transplant recipients
- Toxoplasmosis Ab: a parasitic infection most commonly acquired by handling cat feces
- EBV or Epstein-Barr Virus tests for Epstein-Barr antibodies. EBV is related to mononucleosis
- HLA tissue typing: used to determine how much anti-rejection medication to start you on when you get your donor heart
- Urine culture
- checks for infection in your urine: You know the drill - pee in the plastic cup
- 24-hour urine collection
- Ever carry a gallon jug of that around with you all day? <g>
- Cytotoxic antibody screen
- gives information that helps minimize rejection
- tests for presence of ulcers, which invite infection and will be aggravated by post-transplant meds
Psychological testing is also done before you are placed on the waiting list for a heart. Your family must be involved. Some programs require that you designate a support person, who must accompany you on your visits to the transplant center. You and your support person will probably be required to watch a video describing the transplant process. The big thing to be accepted for heart transplant is committment. If the transplant team doubts your committment to the whole process, your chances of being accepted are lower.
It is possible that if you are turned down by one transplant center during evaluation, that you may be accepted by another center. Of course, this is expensive, may involve travel, and may not be paid for by your health insurance. However, it is not unheard of.
Roadblocks to Transplant
The following are general but common guidelines about what will prevent you from qualifying for a heart transplant. However, the rules vary from one heart transplant center to the next, with no true standardization. So talk to your own transplant center medical staff!
- Pulmonary Hypertension
- Severe PH (pulmonary hypertension) - meaning a PVR greater than 4 to 6 Woods units probably means no transplant. In heart recipients with PH, the new heart's right ventricle can't generate enough pressure to force blood to the lung's blood vessels because it has to fight such high pressures in the lungs. This causes right heart enlargement and heart failure.
During transplant evaluation, it is important to see if high pulmonary pressures can be reversed with drugs. Inotropes, vasodilators, or prostaglandin may be used in this sort of testing. If pressures in the lungs' blood vessels can be reduced with drugs, those drugs can be used before
transplant surgery to prevent acute right heart failure. Patients whose pulmonary pressures cannot be reversed may be considered for heart-lung transplant.
- Serious organ damage from diabetes - such as retinopathy, kidney failure, or neuropathy - may mean no transplant. The steroids (prednisone) used after transplant can interfere with insulin production, resulting in borderline diabetes even in people who did not have diabetes before transplant.
- Obesity-related risks after transplant increase with a weight more than 120% of ideal body weight. A weight more than 140% of ideal body weight probably means no transplant. Body weight significantly affects transplant outcome, with fat people having higher risk of blocked
arteries, infection, diabetes, and high blood pressure.
- Cancer patients must be completely free of malignant disease. A disease-free period of less than one year is only acceptable when tumors have a good prognosis. A disease-free interval of more than one year is usually required in all patients with aggressive tumors.
- Substance Abuse
- Ongoing substance abuse almost certainly means no transplant - this includes smokers and alcoholics. All patients should have at least 3 months free from all substance abuse, with ongoing random testing.
- Psychologic And Social Issues
- Screening for psychosocial problems is required before heart transplant. Requirements include:
- Compliance - willingness and ability to take all meds exactly as prescribed, do proper exercising, follow the special diet, etc,...
- Adequate mental ability
- Adequate social support
- Patients must have suitable insurance, outpatient pharmacy coverage, or enough personal wealth to cover all expenses
- Currently, if you have AIDS you will not get a heart transplant
- Usually means no transplant
- Organ Failure
- Substantial chronic impairment of other vital organs that is irreversible means no transplant
- A current active infection or recent pulmonary (lung) infection may mean no transplant
Material taken from manuals given to potential transplant recipients at transplant centers in the USA, from heart transplant recipients, and partly from a CME provided by the American Association of Critical Care Nurses - Updated August 29, 2002
All information on this site is opinion only. All concepts, explanations, trials, and studies have been re-written in plain English and may contain errors. I am not a doctor. Use the reference information at the end of each article to search MedLine for more complete and accurate information. All original copyrights apply. No information on this page should be used by any person to affect their medical, legal, educational, social, or psychological treatment in any way. I am not a doctor. This web site and all its pages, graphics, and content copyright © 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004 Jon C.