Candidates for heart transplantation typically have end-stage heart failure with a life expectancy of less than one year without transplant. Specific indications include dilated or ischemic cardiomyopathy, congenital heart disease unresponsive to other treatments, ejection fraction below 20%, and intractable angina or arrhythmias.1 Patients must be under 65 years old, have a pulmonary vascular resistance less than 2 Wood units, and demonstrate ability to comply with post-transplant care.1 Careful patient selection is crucial, as transplantation requires lifelong immunosuppression and follow-up.

The heart transplant procedure typically lasts 6-12 hours, depending on the complexity of the case.1 After the patient is anesthetized and connected to a heart-lung machine, the surgeon removes the diseased heart, leaving cuffs of the atria intact. The donor heart is then sewn into place, carefully connecting all blood vessels and arteries.2 Once the new heart is in place, blood flow is restored and the heart is restarted, often with an electric shock if needed.2 Following surgery, patients are closely monitored in the ICU for about 3 days before moving to a regular hospital room for 10-14 days of recovery.1

Following heart transplantation, patients require intensive care and lifelong management. Immunosuppressive medications are crucial to prevent rejection of the new heart, but they also increase the risk of infections and certain cancers.1 Regular follow-up appointments and biopsies are necessary to monitor for signs of rejection and adjust medication dosages. Potential complications include infection, bleeding, blood clots, kidney failure, and coronary allograft vasculopathy (CAV).2 Patients must also adapt to lifestyle changes, including dietary restrictions and exercise regimens, to maintain their new heart's health and function.

Advancements in immunosuppression and post-operative care have significantly improved outcomes, with current 1-year survival rates approaching 90% and a conditional half-life of 13 years for those surviving the first year1. Despite these successes, the field faces ongoing challenges, primarily the shortage of donor organs. Innovative approaches like warm machine perfusion and the use of hearts donated after circulatory death are being explored to expand the donor pool2. Additionally, research into xenotransplantation and the development of more effective immunosuppressive therapies hold promise for further improving long-term survival rates and quality of life for heart transplant recipients.

Recent innovations in heart transplant surgery have significantly improved outcomes and expanded the donor pool. One major advancement is the "heart in a box" technology, which allows for donation after circulatory death (DCD) and extends the viability of donor hearts from 4-6 hours to up to 12 hours12. This system keeps the heart warm and beating during transport, potentially increasing the number of available donor organs4. Another innovation is the use of hepatitis C-positive donor hearts, which has become more common due to effective antiviral treatments34. Additionally, advanced imaging techniques and software have enabled more accurate donor-recipient heart size matching, allowing some pediatric patients to receive adult hearts4. These innovations collectively aim to reduce wait times and improve access to life-saving transplants for patients with end-stage heart failure.