Undergoing a heart or lung transplant is a significant event that comes with potential risks such as bleeding, infection, and complications from surgery or medication. Critical post-transplant testing for heart/lung recipients helps the transplant team monitor their health and ensure the transplant’s success.
So You’ve Had A Heart / Lung Transplant, Now What?
Having a heart or lung transplant is a big deal. There is always the risk of bleeding, infection and complications. Statistically, 1 in 20 patients in Australia do not make it through the transplant surgery.
Worldwide, the overall survival rate is about 90% after one year and about 80% survival rate from a transplant after five years (for adults).
In Australia, survival rates are 80 percent a year after surgery, 70 percent five years after transplant, and 55 percent ten years later.
The specific risks of a heart transplant include: rejection, Primary graft failure leading to death or Cardiac allograft vasculopathy affecting blood flow.
Sobering odds yet you will live longer with the transplant than without it! Right? It’s the end of the road and there were no more options. Big pants on and get as well as you can through jumping through every post transplant routine test hoop there is and do them on time. The only way now is through it.
What Is Critical Post Transplant Follow Up?
The following information provides details about routine testing heart / lung transplant recipients will undergo post-transplant to monitor their health and ensure the success of the transplant. By closely monitoring transplant recipients through routine testing, the transplant team can intervene promptly if any issues arise, ultimately improving the long-term outcomes for transplant recipients.
How Often Do You Need To Go Back To Hospital After A Transplant?
When all things are going well after a heart or lung transplant please still be prepared to visit the hospital 1 to 3 times each week in the first 2 to 3 months. After the first 3 months you will transition to fortnightly visits before moving to monthly visits for the next 12 to 18 months.
Thereafter you will have twice yearly then yearly visits for life. The transplant team will adjust your visits along with the types of testing and the testing schedules to your specific needs. Everyone is different depending on prior illness, rejection and complications.
You can visit other posts for more information about What You Need To Know About A Heart Transplant and the Benefits And Risks Of A Heart / Lung Transplant.
Routine Hospital Tests After A Lung Transplant
Bronchoscopy
A Bronchoscopy is performed after a lung transplant to view the lungs and airways. There are two types that are performed after a lung transplant: Look-See bronch to monitor healing and take samples, and bronch and biopsy to collect tissue samples.
Preparing For A Bronchoscope
The patient is prepared for the procedure, in a way similar to having a surgery. This means you will be required to fast for 12 hours prior to the Bronc. The procedure occurs while the patient is lightly sedated or anaesthetised.
I have had 4 Bronchoscopies before my heart transplant. A mould infection in my lungs caused an inflammatory illness which then went on to damage my heart. The wonderful thing about the Bronchoscope is that you are sedated meaning you are not in discomfort during the process. When you wake up in recovery you may feel a scratchy discomfort in your throat but this passes reasonably quickly.
During a bronchoscopy a thin, flexible tube with a camera at the end, called a bronchoscope, is inserted through the mouth or nose and down into the lungs. This allows the medical team to closely examine the transplanted lung for any signs of complications, such as infection or rejection. The patient is carefully monitored throughout the procedure to ensure their safety and comfort. After the bronchoscopy, the lung recipient is carefully watched in recovery.
A Bronchoscopy is usually a day visit to hospital as an out-patient. You will be discharged home if appropriate, everyone’s journey is different.
If you have had a lung transplant the procedure is covered by Medicare (Australia). Lung transplant recipients will have an initial bronchoscopy after the transplant. This is then repeated Month 1, Month 3 and 6 after transplant as long as there are no signs of infection or rejection. The transplant team will alter this schedule as required.
Lung Function Testing Using A Spirometer
Regular monitoring of your lung function post lung transplant is crucial to detect issues such as lung rejection or infection. During your hospital stay, the transplant nurse will supply you with a spirometer, provide instructions on its usage, and guide you on recording your measurements. It is essential to track how well your lungs are functioning both in the hospital and at home.
Lung Clinic Function Test
Both heart and lung transplant recipients will also have complete lung function testing at the hospital ‘s heart lung clinic. For this test you will be asked to sit in a booth, with a nose plug on and a breathing tube in your mouth. The medical examiner will ask you to perform a number of breath holds and exhalations to determine your lung function.
Routine Hospital Tests For Heart Transplant Recipients
Heart Biopsy (Endomyocardial Biopsy – EMBX)
A heart biopsy (Endomyocardial Biopsy) is used to diagnose heart rejection. Initially, heart biopsies are performed weekly for the first 2 to 3 months post-transplant. The regularity of the heart biopsy will then decrease over time.
Getting Prepared For A Heart Biopsy
The biopsy procedure is similar to the Right Heart Catheter you had before the transplant. Your first heart biopsy will be done while you are still in hospital after the surgery. For follow up heart biopsies after discharge you will go to the day procedures ward. When you arrive at the hospital as a day patient you will be called from the waiting room. The triage nurse will record vital signs and other measures including height, weight, blood pressure, heart rate etc.
The nurse will ask you to gown up, if you prefer you can stay in your loose fitting clothes from the waist down and put the gown on top. You will then be seated in a comfy chair or bed with a blanket and wait your turn. This could be 5 minutes or many hours. It depends on what is happening behind the scenes on any given day.
When it is your turn you will be escorted to a treatment room. During the biopsy procedure, you will lie on a surgical bed on your back with your head turned to the side usually left. The treatment nurse will cover your neck and face with a surgical sheet. An X Ray machine hovers above you and there are multiple screens. The medical team will be in X ray protection vests.
What Happens During a Heart Biopsy?
Local anaesthetic is injected into the skin of the neck near the incision site for the biopsy. A long thin flexible wire is inserted down the right internal jugular vein (RIJV) in the neck. The doctor will use X Ray guidance to assist guide the wire to the heart. Once there the wire is used to take small samples of the inside of the heart lining. This procedure is unpleasant and at times can be uncomfortable even painful.
At times my heart would go into arrhythmia as it was stimulated or reacting to the invasive wire. I was told that the procedure would usually take around 20 minutes. Unfortunately, I had a blood clot (thrombosis) in my right internal jugular vein, which is the preferred vein for heart biopsy. Therefore the left jugular vein was used which I am told has more delicate and tricky access than the right jugular.
How Long Does A Heart Biopsy Take?
It is best to prepare for a whole day at the hospital. Given the time to register, triage, prepare you and recovery time you can be sure the whole process will take 3 to 6 hours at worst. The procedure itself takes 30 to 45 minutes.
I found that all my heart biopsies usually took 45 minutes or so at least, not including prep and recovery time. The worst session took over an hour and after 30 attempts to only achieve 1 tissue sample rather than the 4 to 8 samples required. Due to this, a consultant was called in to complete the task rather than the registrar. While the consultant was on the way, I encouraged the registrar to keep going. I told him that I had absolute confidence he could get the next 3 biopsies in only 3 attempts. He did just that as the consultant entered the room. I think he was more relieved than me.
Given the thrombosis of my right internal jugular vein and the added difficulty of performing a left jugular vein biopsy, I often wondered if the registrars stepped back to avoid doing my biopsies or ran down to the cath lab to get the added experience that my situation offered.
What Happens After The Heart Biopsy Procedure?
After the heart biopsy you will have a waterproof dressing which you need to keep in place for the next 24 hours. You are moved to a recovery room for a minimum of 15 minutes where you are offered something to eat and drink and the nurses will take your vital signs.
The main complication of the heart biopsy procedure is bleeding from the puncture site, which is controlled by applying pressure and sitting up for an hour or so. The specimens are tested for rejection and if it is present treatment will begin.
Cardiac Ultrasound Echocardiography (Heart Transplant Recipients)
An echocardiogram uses ultrasound to view the valves, chambers and movement of the heart. It also checks for anomalies in the heart’s structure, cardiac function and any build up of fluid or potential signs of rejection post transplant. You will have an echocardiography after transplant surgery and before discharge from hospital. Routine echocardiograms are scheduled to determine if any rejection, infection or complication has affected cardiac function.
Echocardiogram of the heart is similar to any other ultrasound you may have had done. Essentially you change into a hospital robe, lay on a bed on your back and or left side with your chest exposed. The sonographer will place clear gel on the chest area and apply the ultrasound wand. You will be asked to hold and exhale your breath and even sniff a few times to measure the rate of aortic valve regurgitation. This routine test is not painful usually. You may need to have an echocardiogram every three months or as required by the transplant team.
Cardiac MRI (Cardiovascular Magnetic Resonance)
Fortunately a Cardiac MRI is a noninvasive surveillance strategy for heart rejection post transplant. It provides detailed images of the heart’s structure and function, allowing the transplant team to assess any signs of rejection without the need for invasive heart biopsy procedures. By utilising powerful magnets and radio waves, cardiac MRI can capture clear and precise images of the heart, enabling early detection of any issues that may arise after a heart transplant.
How Often Do You Have Cardiac MRI’s?
You will continue to have weekly heart biopsies for at least the first 6 to 12 weeks after transplant or until you reach full acceptance where there is no sign of rejection from the biopsy results. The transplant team will then switch you over to regular monthly Cardiac MRI.
Getting Ready For An MRI?
Having an MRI is not painful and requires no fasting or other specific preparation. The medical team will ask you to complete a questionnaire which screens you for risk factors such as kidney disease, pregnancy and implants like a defibrillator or pacemaker.
At the start of the MRI, you will change into a hospital gown with the opening at the front. Next step is to remove all metal jewellery or items from your body.
Once inside the MRI room the medical team will ask you to lie on the MRI scanning table. The sonographers will attach telemetry (sticky tracing dots) to your chest. These telemetry dots trace your heart rate and the heart’s electric pulses. A finger trace will monitor your pulse and oxygen levels during the scan. You will be covered by a blanket, but be aware you do get quite warm towards the end of the MRI as it heats up. A leg wedge, headphones and a weighted chest plate will be placed in position.
During The MRI
The table will then slide into the MRI scanning tunnel. You will hear the machine start to “whir” or “hum”. Shortly after you will hear an automated voice giving you instructions to breathe in and then exhale and hold your breath. Holding your breath without air in your lungs provides a clearer picture of cardiac structure and prevents small movements which occur during breathing.
The scan takes approximately 30 to 45 minutes. If the trace is lost or the scan is compromised by breathing technique the MRI may take a little longer. Once during an MRI scan the batteries on the trace died and the team needed to take the whole set of images again. I think it took over an hour to complete the MRI.
If you are claustrophobic or experience anxiety, let the team know at the very start. I have found that the breathing instructions give your mind something to concentrate on. For more information visit: SVHA Cardiac MRI.
Routine Hospital Tests for Heart and Lung Recipients
Bloods
Blood tests are required after an organ transplant. If you have had a heart or lung transplant you will have weekly blood tests for the first 8 weeks then they may reduce to fortnightly then monthly.
Common Blood Tests After A Transplant
Regular blood tests will screen the following protocol:
FBC – Full Blood Count examines the quantity, variations, and dimensions of various blood cells, such as: Red blood cells, White blood cells and Platelets. This helps the transplant team to diagnose potential illnesses, infections and diseases early.
EUC- Electrolytes and Urea Tests monitors Kidney function and measures levels of electrolytes, specifically sodium, potassium, chloride, bicarbonate. minerals: phosphorus, calcium.
LFT – Liver Function Test will check how the liver is functioning. Anti rejection medications may impact liver function.
Coags – Tests Coagulation of the blood to determine the clotting factor of the blood on how well and how quickly the blood will clot.
Trough Levels – for anti rejection medications (Tacrolimus, Cyclosporine and or Everolimus) to ensure you are on a sustainable and safe dose. See the post on Anti rejection Medications to read about their potential side effects.
Other Blood Tests you may need depending on your individual needs will be:
CMV – CytoMegaloVirus test diagnoses this common illness by looking for the levels of antibodies to cytomegalovirus in the blood sample.
PCR– Polymerase Chain Reaction diagnose certain infectious diseases and genetic changes by finding the DNA of a pathogen (disease-causing organism) or abnormal cells in the blood
INR – International Normalised Ratio (INR) blood test tells you how long it takes for your blood to clot. It is used to test clotting times if you are taking a blood thinner like warfarin.
CPR – C-reactive protein (CRP) CRP is a protein that is made in your liver and blood levels will start to increase with any inflammation or infection.
Iron Studies – include a range of blood tests that determines how much iron is in your blood and body. You can become iron deficient after surgery due to blood loss. Poor kidney function may cause anaemia.
Lipids – A Lipid profile determines levels of cholesterol and other fats in your blood.
Hba1c – Glycated Haemoglobin is used to diagnose type 2 diabetes. Prednisone use may cause diabetes. The post Anti rejection Medications discusses the potential side effects of Prednisone/ Corticosteroids.
Chest X-ray
Regular chest XRay are required every time you visit the heart lung clinic. This is usually weekly for the first 3 months, then once every month for the first year after a transplant.
Stress tests
To prepare for the test you will need to avoid eating, coffee, smoking and alcohol for 3 hours before the test begins. Be sure to wear loose comfortable clothing that is easy to walk in. Wear walking shoes also. Women can not wear an underwire bra as it interrupts the ECG telemetry reading. Perhaps you may be able to wear a wireless bra. However, this may prevent the placement of the ECG dots and wires. You may be able to negotiate this with the medical staff performing the test.
A stress test is usually performed 3 and or 6 months post transplant. During the test you are in a gown dressed from the waist down. Telemetry dots trace your heart’ rate and electric pulses (ECG). A finger probe measures your heart rate and oxygen levels. A blood pressure cuff is placed on the upper arm to measure blood pressure.
Initially you will have a cardiac ECG. This is then followed by you walking on a treadmill or peddling on a cycle. The test will continue until you reach 85% of the maximum heart rate predicted for your age. Every 3 minutes, the speed, incline and resistance of your treadmill or bike will increase, up to 15 minutes maximum. Once you achieve this you return to the bed laying on your left side for another ultrasound.
St Vincent’s Heart Health website has information about the Cardiac Exercise Stress Test.
A Personal Journey
Depending on your personal journey you may experience a variety of more tests. The above is an outline of regular tests you can expect after a heart or lung transplant.
Where are you at in your transplant journey? Are you a carer or relative of a donor or transplant recipient? Reach out and let us know in the form below.
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