From Referral to Recovery: The 11 Steps of a Heart Transplant at Cleveland's University Hospitals

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It could start at 3 a.m., 9 a.m., 2 p.m., or 11:59 p.m. Organ transplants happen around the clock at University Hospitals’ main campus in Cleveland. Lungs, hearts, livers and kidneys are shipped from across the country, and patients are out of surgery within four to 36 hours.

It’s a blur, but it’s never rushed.

In fact, most organs received by donor centers don’t even qualify as a match. Dr. Zoe Stewart Lewis, director of the UH Transplant Institute and chief of the Division of Transplant and Hepatobiliary Surgery, explains that each organ needs to be screened for compatibility and logistical possibility. If the tissue makeup isn’t right, if it’s sat dormant for too long, if it’s too far from the hospital, the organ is rejected. Patients continue waiting days, months or years.

“It’s holding your breath that nothing happens that makes them too sick and would preclude them from being able to go forward with a transplant,” Stewart Lewis says.

When the boxes are checked, calls are made between donor centers, surgeons and anesthesia and scrub teams to prepare for the procedure. Some patients reside at the hospital, some at home. Their organ is already on a plane.

“You’re relying on airline flights,” Stewart Lewis says, “then offloading to ground transportation to your center, transportation of blood samples to your tissue typing lab, timely turnaround on results, having (operating room) availability 24/7. The logistics it takes to pull off a single transplant are mind-boggling; it is literally hundreds of people involved.”

As an abdominal surgeon and institute director, Stewart Lewis is overseeing every part of the process.

“When we see our patients on the other side of it — looking like a normal person, back living their lives and feeling well,” Stewart Lewis says, “that’s the best part of it.”

Go step by step in the heart transplantation process at University Hospitals.

1. Outpatient Referral

Patients are referred by their cardiologist or can self-refer
through the hospital’s website or by calling the hospital system. At this stage, insurance is also verified for both the transplant and the pharmacy coverage needed for the procedure.

2. Intake

After referral, the patient’s medical records are reviewed. If no contraindications are noted and the patient is in stable condition, an evaluation is scheduled to begin testing.

3. Testing

The standardized evaluation takes two to four days, and patients must remain at the hospital. There, they meet with a multidisciplinary medical team that assesses the severity of the illness, weighs treatment options and determines whether the patient would benefit from a transplant. If so, the patient meets with a transplant coordinator, who explains the process and expectations ahead. 

4. The Committee

The multidisciplinary medical team now schedules a presentation to the multidisciplinary Advanced Heart Failure Therapeutics Committee, presenting about the patient and their illness. Here, the committee considers not just the medical risks but also the psychological risks for each patient. The committee makes the final decision.

5. The Letter

Once the Advanced Heart Failure Therapeutics Committee makes its decision, an outcome letter of the presentation is sent to the patient, either declining the need for advanced heart failure therapies or proceeding with listing the patient in the United Network for Organ Sharing. Those who are denied must proceed with alternative care options for their illness.

6. Listed Status

Those who are proceeding with the transplant are listed with a status in the United Network for Organ Sharing. Each status highlights the severity of the illness and the priority of the patient’s care. Status No. 1 and No. 2 are given to the patient with the highest priority, with the status level going as low as No. 6. Those listed at No. 6 are at home and are currently being treated with medication.

7. The Wait

Status No. 1 and No. 2 patients are hospitalized and receiving a high level of care. Because the Organ Procurement Organization offers organs sequentially down the national list, they’re at the top — meaning they could receive an organ within days or months. Status No. 3 patients and lower can wait months to years, and blood type O patients wait even longer, no matter their status. Wait times also vary because a patient’s status can move up or down as their illness changes.

8. Travel

Once a patient is matched to a heart from the national list, they must travel to the hospital for surgery (unless they’re already there). The heart must also be transported to the hospital, which can take a few hours depending on where it is in the United States.

9. Starting Surgery

The patient is prepped for surgery, and the heart arrives at the recipient’s operating room. The surgeon makes the final determination for transplantation based on the organ’s acceptability. With the green light, the procedure lasts between four and eight hours; those running over five hours are typically for patients who’ve had previous cardiac surgery.

10. Going Home

After surgery, patients stay in the hospital for about two weeks on average — longer if complications arise. Even those who head home must return for testing at set intervals for the rest of their lives to assess the body’s acceptance of the heart.

11. Acceptance

In the first months after transplants, patients are tested frequently for rejection, which is when your body’s immune system attacks the foreign organ. The tests taper off in frequency over time, but never cease, as doctors watch for chronic rejection, which is long-term and irreversible.

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