HEART TRANSPLANT: PROCEDURES

Cardiac transplantation is a widely accepted therapy for the treatment of end-stage congestive heart failure. Most candidates for cardiac transplantation have not been helped by conventional medical therapy and are excluded from other surgical options because of the poor condition of the heart. About 45% of the candidates have ischemic cardiomyopathy; however, this percentage is rising because of the increase in coronary artery disease in younger age groups. Of the candidates, 54% have some form of dilated cardiomyopathy, which often has an unclear origin. The remaining 1% of candidates fall into the category of other diseases, including congenital heart disease, that are not amenable to surgical correction.

Candidacy determination and evaluation are key components of the process, as is postoperative follow-up care and immunosuppression management. Proper execution of these steps can culminate in an extremely satisfying outcome for both the physician and patient.

Christian Barnard performed the first successful heart transplant in a human in 1967 in South Africa. The origins of the procedure date to 1905, when Alexis Carrel transplanted a puppy's heart into the neck of a dog. Because of the lack of immunosuppression, the experiment was unsuccessful; however, the work spurred numerous investigations that culminated in the success the procedure has today. Early investigators included Frank C. Mann of the Mayo Clinic, V.P. Demikov of the Soviet Union, and Marcus Wong. These early efforts in transplantation were thwarted by the infancy of cardiopulmonary bypass and a lack of understanding of the immune system. As knowledge in these areas advanced, so did the field of cardiac transplantation.

The clinical use of cyclosporine as an immunosuppressant revolutionized the field of cardiac transplantation in 1983. Recipient survival rates improved, thus producing an explosive increase in the number of transplant centers offering cardiac transplantation. The remaining limiting factor was the number of available organ donors.

During the cardiac transplantation procedure, the ventricles are excised, leaving the great vessels, right atrium, and left atrium of the recipient.

View of the recipient's chest after the heart is removed, with the patient on cardiopulmonary bypass.

The donor heart is then sewn to these areas.

Suturing of the donor heart. Note that the left atrial anastomosis is performed first.The completed operation. Note the suture lines on the now-implanted heart.

A recent trend has been to revert to bicaval anastomoses rather than right atrial anastomoses in an attempt to decrease the incidence of postoperative tricuspid insufficiency.

In the transplantation process, the sinoatrial nodes of the donor and recipient remain intact, and both are present within the recipient. For approximately 3 weeks after surgery, the electrocardiogram demonstrates 2 P waves; however, the heart rate and electrical activity of the new heart are purely dependent on the intrinsic electrical system of the heart and not on the neurological input from the recipient.

Indications

The general indications for cardiac transplantation include deteriorating cardiac function and having a prognosis of less than 1 year to live.

Specific indications

• Dilated cardiomyopathy
• Ischemic cardiomyopathy
• Congenital heart disease for which no conventional therapy exists or that conventional therapy has failed
• Ejection fraction less than 20%
• Intractable angina or malignant cardiac arrhythmias for which conventional therapy has been exhausted
• Pulmonary vascular resistance of less than 2 Wood units
• Age younger than 65 years
• Ability to comply with medical follow-up care

TEN MOST EXPENSIVE MEDICAL PROCEDURES

1. Intestine Transplant
Cost: $1,121,800

A transplant of the intestine is done to replace dead intestinal tissue with live tissue from a donor, often because of disease or the presence of a tumor. Because intestinal disease is sometimes accompanied by liver failure, intestine transplants can be done in conjunction with a liver transplant, adding more than $180,000 to the bill.

2. Heart Transplant
Cost: $787,700

Heart transplants are among the most complicated of procedures, carrying great risk. Waiting lists are long, and preparation for the surgery is lengthy and expensive. Add to this the expensive procurement of the organ, and you can see why the cost is so great.

3. Bone Marrow Transplant
Cost: $676,800 Allogeneic ($300,400 for Autologous)

Bone marrow transplants can be done with a donor's marrow (allogeneic) or your own bone marrow (autologous), costing much less. Finding a donor for a bone marrow transplant is difficult, and complications after the procedure are very common. Add to this the risky nature of the procedure, the lengthy prep time in the hospital as well as an extensive recovery period, and you have a cocktail for a hefty medical bill.

4.      Lung Transplant
Cost: $657,800 double ($450,400 for single)

When other therapies don't work, lung transplants are a last resort for patients of lung disease like emphysema and cystic fibrosis. As with other transplant surgeries, wait lists are long and cost is high because of the lengthy hospital stay.

5.      Liver Transplant
Cost: $523,400

As with a heart transplant, liver transplants are high risk and high cost, with an accompanying waiting list. Criteria are high, which means administrative and prep procedure costs add to the bottom line.

6.      Open Heart Surgery
Cost: $324,000

With heart disease as the leading cause of death in the U.S. at 26%, open heart surgery is a more common procedure than may be expected. Part of the high cost of open heart surgery is because it's often an urgent medical procedure that is usually followed by complications. Longer care and follow-up needed after surgery add to the price tag.

7.      Pancreas Transplant
Cost: $275,500

Transplants of the pancreas are usually needed when a patient has type 1 diabetes or renal failure. It is often done in tandem with a kidney transplant, almost doubling the cost of the surgeries at $439,000.

8.      Kidney Transplant
Cost: $259,000

Kidney transplants, like the other transplants on this list, are expensive due to the risk, recovery and prep expense. The one difference is that with kidney transplants, the old kidney isn't removed because it's been shown it reduces risk that way; surgeons find a different blood supply to attach the new kidney to.

9.      Tracheotomy
Cost: $205,000

A tracheotomy involves making an incision in the neck to allow the patient to breathe, either permanently or temporarily. Since this is often an emergency room procedure, costs are high. After care is extensive, adding to the bill.

10. Destruction of Lesion of Retina
Cost: $153,000

When lesions on a retina (this is part of the eye), also called retinoblastoma, are removed, the risks are great as with the above-mentioned procedures. This procedure is pricey because of the precision skills required for this procedure, the lengthy recovery and follow-up.

Bottom Line
If you think these costs are high, consider that patients with a chronic disease affecting more than one organ often need multiple organ transplants, with bills exceeding a million dollars. Why the whopping price tags for all these surgeries? In cases of transplants, the hospital stay before and after the surgery makes up about 75 percent of the bill. Some of the cost comes from liability insurance, those high premiums hospitals and doctors have to pay to cover themselves in case of lawsuits. A side-effect of the large amount of liability lawsuits is that doctors often order more (expensive) tests than needed to cover themselves, a practice called defensive medicine.

Lack of insurance among more than 47 million Americans drives costs up, since the uninsured use emergency rooms, and often when they've waited so long that pricey emergency surgery is the only option. Add this to the high cost of medication and medical equipment, and you can see how these price tags balloon. The bottom line: health insurance coverage is vital if you need one of these life-threatening and extremely expensive procedures. (Learn what your options are in Fighting The High Costs Of Healthcare and Buying Private Health Insurance.)