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My First Time... Transplanting a Heart

Daniel Goldstein, Vice-chairman of Cardiothoracic Surgery, Montefiore Medical Center

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I had never even seen a heart transplant before. It was 2 a.m., and I went into the OR with Niloo Edwards, my attending. In surgery, it’s like the pilot and co-pilot—there’s a side for the attending and a side for the resident. I was quite surprised when Niloo told me to go to the right side of the patient, the operating side. Immediately my heart raced. I was remembering when I was a harvester for transplants, four years earlier—that had been an emotional training. The whole dynamic of brain-dead patients is horrible: The death is unexpected—a gunshot wound, a motorcycle accident—and usually the patient is young. And you’re actually the one definitively stopping life. The moment you cut their heart out, they are officially dead.

In this case, the donor heart was on its way. And the patient was a young woman in her forties with nonischemic cardiomyopathy—she just had bad heart muscle, for unknown reasons. I didn’t know much about her at all. She was already going to sleep by the time I walked into the room. In that way, it’s impersonal, unfortunately.

The first thing you have to do is open the chest, using a saw to open the breastbone. Then you put in a retractor to keep it open. Then you open the pericardium, the bag that holds the heart. You give the patient a high dose of blood thinners, called heparin, so the blood doesn’t clot in the extracorporeal circulation—the heart-lung machine. Then you insert cannulae, tubes the thickness of your thumb, that are secured to the heart; blood is diverted out of the body into the heart-lung machine and then back in again. Then you take a big clamp and clamp the aorta. And then you begin cutting the heart out: the superior vena cava, the inferior vena cava, the aorta, the pulmonary artery, and finally the left atrium. This is difficult if they’ve had prior surgery—the anatomy can be obscured by the old adhesions. Sometimes, you can’t see where you are. You can make a hole where you don’t want to.

When the heart comes out, you’re staring at an empty chest. That’s when I said, “Am I actually doing this to a human being?” It’s kinda cool, actually. Then you have to reconnect the new heart to those five connections, which is usually simple. The donor heart comes out of the bag where it’s on ice, and the surgeons tailor it to make sure there’s not too much aorta, or holes that we aren’t aware of. Then the sequence of events is kind of backward. First you connect the left atrium, because it’s the farthest back in the heart—it sits against the esophagus. Every fifteen to twenty minutes while you’re making the connections, you give the heart a high dose of potassium; it keeps it from beating, protecting it. Once you’re done, you remove the clamp from the aorta, and restore blood supply. That’s when you see the heart start beating. It can happen immediately, or take a few minutes. It’s magical. The heart wants to pump—even though all the nerve connections have been severed.

Next, you take care of any major bleeding and gradually remove the patient from the heart-lung machine. You reverse the heparin with an antidote called Protamine that allows the blood to become thick again. You close the breastbone with steel wire, and the skin with absorbable sutures that disappear over time. And then you’re done. This patient did well.

A heart transplant is like no other heart surgery: Life is suspended. I started thinking about all of these philosophical questions: It’s been said that the heart is the seat of the soul, so what happens when you replace the heart? Is this patient going to inherit any of the qualities of the donor? Of course it doesn’t happen. Why would someone start playing the piano if they didn’t before? But it hasn’t been studied well. You just don’t know.


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