⚠️ Important Note:
This document is a public information tool. Always consult your physician for personal health decisions. The guideline is prepared to support the shared decision-making process between the physician and the patient.

A. Why is this Guideline Important?

Globally, cardiovascular diseases (heart and blood vessel diseases) remain the leading cause of death. High cholesterol is one of the most important and modifiable causes of this risk. The American College of Cardiology (ACC) and the American Heart Association (AHA) evaluated the latest scientific evidence and published the new cholesterol management guideline in 2026.

Why was the guideline updated?

• New drugs have gained clinical evidence since the 2018 guideline (bempedoic acid, PCSK9 inhibitors)
• More accurate risk calculation methods have been developed (PREVENT equations)
• The importance of new biomarkers such as Lipoprotein(a) and ApoB has been proven
• LDL target values were removed in 2018 — they have returned in 2026
• Very strong new evidence has emerged regarding the importance of early treatment
• The protective effect of bempedoic acid has been demonstrated in patients who cannot take statins

B. Basic Concepts: Cholesterol and Blood Fats

B.1 What is Cholesterol? 

Cholesterol is a fat that our body needs to build cell membranes, produce hormones, and aid in digestion. It is produced by the liver and is also absorbed from the animal-based foods we eat. The problem starts when too much of it accumulates in the blood.

B.2 Atherosclerosis: The Process of Clogged Arteries 

LDL cholesterol sticks to the inner wall of blood vessels and forms plaque over time. This process begins in childhood and progresses silently for decades. When the plaque grows, it either narrows the artery or ruptures, causing sudden blockage (heart attack, stroke).

❤️ Important Fact: The effect of LDL cholesterol on atherosclerosis is cumulative and time-dependent. High LDL starting at an early age causes much more damage than the same level starting in middle age. Therefore, the 2026 guideline particularly emphasizes early treatment.

C. 10 Major Innovations of the 2026 Guideline

This guideline contains radical changes compared to 2018. Here are the 10 most important innovations:

INNOVATION 1: LDL Target Values Have Returned 

In the 2018 guideline, the LDL target was removed, and only a ‘percentage reduction’ was recommended. The 2026 guideline recommends both percentage reduction and absolute target values together.

INNOVATION 2: New Risk Calculation — PREVENT Equations 

The new ‘PREVENT Equations’ are now used instead of the old ‘Pooled Cohort Equations’. This new system can calculate both 10-year and 30-year risk.

CPR Model — Risk Assessment in Three Steps:

• C — Calculate: Calculate the 10-year risk using PREVENT-ASCVD equations
• P — Personalize: Consider risk enhancers (see table)
• R — Reclassify: Clarify the risk with a CAC score if necessary

INNOVATION 3: Lp(a) Measurement is Now Recommended for Everyone 

The 2026 guideline states as a Class 1 (highest) recommendation that all adults should have their Lp(a) [Lipoprotein(a)] measured at least once in their lifetime.

Why is Lp(a) Important?

• Lp(a) levels are primarily genetically determined and do not change
• Lifestyle changes have very little effect on Lp(a)
• A single measurement is usually sufficient

🧬 Genetic Risk: High Lp(a) is passed down to children. If you or your first-degree relatives have high Lp(a), it is recommended that all first-degree family members (parents, siblings, children) get tested.

INNOVATION 4: ApoB Test — To Find Hidden Risk 

The new guideline states that after LDL and non-HDL targets are reached, the ApoB test is useful for additional risk assessment. It is especially valuable in the following situations:

• People with elevated triglycerides (> 200 mg/dL)
• In patients with diabetes
• Those who continue to have risk concerns despite having achieved low LDL (< 70 mg/dL)

🔬 Why is ApoB Important? Standard cholesterol measurements can sometimes hide the risk. Even if LDL appears ‘normal’, ApoB can be high. ApoB counts all the harmful lipoprotein particles circulating in the blood and more accurately reflects the true danger.

INNOVATION 5: Coronary Artery Calcium (CAC) Score — A Determinant in Treatment Decisions 

In some individuals, it may be uncertain whether to start medication. In these cases, the coronary artery calcium (CAC) score helps clarify the decision by measuring plaque accumulation in the heart arteries.

*Exceptions: In those with familial hypercholesterolemia, LDL≥190, diabetes and over age 40, active smoking, or a family history of premature heart disease, even a CAC=0 is not enough to delay treatment.

INNOVATION 6: Early Treatment — Starting in Youth is Critical 

The 2026 guideline presents strong evidence that bringing cholesterol management to earlier ages is life-saving.

• Preventing dyslipidemia with a healthy diet and exercise in childhood is the core strategy
• Early medication for children with genetic (familial) hypercholesterolemia
• Early initiation of medication in young adults if LDL ≥ 160 mg/dL or if there is a family history of premature heart disease
• Early and prolonged elevation of LDL causes much more damage than a short-term elevation

👶 Why is it so important to start early? The damage LDL does to the vessel wall accumulates over time. Someone living with high LDL from their 20s to their 60s is not in the same situation as someone whose high LDL started at age 40. Early prevention = less damage.

INNOVATION 7: Cholesterol Treatment in Diabetes, Chronic Kidney Disease, and HIV 

For people aged 40-75 with diabetes, chronic kidney disease (stages 3-4), or HIV infection, cholesterol-lowering medication is recommended regardless of their LDL level.

INNOVATION 8: Ezetimibe Prerequisite for PCSK9 Inhibitors Removed 

In the 2018 guideline, it was mandatory to use ezetimibe before switching to PCSK9 inhibitors (evolocumab, alirocumab). The 2026 guideline has removed this requirement. New Approach:

• Drug selection after statin therapy is now based on ‘how much LDL needs to be lowered?’ and ‘patient preference’
• The choice between ezetimibe, bempedoic acid, or a PCSK9 inhibitor is left to the clinician and the patient
• Long-term safety data for PCSK9 inhibitors has strengthened; the cost has also decreased

💊 Bempedoic Acid: A New Option for Those Who Cannot Take Statins 

Bempedoic acid is a new hope for people who cannot take statins due to muscle pain. In the CLEAR Outcomes trial, it lowered LDL by 20% and significantly reduced the risk of heart attacks. Because it is not activated in muscle tissue, it does not cause statin-like side effects.

INNOVATION 9: A Clear ‘No’ to Dietary Supplements 

The 2026 guideline explicitly opposes the use of dietary supplements to lower cholesterol or triglycerides. This is a Class 3 recommendation level — meaning ‘do not do it, it may cause harm or has no benefit’.

• Garlic capsules, red yeast rice, fish oil pills (not prescription high-dose omega-3), plant sterols, etc.
• The efficacy of these products in lowering LDL or triglycerides was found to be inconsistent and limited in clinical trials
• Using dietary supplements can lead to risk by delaying real treatment

⚠️ Beware of cholesterol supplements sold in pharmacies or online! 

Supplements claiming to ‘lower cholesterol’ lack sufficient scientific evidence. They cannot replace real treatment. Do not use them without talking to your physician.

INNOVATION 10: Female-Specific Risk Factors Are Now Official 

The 2026 guideline recommends that female-specific reproductive health history be included in the cardiovascular risk assessment. 

Risk-Enhancing Women’s Health Factors:

• Premature menopause (before age 45)
• Hypertension during pregnancy (preeclampsia, gestational hypertension)
• Gestational diabetes
• Premature birth (before 37 weeks)
• Recurrent pregnancy loss
• Early menarche (before age 10)

In the presence of these factors, a woman’s risk of heart disease may be evaluated higher than it otherwise would be, and cholesterol-lowering treatment may be considered earlier.

D. Lifestyle — The Foundation of Treatment

Alongside any drug treatment, or even if medication is not required, lifestyle changes form the foundation of cholesterol management. The 2026 guideline states that lifestyle alone can reduce cardiovascular risk by approximately 50%.

D.1 Heart-Healthy Diet

D.2 Physical Activity AHA Recommendation — How Much Per Week?

• Moderate-intensity aerobic activity: At least 150 minutes per week (30 min a day, 5 days)
• Or: Vigorous-intensity aerobic activity: 75 minutes per week
• Muscle strengthening: 2 days a week
• Walk for 5 minutes every hour to reduce the harms of prolonged sitting

Effect of Exercise on Cholesterol:

• Lowers LDL by 5-10%
• Increases HDL
• Significantly lowers triglycerides
• Contributes to weight loss — weight loss lowers LDL even further

D.3 Other Lifestyle Recommendations

E. Drug Treatments — Current Options

The choice of cholesterol-lowering medication is individualized by the physician, taking into account the person’s risk level, other diseases, tolerability, and preferences. Current options are summarized below.

💊 If You Are Experiencing Statin Side Effects: If you cannot use statins due to muscle pain or liver problems, alternatives like bempedoic acid are now available. Talk to your physician; look for an alternative instead of stopping treatment. Stopping medication can increase your risk.

F. High Triglycerides — A Separate Problem

While high triglycerides (TG) are an independent cardiovascular risk factor, very high levels (≥ 1000 mg/dL) also increase the risk of pancreas inflammation (pancreatitis).

Main Causes That Raise Triglycerides:

• Alcohol consumption
• Sugary drinks, refined carbohydrates, white flour
• Obesity and uncontrolled diabetes
• Hypothyroidism, kidney disease
• Some medications (beta-blockers, estrogen, glucocorticoids, some antipsychotics)
• Genetic disorders

G. Cholesterol in Children and Young Adults

The 2026 guideline now starts cholesterol management from childhood. Early diagnosis and treatment are life-saving in children with familial hypercholesterolemia.

When to Screen for Cholesterol in Children?

• Children aged 2 and older should have lipid measurement if there is obesity, diabetes, or a family history of premature cardiovascular disease
• Universal screening is recommended for all children aged 9-11
• Re-evaluation between ages 17-21
• Test at the earliest possible age if there is high LDL or familial hypercholesterolemia in the family

👨‍👩‍👧 If There is a Family History of High Cholesterol: If one of the parents has LDL > 190 mg/dL or a history of an early heart attack/stent/bypass, take your children to a physician and have their lipid profile measured, including Lp(a). Early treatment of familial hypercholesterolemia makes a massive difference.

H. Which Tests Should Be Done? — Checklist

⏱️ When to Retest After Starting Medication? A new lipid measurement is required 4-12 weeks after starting medication or changing the dose. Then, a check-up every 6-12 months. Once values are stable, 1 measurement per year is sufficient.

I. Frequently Asked Questions

Do I have to take cholesterol medications for life? 

In the vast majority of conditions such as familial hypercholesterolemia or established heart disease, yes. However, if LDL can be sufficiently lowered through lifestyle changes, the dose may be reduced or the medication stopped in some people. This decision must be made with your physician. When medication is stopped, LDL rises again.

Are statins harmful? Do they ruin the liver and muscles? 

Statins have been safely used by millions of people for decades. Serious liver damage is extremely rare. Muscle pain can occur in about 1 in 10-15 people, but it is usually mild and is resolved by adjusting the dose or changing the medication. Severe myopathy indicating muscle damage occurs in less than one in a thousand. Stopping statins poses a much greater risk than these rare side effects.

Are there always symptoms when cholesterol is high? 

No. The vast majority of high cholesterol is completely asymptomatic (causes no symptoms). A person can live with high LDL for years, while the progressing atherosclerosis in their arteries grows unnoticed, manifesting suddenly with a heart attack or stroke. This is why regular screening is vitally important.

What can I do if my Lp(a) is high? 

It is not yet possible to significantly lower Lp(a) with lifestyle or current medications. However, in the presence of high Lp(a), it is recommended to control other risk factors (LDL, blood pressure, smoking, diabetes) much more aggressively. New drugs specifically targeting Lp(a) (olpasiran, muvalaplin) are currently in the final stages of clinical trials.

Do natural supplements like omega-3 and garlic work? 

The 2026 guideline is very clear on this: Dietary supplements do not lower LDL or triglycerides to a clinically meaningful level and do not appear to prevent cardiovascular disease. Prescription high-dose omega-3 (icosapent ethyl) is in a separate category and is different. It should not be confused with fish oil capsules sold in pharmacies.

What should I ask my physician?

• Question 1: What are my LDL, HDL, triglyceride, and non-HDL values, and what should my target be?
• Question 2: Have I ever had my Lp(a) measured in my life? Should I?
• Question 3: What is my cardiovascular risk category? (low/borderline/intermediate/high)
• Question 4: Do I need a coronary calcium score?
• Question 5: Are my current medications sufficient? Are changes needed?
• Question 6: There is a cholesterol problem in my family. Do my children need to be tested?

J. Quick Reference: Summary of the 2026 Guideline

10 MAJOR INNOVATIONS — BRIEF SUMMARY

1. LDL target values have returned: Very high risk < 55, high risk < 70 mg/dL
2. More accurate risk calculation with PREVENT equations: CPR model (Calculate-Personalize-Reclassify)
3. Lp(a): Measurement is recommended for all adults at least once in their lifetime
4. ApoB: Useful for additional risk detection, especially in diabetes and high triglycerides
5. CAC score: A deciding tool in treatment uncertainties — men ≥40, women ≥45
6. Early treatment is critical: High LDL starting in youth leads to more damage
7. Diabetes, CKD, HIV: Medication treatment regardless of LDL level between ages 40-75
8. Ezetimibe prerequisite for PCSK9 inhibitors removed: Bempedoic acid is a new option
9. Dietary supplements are not recommended for cholesterol: Class 3 (harm or no benefit)
10. Female-specific risk factors have become official: preeclampsia, gestational diabetes, premature menopause

📚 Source 

Blumenthal RS, Morris PB, Gaudino M, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2026;153. DOI: 10.1161/CIR.0000000000001423

This document has been prepared for public information purposes. Consult your physician for individual medical decisions.

TABLE OF CONTENTS

1. What is High Blood Pressure (Hypertension)?

    • Blood Pressure Categories Chart

    • Risk Factors (Controllable / Uncontrollable)

2. What Are the Consequences of High Blood Pressure?

    • Stroke, Heart Failure, Kidney Disease, and More

3. How Can I Improve My Blood Pressure?

    • Lifestyle Changes Chart

    • Why Should I Restrict Sodium?

    • High Blood Pressure Medications and Side Effects

4. African Americans and High Blood Pressure

5. How Do I Measure My Blood Pressure Correctly?

6. Resources and Reference Links

1. What is High Blood Pressure (Hypertension)?

Blood pressure is the force exerted by circulating blood against the walls of the blood vessels. It is measured in millimeters of mercury (mm Hg) and is written as two numbers (e.g., 112/78 mm Hg). High blood pressure usually has no symptoms; therefore, it is called the ‘silent killer.’ Nearly half of the American population over the age of 20 has high blood pressure, yet many are unaware of it.

Basic Definitions

• Systolic pressure (top number): The pressure in your blood vessels when your heart beats.
• Diastolic pressure (bottom number): The pressure in your blood vessels between heartbeats.
• Normal blood pressure: A value below 120/80 mm Hg.

Why is High Blood Pressure Dangerous? Left untreated, high blood pressure damages the heart, brain, kidneys, and eyes. It significantly increases the risk of heart attack, stroke, and kidney failure.

Blood Pressure Categories

Risk Factors

Controllable Factors:

• Smoking and secondhand smoke exposure
• Diabetes
• Obesity or being overweight
• High cholesterol
• Unhealthy diet (diet high in sodium, low in potassium, and excessive alcohol)
• Physical inactivity

Uncontrollable Factors:

• Family history of high blood pressure
• Race / ethnicity
• Advanced age
• Gender (higher risk in men)
• Chronic kidney disease
• Obstructive sleep apnea

Important Note: Socioeconomic status and psychosocial stress are also risk factors for hypertension. This situation can negatively affect access to basic life needs, medication use, access to healthcare professionals, and the capacity to adopt healthy lifestyle changes.

2. What Are the Consequences of High Blood Pressure?

High blood pressure is the first stone that paves the way for devastating health problems, much like a ‘domino effect’. If left uncontrolled, it can lead to a heart attack, stroke, heart failure, or kidney failure.

Affected Organ Systems

How Does High Blood Pressure Increase Stroke Risk? High blood pressure is one of the most important risk factors for stroke. Over time, it increases the workload of the heart and damages your blood vessels. People with high blood pressure are much more likely to have a stroke compared to people with normal blood pressure.

• Ischemic Stroke (87%) Caused by narrowed or blocked blood vessels that cut off blood flow to the brain and kill brain cells. High blood pressure damages the inner lining of the blood vessels, paving the way for this blockage.
• Hemorrhagic Stroke (13%) Occurs when a blood vessel in or near the brain ruptures. Chronic high blood pressure or age-related blood vessel damage is the main cause of this type of stroke.

How Can I Control High Blood Pressure? Even if you have previously had a stroke or heart attack, keeping your blood pressure under control can prevent a new event:

• Do not smoke; avoid exposure to secondhand smoke.
• Maintain a healthy weight.
• Eat a diet rich in fruits and vegetables, and low in sodium and saturated/trans fats.
• Get at least 150 minutes of moderate-intensity physical activity per week.
• Alcohol causes your blood pressure to rise.
• Take all medications exactly as prescribed.
• Know what your blood pressure should be and try to maintain that value.
• Do not skip your regular follow-up appointments.

3. How Can I Improve My Blood Pressure?

By treating high blood pressure, you can significantly reduce the risk of stroke, heart attack, heart failure, and kidney failure. Each of the lifestyle changes below reduces blood pressure by a certain amount:

Effect of Lifestyle Changes on Blood Pressure

SBP = Systolic Blood Pressure | BMI = Body Mass Index

Weight Loss To lose weight, you must burn more calories than you consume every day. Consult your healthcare professional for a healthy eating and physical activity plan. Losing at least 5% of your body weight will help lower your blood pressure.

Why Should I Restrict Sodium? Excess sodium in the blood pulls water into the blood vessels, increasing the amount of blood inside them; this leads to an increase in blood pressure. In some people, it can cause high blood pressure or make it even higher.

Daily Sodium Goals and Practical Tips

• Daily goal: 1,500 mg or less. Even a 1,000 mg reduction improves heart health.
• Ways to Reduce Sodium:
  • Read nutrition labels; products containing 140 mg or less of sodium are considered low sodium.
  • Avoid ready-made, packaged, and processed foods.
  • Do not use salt when cooking or at the table; prefer herbs and salt-free spices instead.
  • When eating out, ask for your food to be prepared without salt.
  • The ‘Salty 6’: bread, pizza, sandwiches, cold cuts, soup, burritos — the 6 foods containing the most salt.
  • Watch out for ‘hidden sodium’ sources like cheese, canned vegetables, frozen meals, and fast food.

Alcohol Alcohol can raise blood pressure. If you have difficulty cutting back on alcohol, ask your doctor for information about support groups.

Physical Activity Regular physical activity helps lower blood pressure, control weight, and reduce stress. Aim for at least 150 minutes of moderate-intensity or 75 minutes of high-intensity aerobic exercise per week. Start with activities you enjoy, such as brisk walking or cycling (Consult your family doctor before starting exercises, and adjust the durations according to their recommendations).

About High Blood Pressure Medications Depending on your risk level and blood pressure readings, one or more medications may be necessary. Your doctor may implement a trial process to find the most suitable combination for you.

Common Side Effects

• Weakness, fatigue, or sleepiness
• Cough
• Muscle cramps
• Headache, dizziness
• Erectile dysfunction
• Sleep problems
• Constipation or diarrhea
• Feeling thirsty, skin rash

Important Reminder:

• Take your medications exactly as prescribed; do not stop taking them without your doctor’s approval.
• Medication use usually continues for life even after your blood pressure returns to normal.
• If you experience side effects, do not stop taking the medication yourself — call your doctor.

How Do I Remember to Take My Medication?

• Take your medication at the same time every day.
• Combine taking your medication with a daily habit, like brushing your teeth.
• Use a weekly pillbox with separate compartments for each day.
• Ask family members or friends for reminders.
• Set a reminder on your smartphone or keep a medication calendar.

4. African Americans and High Blood Pressure

African Americans in the US have a higher rate of hypertension compared to other racial and ethnic groups. High blood pressure can be more severe in this group, and some medications may be less effective in these individuals. High blood pressure usually has no symptoms; therefore, it gets the name ‘silent killer’.

Special Dietary Recommendations:

• Aim for 1,500 mg or less of sodium per day (even a 1,000 mg reduction is beneficial).
• Consume 3,500–5,000 mg of potassium per day (bananas, potatoes, beans, spinach).
• Alcohol consumption can increase your blood pressure.
• Do at least 150 minutes of moderate-intensity aerobic exercise per week (Always consult your doctor before exercising).

Caution in Medication Treatment:

• Thiazide-type diuretics and/or calcium channel blockers may be more effective alone or in combination in African Americans.
• Your doctor may implement a trial process to find the most suitable combination for you.
• Continue medication treatment along with lifestyle changes.

Conditions Uncontrolled Hypertension Can Lead To:

• Heart attack and heart failure
• Stroke
• Kidney disease and kidney failure
• Erectile dysfunction
• Vision loss

5. How Do I Measure My Blood Pressure Correctly?

Preparation before and during the measurement is of great importance to get accurate results. Follow the steps below:

BEFORE MEASUREMENT:

• Do not smoke, exercise, consume caffeine, or drink alcohol 30 minutes before the measurement.
• Sit in a chair for at least 5 minutes with your left arm resting comfortably at heart level.
• Relax; sit upright, keep your feet flat on the floor, and have your back supported.
• Do not talk during the measurement.

DURING MEASUREMENT:

• Take at least 2 readings at least 1 minute apart; measure in the morning before taking medication and in the evening before dinner. Record all results.
• Use a properly calibrated and validated device. Check the cuff size.
• Place the bottom edge of the cuff just above the bend of the elbow.

⚠ HYPERTENSIVE CRISIS — EMERGENCY If your blood pressure is over 180/120 mm Hg, wait a few minutes and measure again. If it is still high, IMMEDIATELY CALL YOUR DOCTOR OR GO TO THE EMERGENCY ROOM.

6. Resources and Reference Links

Useful Websites and Videos

References

1. American Heart Association (AHA) (2021). Blood pressure fact sheets. heart.org
2. AHA (2021). Getting active to control high blood pressure. heart.org
3. AHA (2022). Recipes. recipes.heart.org
4. American Medical Association (2022). 7-step quick guide to measuring home blood pressure. ama-assn.org
5. CDC (2017). Tips for taking blood pressure medicines as directed [Video]. YouTube.
6. NHLBI (2020). Easy ways to add exercise to your life [Video]. YouTube.
7. NHLBI (2019). 3 Delicious Heart-Healthy Recipes [Video]. YouTube.
8. NHLBI (2022). Delicious healthy eating recipes for heart health. healthyeating.nhlbi.nih.gov
9. USDA (n.d.). Budget-friendly healthy eating. myplateprod.azureedge.us
10. USDA (2022). MyPlate. myplate.gov

This document is based on American Heart Association (AHA) resources. Please consult your healthcare professional for medical decisions.

Organ transplantation is the treatment of a patient by surgically replacing organs that have been damaged to the point of being unable to function due to untreatable diseases with a healthy organ taken from a living or deceased person. Among these, heart transplantation can only be performed from a cadaver (a person whose brain death has been confirmed).

Who Can Undergo Heart Transplantation?

Heart patients under the age of 65 who have reached the end stage of heart failure despite all medical treatments and have a life expectancy of less than 1 year are candidates for heart transplantation. Patients of more advanced age can be included in the heart transplant program if they are found suitable after a careful evaluation of their physical characteristics beyond their chronological age. The necessity for a heart transplant most commonly arises due to serious and major irreversible damage to the heart muscle caused by a previous crisis related to the blockage of coronary vessels, or due to a severe decrease in the contractile power of the heart muscle—either congenital or subsequently occurring due to bacteria, viruses, etc.—known as cardiomyopathy. Other rare causes include rheumatic fever, hypertension, valve diseases that have led to heart muscle damage, congenital heart anomalies that cannot be surgically corrected, heart tumors, and patients with serious rhythm disorders resulting from various diseases that continue in a life-threatening manner and cannot be stopped despite all kinds of medication and pacemaker treatments.

Can Everyone Undergo Heart Transplantation?

Heart transplantation is recommended by specialist physicians after ensuring that all known treatment methods for patients with heart failure have been considered, applied, and tried. This is because these patients will lose their lives shortly if they do not receive a heart transplant. However;

• Patients who have developed irreversible high pulmonary hypertension (Pulmonary hypertension = high pulmonary pressure, high pulmonary vascular resistance) that cannot be treated due to long-term heart failure,
• Patients with severe obesity with a Body Mass Index (BMI) over 30,
• Patients with active, uncontrollable infections,
• Patients who have developed irreversible other organ dysfunctions (especially kidney failure) due to advanced diabetes (Diabetes Mellitus),
• Patients with an untreatable tumoral (cancer) disease,
• Serious osteoporosis (bone loss),
• Patients with psychiatric disorders or alcohol/drug addiction are not suitable candidates for heart transplantation.

How to Get on the Heart Transplant List?

When the cardiologist who knows and follows the patient’s medical history thinks that a heart transplant is necessary for the treatment of the disease, they present the case to the heart transplant and artificial heart support systems council. A preliminary evaluation is made by discussing the patient’s medical history, all treatments performed, current status, latest tests, physical capacity, and other details. Then, the patient’s condition is thoroughly evaluated by the regularly convened board. Other necessary tests and consultations (psychiatry, endocrinology, nephrology, dentistry, etc.) are planned. If the patient is found suitable for a heart transplant as a result of all these evaluations by the heart transplant and artificial heart support systems council, they are placed in the heart transplant program according to their urgency and recorded in the organ waiting list. The average waiting time for heart transplantation is approximately 6-7 months for patients on the emergency list.

Heart Transplant Surgery, Intensive Care, and Afterward

Once the team sent to retrieve the organ examines the heart during the surgery and declares it suitable, the patient to receive the heart transplant is taken into surgery at the recipient hospital. Thus, the operation process begins. While the heart transplant is being performed, the patient is connected to a heart-lung machine. The goal is to perform the transfer of the organ and the operation within 4 hours. For this, a very good organization and an expert team are required. After the heart transplant, the patient is taken to the cardiac surgery intensive care unit. The patient remains connected to a respiratory device for the first 8-24 hours. Immunosuppressive (immune-suppressing) drugs are started while the patient is still in surgery to prevent rejection. Because these drugs are administered, the patient is very susceptible to infection. Therefore, the patient is given the most careful care possible. If everything goes well, the patient is usually transferred to a ward room on the 3rd to 5th day on average. Close monitoring is performed for rejection during the initial period. The patient is usually discharged after 20 days. According to the physician’s recommendation, the patient is generally called for follow-up at the 1st, 3rd, 6th, and 12th months.

Results of Heart Transplantation (Life Expectancy)

• Heart transplant surgeries continue to be the distinguished treatment approach for patients who have reached the final stage and will not respond to medication or surgical treatments. The fact that organ donation is not at the desired level—not only in our country but even in leading countries in heart transplantation—makes it mandatory to use the hearts to be used for transplantation in the most efficient way. Providing available organs to the recipients who need them most and will benefit the most is increasing in importance every day.
• Immunosuppressive treatment, developments in immunological monitoring, and the fight against sterilization and infection have been the cornerstones for the good survival results in the last 20 years. Particularly as a result of developments in immunosuppressive treatment, death rates due to rejection have decreased significantly.
• Looking at the results of leading centers in heart transplantation worldwide, the 1-year survival rate after heart transplantation is over 85%, and the 5-year survival rate is over 70%. At Türkiye Yüksek İhtisas Hospital, the one-year survival rate is 88%, the five-year survival rate is 76%, and the 10-year survival rate is over 54%.

Heart Transplant Numbers and Organ Donation in the World and Türkiye ​

• The need for heart transplantation is greater than the organ supply. In America, there are approximately 5-6 million heart failure patients, with 500,000 patients added each year. The number of patients waiting for a heart transplant is approximately 25,000-30,000. However, the number of heart transplants performed is approximately 2,500–3,000 per year (10-15% of the waiting patients). 20-40% of the patients lose their lives before a heart transplant can be performed.
• The money spent on patients with heart failure is approximately 34 billion dollars per year. In Türkiye, the number of heart failure patients is approximately 1.5 million. The number of patients in need of a heart transplant is approximately 3,000-5,000. However, according to the records in the National Coordination Center (UKM) data, the number of heart transplants performed is 50-60 (1-2%) per year.

Pediatric Heart Transplantation

Many causes lead to heart failure, such as rheumatic heart valve diseases and congenital structural anomalies; congenital and acquired diseases of the inner layer of the heart, the heart muscle, and the heart membrane; volume-loading diseases such as severe anemia, excessive blood or fluid transfusion, and hormonal reasons; babies of diabetic mothers; and rhythm and conduction disorders of the heart. Despite all medical treatments or all surgical correction operations in children with congenital heart disease, patients’ heart failure may not improve. For these patients, heart transplantation or artificial heart devices can be life-saving. A pediatric heart transplant and artificial heart device program was launched at Türkiye Yüksek İhtisas Hospital in 2012 together with the pediatric cardiology and heart transplant group. Our clinic intervenes in patients with end-stage heart failure from all age groups.

Diagnosis and Symptoms of Heart Failure

• Pain in the chest,
• Shortness of breath (labored breathing),
• Weakness,
• Fatigue,
• Tiring easily,
• Inability to show resistance to simple illnesses (such as the common cold or flu),
• Swelling of the ankles,
• Weight loss due to decreased appetite,
• Frequent urination,
• Deterioration of heart rhythm and rapid heartbeat,
• Blood accumulation in the lungs.

Since blood cannot sufficiently reach the tissues, the patient has difficulty while climbing a slope or stairs, feels forced to rest frequently, and swelling (edema) occurs in the ankles. In severe cases, bruising increases along with shortness of breath. Along with this, blood accumulation may occur in the lungs. Despite all these symptoms, heart failure can only be understood as a result of examinations and tests performed. Sometimes, there may be no symptoms even if heart failure is present.

Treatment of Heart Failure

The first stage of treatment begins with a change in the patient’s nutritional lifestyle. It is necessary to significantly reduce the intake of fat and especially salt. Since salt increases water retention in the body, it prevents the reduction of swelling in the body. If less salt is taken, water excretion through urine increases and swelling decreases. Thus, the workload of the heart is reduced. Patients with heart failure must stay away from tiring tasks that require heavy strength. However, just as a person leading a sedentary life experiences a loss of strength and conditioning, the heart muscle also loses strength. To prevent this, an exercise program should be implemented under a doctor’s supervision. The second stage in treatment is carried out with medications. As for the third stage; devices to eliminate rhythm disorders and corrective surgeries (coronary bypass, valve surgery, etc.) directed at the disease causing heart failure can be applied. However, if the aforementioned treatments are applied but the condition cannot be corrected in the treatment of end-stage heart failure, the most effective treatment methods are heart transplantation and auxiliary artificial heart devices that support the functioning of the heart.

Heart support devices (HSD) are high-technology devices produced to take over the pumping duty of the heart in patients with end-stage heart failure. There are models whose mechanical parts can be placed inside the chest or abdomen, as well as paracorporal (outside the body) models. Generally, the battery is located outside the body. The fundamental reason leading to the development of these devices is that some of the patients waiting on the heart transplant candidate list are lost during the waiting period due to limitations in finding donors. There have been major developments regarding HSDs in the last 10 years, and significant progress has been made toward reaching ideal devices. While the 1-year survival rate was 50% in the first-generation artificial support devices, this rate was reported as 68-86% in the 2nd generation devices and around 90% in the 3rd generation devices. Following the successful results obtained with systems used in the treatment of cardiogenic shock in the early years, multi-purpose use is increasing today with the aims of keeping the patient alive until transplantation (bridge to transplantation) and improving heart failure (bridge to recovery). In the REMATCH study concluded in the USA in 2002, the superiority of implantable HSDs over optimal medical treatment in terms of survival and quality of life in patients not suitable for heart transplantation resulted in the granting of FDA approval for long-term use (destination therapy). In patient selection, besides updated indications, the cardiac and extracardiac characteristics of the patient are the primary determinants, while in device and system selection, preference for the one most suitable for the patient’s clinical picture is essential. In recent years, along with well-known pulsatile systems, interest in miniaturized flow pumps has been increasing. Consequently, it is suggested that in the next decade, the transformation of HSDs into a special field of expertise within heart failure surgery, new organizations inside and outside hospitals, and financing regulations in the health system will necessitate a total institutional restructuring in societies.

Heart transplantation and artificial heart support devices are performed by fully equipped hospitals authorized by the R.T. Ministry of Health, which have experienced teams in organ transplantation and artificial heart systems and carry out heart transplantation programs.

Who Needs an Auxiliary Artificial Heart Device and When?

Auxiliary heart support devices are mainly used for the following purposes in patients with end-stage heart failure:

• For short-term use (short-term applied devices) in patients who suddenly develop heart failure, to prevent deterioration in other organ functions and to keep the patient alive until a long-term support system is applied,
• For the purpose of recovery (short-term applied devices) in diseases that cause sudden heart failure such as inflammation of the heart muscle (Myocarditis) but heal completely as a result of drug treatment, in order to keep the patient alive during the severe period of the disease,
• To keep the patient alive until heart transplantation (long-term applied devices) in patients who are on the waiting list for heart transplantation but whose heart failure progresses while waiting for a heart,
• For lifelong use (long-term applied devices) to increase the life span and quality of patients who cannot undergo heart transplantation for various reasons (advanced age, serious kidney, liver disease, etc.),
• To provide the chance of heart transplantation later (long-term applied devices) in patients who cannot undergo heart transplantation due to high pulmonary (lung) resistance/pressure (PVR), as a decrease in PVR can be seen after VAD implantation.

If severe failure has developed in both the right and left sides of the heart, a total artificial heart device is placed.

Total Artificial Heart Device

It is the device that is placed in stead of the diseased heart after it is removed from the body and carries out the circulation. It keeps the patient alive for temporary purposes, that is, until heart transplantation.

Frequently Asked Questions and Problems Regarding Auxiliary Artificial Heart Devices

Artificial heart support devices are in two different groups: those placed inside the body (implantable, miniature) and those outside the body (paracorporal). Which one will be installed is determined according to the characteristics of the patient’s heart failure and general condition. Although the artificial heart support device surgery varies according to the type of device installed, if no complications develop, it is a surgery that lasts 4-6 hours on average. The pump stays inside your chest and is directly connected to your heart. It pumps blood from the left side of your heart into your aorta (the large blood vessel that carries blood from your heart to other parts of your body). Patients whose surgery is finished wake up in a special transplant room in the intensive care unit; they are disconnected from the respiratory device when all findings return to normal. Blood comes out of the pump in a continuous flow, like water coming out of a garden hose. This continuous flow is different from the pulse of a normal heart and as a result, you may not be able to feel your pulse. There is no need to worry, this is a normal situation. These patients have to use blood-thinning medications for as long as they live with the device and consult their doctors for the doses of these medications by having regular blood tests. The pump works with a small external computer called a controller. The pump and controller are connected to each other by a small cable (driveline) passing through the skin in your upper abdominal region. The controller runs the pump and also provides text messages and audible alarms for you to check the operation of the system. The controller works with two batteries or one battery and wall electricity. The entire system is portable and weighs approximately 1.5 kg. You can attach a carrying case to your waist or carry it on your shoulder, so you take the system everywhere you go.

Artificial Heart Device Program

The Artificial Heart Support Device Program at our hospital began in 1990 and has continued to the present day. In 2001, the first intracardiac heart pump in Türkiye was successfully implanted in our patient. Technological developments regarding artificial heart support devices are closely monitored by our teams. Today, miniaturized heart pumps used in leading transplant centers worldwide are also utilized for our patients at our hospital. In 2013, for the first time at our hospital, total artificial heart devices were successfully implanted in two of our patients.

The body perceives transplanted organs as foreign objects and goes on the attack. Cells of the complex system we call the immune system want to attack and damage the tissues of the transplanted organ—connected to the body’s circulatory system—just as they would attack any virus or bacteria entering the body that causes a cold. We call this attack of immune cells on the new heart rejection. This event, called rejection, is usually seen within a few weeks following the organ transplant. However, such a reaction can be encountered months or even years later. For this reason, organ transplant patients must take these anti-rejection (immunosuppressive) medications for the rest of their lives. The success of organ transplants depends on patients following the doctor’s advice and using these medications at the recommended dose and time, without ever skipping them.

To reduce your body’s reaction to the transplanted organ: You must take your medications in accordance with your doctor’s recommendations. Your immunosuppressive medications, which are very important for you to prevent the body from reacting to your new heart, are:

• Sandimmun-Neoral (Cyclosporine-A) or Imuran or Prograf (Tacrolimus)
• Cell-cept (Mycophenolate Mofetil) or Myfortic
• Deltacortil (Prednisolone)

Your other medications are also important and should be taken on time. Never neglect taking your medicine and do not change the dose yourself. Try to take your medicine at the same time every day. Drink your medicine with plenty of water (at least one full glass). Your physician may prescribe additional medications in addition to the ones above.

If you forget to take your medicine, take it as soon as you remember. If you are very close to the time of your next dose, do not take the forgotten dose and do not change your normal dose and medication time. When it is necessary to stop any medication you are taking upon your doctor’s advice, examine the interaction it will have with immunosuppressive drugs.

Adjust your medication stocks, taking into account holidays and travels you will make. Investigate the interactions of any medications you take without a doctor’s recommendation with anti-rejection drugs; if possible, do not take a new medication without consulting your doctor. Definitely stay away from “folk remedies” (Lokman Hekim medicines)!!!!!!!!

You should not drink your medications with grapefruit juice. Grapefruit juice can change the effects of your medications and cause negative results (especially increasing the effects of Cyclosporine, antihistamines, and cholesterol-lowering drugs). Be sure to inform any new doctor during visits that you have had an organ transplant. If new side effects occur or if there is an infection, be sure to inform your doctor.

In Case of Rejection: Even if the anti-rejection drugs mentioned above (Cyclosporine, Prograf, Imuran, Cell-Cept/Myfortic, Prednisone/Deltacortil) are taken regularly, immune cells may sometimes attack the new heart. Almost all patients may experience one or more rejections. In this case, medications for this are started without wasting time. While the rejection gradually passes after a while, treatment is continued by reducing the dosage. As a result, you must take anti-rejection drugs continuously for the rest of your life. Dosages may decrease, but they should never be skipped or stopped. Rejection may be seen more frequently within the first six weeks after surgery. The probability decreases in later times, but it can happen at any moment in the future. For this, it is necessary to continue periodic check-ups without interruption. In case of rejection, the only way to detect it at an early stage before your immune system damages your new heart is to be under frequent control. Your doctors diagnose whether rejection is occurring through frequent examinations in the first stage, blood tests, echocardiograms (ECHO), and biopsies. In later years, the interval between control times may be extended.

Infections: Since the medications that prevent your immune cells from attacking your new heart also prevent attacks on harmful organisms such as bacteria, viruses, parasites, and fungi that enter the body and circulatory system, the patient’s body remains unprotected. This risk is higher when high doses of medication are taken during rejection periods. After surgery and in cases of rejection, the patient must be cared for under sterile conditions with maximum hygiene provided.

Other diseases that may occur due to the continuous use of anti-rejection drugs:

• High Blood Pressure: Should be monitored constantly. If necessary, your doctor can prescribe blood pressure-lowering medication. If high blood pressure is not monitored and controlled, it can damage the kidneys, heart, vascular system, and brain. It can cause strokes and heart attacks.
• Diabetes: Your blood sugar may rise due to medications. Particular attention should be paid to nutrition.
• High Cholesterol: Prevented by giving a prescription to control cholesterol.
• Cancer: Although the frequency has decreased with the use of new-generation drugs, certain types of cancer (such as Lymphoma and skin cancers) may appear. This is prevented by the doctor reducing drug doses.
• Osteoporosis: This disease is the thinning of the bones due to poor nutrition, inactivity, prednisone, and other anti-rejection drugs; it can be diagnosed with tests.
• Vision: In case of visual impairment, go to an ophthalmologist for cataract and glaucoma tests.
• Kidney Diseases: Kidney functions should be monitored by performing regular blood and urine tests. As a precaution, the drug level is reduced. Damage is prevented by drinking plenty of water.

Vitamins, minerals, antibiotics, and antiviral drugs:

• Bactrim (Trimethoprim-Sulfamethoxazole): Prevents Pneumocystis carinii pneumonia, which is common in patients receiving immunosuppressive drugs. Some side effects may be seen; it can interact with Cyclosporine and lower its blood level. Although rare, it can cause nausea and vomiting. For those with allergies, your physician may give other medications instead of this drug until the 6th month.
• Valtrex: Used in the prevention of viral infections such as Cytomegalovirus (CMV), Herpes Zoster, and Herpes Simplex that can be seen after organ transplantation.
• Mycostatin: Prevents fungal infections in the mouth while taking high doses of immunosuppressive drugs. Gargle 5cc in the mouth 4 times a day and swallow. It can be discontinued by your doctor’s decision when Prednisolone (Deltacortil) drops to the required level.
• Folic Acid: Works with iron to increase the red blood cell count. An iron compound that interacts with folic acid. Iron and folic acid help increase red blood cells by providing the nutrients necessary for your body. After surgery, iron is only given until the blood value returns to normal. Side Effect: Constipation.
• Omeprol (Omeprazole) 20mg: Used as a stomach protector against intensive medication use.

Inform your doctor in the following situations:

• High fever over 37.5°C lasting for a long time.
• Fatigue, tiring easily, shortness of breath, persistently high blood pressure.
• Rapid weight gain within one or two days.
• Fluid accumulation in tissues (edema).
• Heart rhythm disorder.
• Fainting for unknown reasons.
• Diarrhea lasting more than one day, bloody diarrhea.
• Constipation lasting more than two days.

What will your lifestyle be like? Rest plenty in the first weeks and months. At least half an hour of rest is required after meals. Walks should not be immediately after meals. Organ transplantation can enable you to return to a normal life. After experiencing health problems for a long time, you need to pay importance to your health in your new life that will come with organ transplantation. This issue is quite important because after organ transplants, you must protect your new heart and health well so as not to experience the health problems you had before the transplant again.

Nutrition: Before being discharged, visit the diet department in our hospital, get your diet program suitable for your weight, height, and age from our dietitians, and follow the given diet exactly (Especially reduce salt, sugar, and carbohydrate foods). You will probably feel your appetite increasing after the organ transplant, especially if your illness lasted for a long time before the transplant. Healthy nutrition is part of your treatment in your recovery process after organ transplantation. Since some anti-rejection drugs will increase your appetite significantly, you may gain weight quickly after transplantation. In such a case, inform your doctor, and they can readjust your medication doses. It is recommended that you eat with conscious nutrition and a low-fat, low-sugar, fiber-intensive diet. You can also ask your doctor questions about your nutrition. It is recommended to weigh yourself once a week after surgery. Blood pressure monitoring should be done once a day. You should reduce salt consumption because it can raise your blood pressure. As in every subject, you must follow your doctor’s advice on nutrition. Avoid one-sided nutrition. Salted, smoked, dried meats and foods, canned, and frozen foods should not be eaten. Meat, milk, chicken, turkey, fish, and dairy products should be taken fresh and daily. Care should be taken that your food and drinks are fresh, clean, prepared in accordance with hygiene rules, and well-cooked (especially meats should be well-cooked). Prepared meals should be consumed daily. They should not be stale, spoiled, or molded. Prefer vacuum-packed food items if possible.

Restrictions to be made:

• Fluid and salt restriction.
• Foods with high Na+ (sodium) content.
• Restriction in protein intake.
• Calorie restriction.
• Concentrated carbohydrate restriction.
• Cholesterol and fat restriction.
• Caffeine restriction.
• Restriction of brain, offal, dried fruits, sugary foods, chocolate, cream, floury foods, etc.
• Alcohol restriction.

Fluid and salt restriction: Since Prednisolone intake keeps salt and fluid in the body, salt should be used in a controlled manner. Salt causes excess water retention in the body, arteries, and veins. To avoid this, you should reduce both. To get fluid, eat fruit instead of fruit juice. Your doctor can prescribe salt restriction. Foods with high sodium content: Ready-made sauces, instant soups, canned foods, tomato paste, salty cheeses, frozen peas, salted fish, anchovies, meat products such as soujouk, pastrami, sausage, salami, salted or unsalted nuts, tarhana soup, ketchups, biscuits, crackers, salty galettes, salty butters, all kinds of ready-made foods and ready-made drinks, salty bread, pita, crackers, corn bread, chips, pickles, mayonnaises, and spicy foods.

Protein intake: High-protein foods can be given for a short time for the healing of wounds after surgery. However, the amount of protein given can be changed depending on the functioning of the kidneys. There is no need for a protein-rich diet after surgical wounds heal.

Calorie restriction: The total calories you take should be adjusted by dietitians for reasons such as maintaining, increasing, or decreasing your weight. Excessive weight increases the workload of the heart. Medication treatment can cause excessive eating and weight gain. Therefore, you should pay attention to the total calories you take. Excessive weight also causes fat in the blood. This lubrication causes the blood vessels in your heart to narrow and become blocked. The calorie value of the total amount of fat you take daily should not be more than 30% of the calories you need daily.

The following points are very important to ensure food hygiene: The person who will prepare the meals should wash their hands thoroughly with liquid soap before starting to cook. When you take the product you store in the refrigerator out of its vacuum-packed packaging, keep it in a storage container with a glass lid. Wash your vegetables and fruits with plenty of water in the washing bowl. You can rinse the vegetables and fruits you will consume raw by adding 5% vinegar to the final water. Kitchen utensils such as pots, forks, spoons, knives, glasses, plates, and bowls should be washed in the dishwasher at a high temperature setting if possible. The person receiving treatment should always eat and drink from their own special glasses, dishes, and plates.

Sports and exercise: Gaining strength for your body after heart transplant surgery is one of the most important parts of your recovery process. Continue the daily exercises performed by physiotherapists in the hospital in the morning and evening. Be sure to consult your doctor about what level of sports you can do after the transplant surgery and how to start. Make a regular sports plan and follow it without interruption. When doing sports, remember that your body has weakened due to the long-term illness you have had, and it will take time to regain its former strength. Walking will be a good option to start with. Walks should not be immediately after meals. You can walk for sports purposes after resting for at least two hours. You should not overdo it while doing sports. If you feel pain in your chest, a sudden shortness of breath, dizziness, or an irregularity in your heartbeat, be sure to consult your doctor. You can sleep at least four hours after eating dinner.

Smoking and alcohol: If you use cigarettes or alcoholic beverages, you must quit smoking and drinking after the organ transplant. If you use cigarettes and alcoholic beverages, your risk of heart disease and the damage it will cause to other organs will increase due to medication use. This situation will cause treatment failure or even rejection.

Ways to Avoid Infection: Since anti-rejection drugs reduce the body’s immune system, organ transplant patients become sensitive to bacteria and microbes. To reduce the risk of catching a disease, hygiene should be given great importance. Hands should be washed frequently. You must wash your hands before and after meals. Hands and feet should be checked frequently to prevent fungus formation. Underwear and towels should be changed every day. Underwear should be washed in an automatic machine with high-degree hot water.

Dental and oral health: Teeth should be brushed after every meal with a soft toothbrush and a toothpaste providing full protection. Then, it should be rinsed with a mouthwash containing nystatin (Mycostatin) (this mouthwash should be used for the first 6 months after the operation). You should use antibiotic medication before treatments that are not superficial, such as tooth extraction or root canal treatment.

Pets: If possible, do not keep pets in your home. Be sure to wash your hands after contact. Keep your pets’ feeding bowls and places away from the area where you eat. Use gloves during pet cleaning and avoid contact with birds and poultry.

Travel: If your doctor has no objection after the surgery, there is no harm in traveling. However, there are some points you should pay attention to, especially on your international travels:

• Avoid going to countries where there is dirty water and food and where treatment systems are lacking.
• Avoid drinking tap water, ice, shellfish, unpeeled foods, and undercooked meats in places where you doubt hygiene.
• Make sure you take enough medication to last for your travel. It may be difficult to obtain your medicine in some countries.
• Take your medications with you, considering the risk of your luggage getting lost.
• It is highly recommended to get vaccinated before traveling to some countries. You can obtain a list of vaccines that are safe to use from your organ transplant center.
• Your doctor may want you to get a flu shot every year. (Do not get a live virus vaccine).
• It is necessary to have malaria medication with you when traveling to countries where malaria is intense. Consult your doctor for a suitable malaria medication you can safely take.

Sun protection: You can take some simple precautions to protect yourself from the sun:

• You can use sunscreens with high protective properties. You can take precautions by oiling your organs that are most exposed to the sun, such as your face, neck, ears, and hands, several times a day.
• Do not stand in sunny places and do not walk in the sun between 10:00 and 15:00.
• If you have to stand under the sun for a long time, wear long-sleeved shirts, pants, and a hat.
• If you have different formations on your skin that change, color change, or if an existing nevus (mole) suddenly grows or takes a different shape, consult a specialist physician.

MISTAKES MADE BY HEART TRANSPLANT PATIENTS

Patients must receive psychological support, and if medication has been given by doctors, they should use it without interruption.

Not taking their medications on time (30 minutes or later).

If the patient does not tell their doctor that they have reached more weight than the weight at the time of the first operation, they will have taken the medicine in incomplete doses since the drug dose is calculated according to the weight.

The patient will not change or stop any of their medications without telling their doctor. If another additional medication has been given by other doctors (due to another disease), they will definitely inform their own doctor and have the drug interactions checked.

When going to the doctor for periodic check-ups, the patient must take the follow-up chart and medications with them.

Since patients do not visit the diet department when they are discharged, they go home without getting their diet programs. They make some mistakes as a result of wrong nutrition. They do not pay attention to salt, cholesterol, sugar, overfeeding, and the prohibitions set by the dietitian. The issue of getting the diet program should not be left to the initiative of the patient (or their relatives); they should be visited in the room by dietitians the day before discharge and delivered against a signature.

In case of acute rejection, the patient should apply a salt-free diet and be more careful about food hygiene, general cleaning conditions, and infections.

Patients should be ensured to apply the exercise programs given by physical therapy specialists during the rehabilitation period, and the importance of this should be explained to them.

Relatives should be warned so that they can stay away from stress. They should be reminded to avoid behaviors that will cause stress to the patient.

Brain death is the irreversible loss of all brain functions. In a person whose brain death has occurred, respiration and circulation can only be maintained in intensive care conditions by connecting to support machines such as ventilators. While respiratory and heartbeats can be sustained via support machines, brain functions cannot. Therefore, it is impossible for individuals diagnosed with brain death to return to life!!! Despite all medical support provided in intensive care units, organs other than the brain lose their functions after an average of 24–36 hours. After brain death occurs, these individuals are referred to as cadaveric donors. It is necessary to retrieve organs from these donors and transplant them into waiting patients as soon as possible (before the organs lose their functions). Brain death is a clinical diagnosis and represents the complete and irreversible loss of brain functions.

Brain Death and Organ Donation, Organ Distribution Services and Principles, National Coordination Center, and Regional Coordination Centers

Brain Death and Organ Donation (Revised Title: Organ Transplantation Regulation, Official Gazette-26/9/2025-33029)

ARTICLE 8– (1) Brain death is decided unanimously by two physicians, one of whom is a specialist in neurology or neurosurgery, and the other an anesthesiology and reanimation specialist or intensive care specialist, in accordance with the criteria in Annex-1, the criteria in the Implementation Guide of the National Organ Transplantation and Donation Coordination System, and evidence-based medical rules. (2) It is not mandatory for the physicians mentioned in the first paragraph to be part of the same hospital staff. (3) Cases diagnosed with brain death are recorded in the software system by the organ and tissue transplant coordinator at the hospital where the case is located and reported to the Regional Coordination Center. (4) In the event that there is no organ and tissue transplant coordinator at the relevant hospital, the notification is made by the chief physician’s office to the Regional Coordination Center. In this case, the Regional Coordination Center is responsible for the relevant notification and recording procedures. (7) (Addition: OG-26/9/2025-33029) Procedures for organ donation from deceased persons are carried out according to the procedures and principles set forth in the Law. The Ministry keeps records of donation declarations made electronically and stores them in accordance with the Personal Data Protection Law No. 6698 dated 24/3/2016. The following rules apply to procedures regarding organ donation carried out in electronic environments: a) Procedures regarding organ donation to be made by individuals electronically are carried out via the organ donation application on the e-Government Gateway or the e-Nabız (e-Pulse) System. b) In the method of logging into the individuals’ e-Nabız profile, logging in via the e-Government Gateway or secure electronic signature/mobile signature via e-Nabız is used as a secure authentication tool. c) Procedures for organ donation made electronically are completed with a two-step verification method. ç) Organ donation declarations are notified to the persons determined by the donor at the time of declaration via e-Nabız. d) The donor may change their declaration regarding organ donation subject to the procedure specified in this paragraph. (8) (Addition: OG-26/9/2025-33029) A person may determine or rank their spouse, adult children, mother or father, or one of their siblings—or if these are not present, any relative—to express their will regarding organ donation after death. In the event that the will of the determined person is contrary to that of the deceased’s other relatives, the will of the determined person shall prevail. (9) (Addition: OG-26/9/2025-33029) In cases where the person has no declaration regarding organ donation, organs or tissues are retrieved from the deceased with the consent of the spouse present at the time of death, adult children, mother or father, or one of the siblings, respectively; if none are present, with the consent of any relative present. (10) (Addition: OG-26/9/2025-33029)Spouses and first-degree relatives of donors whose organs have been transplanted to others are given priority—after urgent patients—should they need an organ transplant.

What is the Difference Between Brain Death and Vegetative State?

The concepts of brain death and vegetative state are different. The most important difference is that patients in a vegetative state continue to breathe on their own. These patients continue to live for months or years and, in some cases, can even recover and return to their normal lives.

What is Organ Donation?

It is a person’s permission, while alive and of their own free will, for their tissues and organs to be used for the treatment of other patients after their medical life has ended. According to Law No. 2238, everyone over the age of 18 (eighteen) who is of sound mind can donate all or part of their organs.

Where Can Organ Donation Be Made?

• Via e-Government (e-Devlet)
• To Health Directorates
• To Hospitals
• To Police Directorates (During Driver’s License acquisition)
• To Centers performing Organ Transplantation
• To foundations, associations, and similar organizations dealing with organ transplantation.

Is Organ Donation Permissible from a Religious Perspective?

Organ donation has no religious drawbacks. The High Board of Religious Affairs of the Presidency of Religious Affairs declared organ transplantation permissible with its decision dated 6.3.1980 and numbered 396/13. The Quran states: “Whoever saves a life, it is as if he had saved the lives of all mankind.” (Surah Al-Ma’idah, Verse 32)

To Whom are Donated Organs Transplanted?

Patients to receive organs are primarily determined according to:

• Blood type and tissue type compatibility,
• Criteria such as age, height, and weight,
• Medical urgency status.

Cadaveric Donor: If the organs of patients who develop irreversible brain damage (brain death) while continuing treatment in intensive care are donated, they are defined as cadaveric donors. Living Donor:A person who donates one or part of their healthy organs to another person in need, provided that it does not impair their own health and quality of life. LIVING DONOR TRANSPLANTATION can be made from relatives of the recipient up to the fourth degree (including the 4th degree). Non-relative transplants are performed following the evaluation of the Local Ethics Committee at the Organ Transplant Center.

When an organ donation occurs in any hospital across the country, the organ transplant coordinators on duty at that hospital are obliged to report this donation to the “National Coordination Center” (NCC).

Coronary artery bypass grafting (CABG), also known as heart bypass surgery, is a surgical procedure performed to improve blood flow to the heart. This surgery may be necessary when the coronary arteries that carry blood to the heart become narrowed or blocked.

Your doctor may recommend this surgery to reduce the risk of a heart attack if you have coronary heart disease. It can also be performed in emergency situations to treat a severe heart attack.

In CABG surgery, healthy blood vessels taken from another part of the body are used and connected above and below the blocked artery. Thus, a new pathway is created that allows blood to reach the heart by bypassing the narrowed or blocked coronary arteries.

The blood vessels used for this procedure are generally:

• Arteries taken from the chest or arm
• Veins taken from the legs

How is the surgery performed?

In traditional “open-heart” CABG surgery, the heart is temporarily stopped, and a heart-lung machine keeps the blood circulating through the body during the surgery. This method is still the most commonly used technique.

However, in some patients, a method called “off-pump” CABG can be performed. In this technique, the heart is not stopped, and the surgery is performed on the beating heart.

Post-surgery process and risks

As with any surgical procedure, CABG surgery has some risks and possible complications.

During the recovery process after surgery, your doctor may recommend:

• Medication therapy
• Heart-healthy lifestyle changes

These recommendations help to:

• Reduce your symptoms,
• Treat your coronary artery disease,
• Prevent complications such as blood clots.

Your doctor will also inform you about lifestyle changes you can make to reduce the risk of new arterial blockages or other heart problems in the future.

Who Might Need Coronary Artery Bypass Grafting (CABG) Surgery?

Coronary artery bypass grafting (CABG) is used to treat obstructive coronary heart disease caused by plaque buildup in the coronary arteries, which carry oxygen-rich blood to the heart.

Whether CABG surgery is right for you is decided together with your heart team. This team typically includes:

• Cardiologist (heart disease specialist)
• Cardiovascular surgeon

Surgery may not be the best option for every patient. Depending on your overall health and other medical conditions, your team may recommend an alternative treatment called percutaneous coronary intervention (PCI).

PCI is a procedure that typically involves balloon angioplasty and stent placement. This method is not surgical but is an interventional procedure performed inside the blood vessel, and it aims to widen the artery to increase blood flow.

Who can benefit from CABG surgery?

People with the following conditions may benefit from CABG surgery:

• Coronary heart disease with angina (chest pain) that does not go away with medication, or a history of cardiac arrest due to an arrhythmia
• Diabetes
• Heart attack caused by coronary artery disease that cannot be appropriately treated with PCI
• Blockages in multiple coronary arteries or a large amount of plaque buildup in the left main coronary artery, making it difficult to treat with PCI
• Severe heart failure affecting the heart’s blood-pumping capacity

In these cases, CABG surgery can reduce symptoms and lower the risk of a heart attack by increasing blood flow to the heart muscle.

Preparation for Surgery

Coronary artery bypass surgery (CABG) can be planned in advance or performed in emergency situations, such as severe heart failure developing after a heart attack. If your surgery is scheduled, it is important to talk to your doctor beforehand about what to expect and how you should prepare.

Some important questions you can ask your doctor are:

• Which medications you should stop taking and when (including supplements and herbal products)
• Which medications you should start taking and when
• How to bathe before the surgery (whether you need to use a special antiseptic soap)
• When to stop eating and drinking before the surgery
• When to arrive at the hospital and where to go
• What you might experience after the surgery and during the recovery period

Before CABG surgery, your doctor may use heart imaging tests or interventional procedures to determine how severe your coronary heart disease is and the location of the narrowing in the coronary arteries.

If you need CABG surgery, it is important to discuss in detail with your doctor how to prepare for the surgery.

Your doctor will also review with you the available treatment options, the risks of the surgery, and the possible complications that may develop during or after the procedure.

Do not hesitate to ask your doctor any questions you have to make the most accurate decision about your treatment.

What to Expect During the Surgery?

During coronary artery bypass surgery (CABG), the surgical team takes one or more healthy blood vessels from another part of your body and connects them above and below the blocked coronary artery in the heart. This creates a new pathway for blood to bypass the blockage and reach the heart.

CABG surgery can be performed in three different ways:

• Traditional CABG: The chest is opened, and a heart-lung machine is used for blood circulation.
• Off-pump CABG: The chest is opened, but a heart-lung machine is not used.
• Minimally invasive CABG: Small incisions are made in the chest, and typically, a machine is not used.

Heart Surgery Team

The team involved during the surgery generally consists of:

• Cardiovascular surgeon: Performs the surgical procedure on the heart
• Anesthesiologist: Puts you to sleep before the surgery, connects you to a ventilator, and monitors your vital signs throughout the operation
• Perfusionist: Operates the heart-lung machine
• Nurses and other surgeons: Provide support throughout the surgery

Traditional CABG Surgery

Traditional CABG is the most commonly performed method. Depending on the number of blocked arteries, the surgery usually takes 3–6 hours.

During the surgery process:

• Before the surgery, medications are given intravenously (IV), and you are put to sleep.
• You are connected to a ventilator to support your breathing.
• The surgeon makes an incision down the middle of the chest and opens the breastbone (sternum) to reach the heart.
• The heart is temporarily stopped with medications.
• Meanwhile, a heart-lung machine oxygenates the blood and pumps it to the body.

How does the heart-lung machine work?

• Deoxygenated blood from the heart goes to the machine through tubes.
• The machine removes carbon dioxide from the blood and adds oxygen.
• The oxygenated blood is pumped back into the body.

The surgeon then:

• Removes a blood vessel from the leg, arm, stomach, or chest.
• Connects this vessel before and after the blocked coronary artery, creating a new blood pathway (graft).
• Multiple grafts can be used depending on how many arteries need to be bypassed.

After the grafting is completed:

• The heart is restarted (often on its own, sometimes with small electric shocks).
• The breastbone is wired back together.

Off-Pump CABG (Beating-Heart Bypass)

In some cases, the surgery can be performed without stopping the heart. This is called off-pump CABG because a heart-lung machine is not used.

• The heart is stabilized with special mechanical devices.
• Surgeons perform the bypass on the beating heart.

This method is surgically more difficult because the heart continues to beat. However, it may be safer for some patients. Especially:

• Older patients
• Those with ventricular dysfunction
• Diabetic patients
• Those with kidney disease
• Those with chronic lung disease

This method is also referred to as “beating-heart bypass surgery”.

Minimally Invasive CABG

In some patients, bypass surgery can be performed without open-heart surgery.

MIDCAB (Minimally Invasive Direct CABG)

• The breastbone is not cut.
• A small incision is made on the left side of the chest.
• The surgeon reaches the heart between the ribs.
• It is usually performed off-pump.

Robotic CABG

• The graft placement procedure is performed with a robotic system.
• The surgeon controls the robot via a computer.
• Only small holes are made in the chest.
• Sometimes a heart-lung machine may be used.

Hybrid Bypass Surgery

• A bypass is performed for a main coronary artery.
• Other blocked arteries are treated with stents.
• This method is usually preferred for patients who cannot undergo classic bypass.

Possible Risks

Your heart team will inform you about the risks that may occur before and after the surgery. You will be closely monitored after the surgery so that possible problems can be detected early.

The risk may be higher in patients undergoing emergency bypass or those with other serious illnesses.

Possible serious complications include:

• Arrhythmia (heart rhythm disorder) – usually temporary
• Bleeding – sometimes requiring repeat surgery
• Heart attack
• Infection – can occur at the incision site or inside the chest
• Kidney failure
• Stroke

Some patients may also experience:

• Temporary confusion
• Thinking and concentration problems
• Temporary memory loss
• Vision problems
• Speech impairment

This condition is called Postoperative Cognitive Decline (POCD). It is usually short-term, and the exact cause is not fully known. The patient’s general health status before the surgery may also play a role in this condition.

Post-Surgery Recovery

Recovery in the Hospital

After coronary artery bypass surgery (CABG), you usually stay in the hospital for about 1 week. If other procedures were performed or if complications develop, the hospital stay may be longer.

For the first day or two, you will stay in the Intensive Care Unit (ICU). During this process, the healthcare team may do the following:

• Apply bandages to the chest area and the graft sites
• Place tubes to drain fluid from the chest cavity and urine from the bladder
• Connect you to an electrocardiogram (ECG/EKG) machine to monitor your heart rhythm
• If necessary, place a temporary pacemaker, or in some cases, an implantable cardioverter defibrillator (ICD)
• Provide compression stockings to support blood circulation and prevent blood clot formation
• Administer medications for pain control, preventing blood clots, reducing arrhythmias, and controlling cholesterol levels
• Provide oxygen therapy (via a nasal cannula or mask)
• Monitor vital signs such as heart rate, blood pressure, and oxygen levels

After being discharged from the hospital, full recovery usually takes 6–12 weeks. For people who have had minimally invasive bypass surgery, the recovery time is generally shorter.

Home Recovery Process

After discharge, you must continue taking your medications regularly. To stay healthy after CABG, it is important to stay in regular contact with your doctor.

Short-Term Side Effects Common symptoms after surgery, which usually resolve within 4–6 weeks, include:

• Chest pain at the surgical incision site
• Constipation
• Discomfort or itching at the healing incisions
• Loss of appetite
• Mood swings or depression
• Muscle pain or stiffness in the shoulder and upper back region
• Sleep problems and excessive fatigue
• Swelling in the area where the vein was taken for the graft

Medications That May Be Used

Your doctor will discuss in detail the medications you need to take after the surgery.

• Blood pressure medications: Control high blood pressure.
• Arrhythmia medications: Reduce the risk of heart rhythm disorders after CABG.
• Blood thinners / antiplatelet drugs:
  • Aspirin
  • Clopidogrel
  • These medications help prevent the formation of blood clots in the graft or elsewhere in the body. However, they may pose a bleeding risk in some patients.
• Diuretics: Reduce excess fluid in the body.
• Statins: Reduce plaque formation by lowering cholesterol and lipid levels in the blood. If you were not using a statin previously, your doctor may recommend starting one before or after the surgery.

Healthy Lifestyle Changes

After CABG surgery, lifestyle is crucial to protect heart health. Your doctor will recommend the following habits:

• Heart-healthy diet
• Maintaining a healthy body weight
• Regular physical activity
• Stress management
• Adequate and quality sleep
• Quitting smoking

These changes help to prevent new arterial blockages and protect heart health in the long term.

Cardiac Rehabilitation

Cardiac rehabilitation is a medically supervised program for people recovering from heart diseases or heart surgery. The goal of this program is to help you adopt heart-healthy lifestyle changes to reduce the risk of cardiovascular diseases.

Cardiac rehabilitation programs typically include the following components:

• Exercise training
• Education on a heart-healthy lifestyle
• Counseling to help reduce stress and return to an active life

Cardiac rehabilitation is usually provided in outpatient clinics or hospital rehabilitation centers. Your healthcare team will create a customized program tailored to your needs.

During rehabilitation:

• You learn to exercise safely.
• You learn how to increase your physical activity.

The duration of rehabilitation depends on the patient’s condition.

Benefits of Cardiac Rehabilitation Cardiac rehabilitation can be beneficial in the following ways:

• Improving your health and quality of life
• Reducing the need for medication for heart or chest pain
• Reducing the risk of returning to the hospital or emergency room due to heart problems
• Preventing future heart problems

The risks of the heart-healthy lifestyle changes made in cardiac rehabilitation are quite low. In very rare cases, during exercise:

• Muscle or bone injuries
• Serious problems such as life-threatening heart rhythm disorders can occur.

Pay Attention to Your Mental Health

Your doctor may ask if there is a change in your mood or general well-being. Treating depression is important to increase the chances of a full recovery.

If you have symptoms of depression, your doctor may refer you to a mental health professional. Treatment may include:

• Psychological counseling
• Medication therapy

When Should You See a Doctor?

Problems after CABG surgery can occur shortly after the surgery or years later. A possible complication is that the graft vessel becomes blocked again due to plaque. This situation can reduce or completely stop the blood flow to the heart.

If the graft stops working:

A heart attack or other heart problems may develop, and additional surgery or PCI (angioplasty and stent) may be required.

Problems with the valves can occur in the following ways:

• Insufficiency (Regurgitation): The valve does not close completely and blood leaks backward.
• Narrowing (Stenosis): The valve narrows and the passage of blood becomes difficult.
• Atresia: There is not enough opening in the valve or the valve does not open at all.

Causes of Heart Valve Diseases

The causes of heart valve diseases can vary from person to person. These diseases:

• Can be present at birth (congenital valve diseases)
• Can develop due to aging
• Can occur due to infections

Even though some people have a valve disease, no symptoms may be seen at all. Symptoms can develop over time.

Possible Symptoms

The most common first symptom of heart valve diseases may be excessive tiredness (fatigue).

Other symptoms may include:

• Fainting or feeling lightheaded
• Shortness of breath
• Chest pain
• Skipping a beat, palpitations, fluttering sensation, or rapid heartbeat

How Is It Diagnosed?

To diagnose a heart valve disease, your doctor may:

• Ask about your symptoms
• Listen to your heart
• Order heart imaging tests

In newborn babies, screening tests can help in the early diagnosis of heart valve diseases.

Treatment

Most heart valve diseases are treatable.

Treatment options may include:

• Medication: To reduce symptoms or slow the progression of the disease
• Surgical or interventional procedures: To repair or replace the damaged valve

Problems That May Occur If Left Untreated

If heart valve diseases are not diagnosed and treated early, they can lead to the following serious problems:

• Arrhythmia (heart rhythm disorders)
• Infection (especially endocarditis)
• High blood pressure in the lung arteries (pulmonary hypertension)
• Heart failure
• Cardiac arrest

Types of Heart Valve Diseases

There are three main types of heart valve diseases:

1. Regurgitation (insufficiency / backward flow)
2. Stenosis (narrowing)
3. Atresia

The type of valve disease you have depends on which valve is affected and how the valve is affected.

Heart valve diseases can occur in any of the four valves in the heart:

• Aortic valve
• Mitral valve
• Pulmonary valve
• Tricuspid valve

What Are Heart Valves?

Heart valves control the flow of blood within and out of the heart. When working healthily, they ensure that blood travels in the right direction from the heart to the lungs and the rest of the body.

Each valve has structures called leaflets (flaps or cusps). These leaflets open and close with every heartbeat, ensuring that blood flows in a single direction.

In a normally developed heart:

• Aortic valve: Located between the left ventricle and the aorta.
• Mitral valve: Located between the left atrium and the left ventricle.
• Pulmonary valve: Located between the right ventricle and the pulmonary artery.
• Tricuspid valve: Located between the right atrium and the right ventricle.

Types of Heart Valve Problems

1. Atresia

Atresia is a heart disease usually present at birth (congenital heart defect). It can rarely develop later in life.

In this condition, there is no opening in the valve at all. A solid tissue forms, blocking blood flow between the heart chambers.

There are two main types:

• Pulmonary atresia: The pulmonary valve is affected. Blood cannot pass from the heart to the lungs through the pulmonary artery.
• Tricuspid atresia: The tricuspid valve is affected. Blood cannot pass from the right atrium to the right ventricle.

2. Regurgitation (Valve Insufficiency)

Regurgitation occurs when a valve does not close completely. In this case, blood leaks backward instead of flowing forward.

This condition makes it difficult for the heart to pump enough blood to the body.

Regurgitation can develop in the following situations:

• Inappropriate size or shape of the valve leaflets
• Widening of the valve opening
• Weakening of the valve leaflets

Some people may be born with this condition congenitally, or it may develop over time.

Mitral Valve Prolapse Regurgitation is most commonly seen due to mitral valve prolapse.

In this condition:

• The leaflets of the mitral valve sag or bulge back into the left atrium.
• This condition can lead to mitral insufficiency (regurgitation).

However, many people with mitral valve prolapse do not develop regurgitation and experience no symptoms. If regurgitation does develop, it can progress over time and lead to the following problems:

• Enfection (endocarditis)
• Increased pressure in the heart and lung vessels

3. Stenosis (Valve Narrowing)

Stenosis is when the valve opening is narrower than normal.

This condition can occur for the following reasons:

• The valve may have developed incorrectly at birth
• The valve leaflets may have become stiff or thickened

For example: Bicuspid Aortic Valve Normally, the aortic valve has three leaflets. However, in some people, the valve forms with two leaflets. This is called a bicuspid aortic valve.

This condition can lead to aortic valve narrowing (aortic stenosis) over time.

In stenosis, it is harder for blood to pass through the valve, and the heart has to work harder to pump blood.

Multiple Valve Problems

Sometimes:

• There can be more than one problem in a single valve
• More than one valve can be affected at the same time

This condition causes the heart to work harder and can affect its blood-pumping capacity.

If left untreated, valve diseases can progress over time and lead to the following serious problems:

• Heart failure
• Stroke
• Arrhythmia
• Pulmonary hypertension

Symptoms

The symptoms of heart valve diseases can vary depending on the type of disease and the age of the patient. Symptoms seen in newborns can differ from those seen in adults. Some symptoms may be related to heart failure, because valve diseases can impair the heart’s blood-pumping function.

Symptoms in Newborns and Young Children

Symptoms of heart valve disease may be present at birth. Sometimes these symptoms are noticed during newborn screening tests performed after birth. In some cases, symptoms may appear weeks or months after birth.

Symptoms that may be seen include:

• Failure to gain enough weight or grow
• Difficulty may be observed during feeding
• Some babies may sweat while feeding
• Bluish skin (cyanosis)
  • Especially on the lips, fingers, and toes
• Low oxygen levels in the blood
  • A doctor can measure this with pulse oximetry
• Pale skin, rapid pulse or rapid breathing, cold and clammy hands
  • These can be signs of shock and are a medical emergency for newborns
• Weak pulse

Symptoms in Adults

Symptoms of age-related heart valve diseases can appear gradually. Many people may mistake early symptoms, such as shortness of breath during exercise, as a normal part of aging.

Some people may have no symptoms at all.

When symptoms occur, they may include:

• Nefes darlığı (Shortness of breath)
  • Especially when climbing stairs, walking fast, or during physical activity
• Chest pain or feeling of discomfort (angina)
• Dizziness, fainting when standing up, or brief loss of consciousness
• More fatigue than normal
• Fever
  • Could be a sign of infection of the heart’s inner lining (endocarditis)
• Heart palpitations
  • Feeling that the heart is beating too fast or skipping a beat
• Heart murmur
  • An abnormal sound heard between heartbeats
• Swelling around the eyes, ankles, or in the abdomen

These symptoms can also be seen in other diseases. To confirm heart valve disease, your doctor may perform a test called an echocardiogram. This test shows the structure of the heart and how the valves are working in detail.

Diagnosis

To diagnose a heart valve disease, your doctor evaluates your medical history, performs a physical examination, and orders tests that examine the structure and function of your heart.

Medical History and Physical Examination

Your doctor may ask about the following topics:

• Your risk factors
• The symptoms you are experiencing
• Your family history of heart valve disease

During the physical examination, your doctor:

• Checks for a heart murmur or rhythm disorder by listening to your heart with a stethoscope
• Evaluates the strength of the pulse in the neck or arm
• May check for liver enlargement in newborns.

Echocardiography

Echocardiography (ECHO) is the most commonly used test in diagnosing heart valve diseases.

This test:

• Is painless
• Creates moving images of the heart using sound waves

With echocardiography:

• The size and shape of the heart
• How well the heart pumps blood
• How the valves open and close are evaluated.

Doppler echocardiography shows the speed and direction of blood flow within the heart chambers and valves.

An ECHO can also show:

• Blood clots inside the heart
• Pericardial fluid
• Tumors
• Aortic diseases
• The cause of a heart murmur

Other Diagnostic Tests

In addition to an echocardiogram, your doctor may order other tests.

Electrocardiogram (ECG/EKG) An ECG is a simple and painless test that measures the electrical activity of the heart.

With this test:

• Heart rate
• Heart rhythm (regular or irregular)
• The spread of electrical impulses in the heart can be evaluated.

During the test, electrodes are placed on the chest, arms, and legs, and the heart activity is recorded.

Chest X-ray A chest X-ray provides quick and painless imaging of the structures inside the chest.

This test can help in evaluating:

• Heart enlargement
• Heart failure
• Lung diseases

Stress Test A stress test measures the heart’s performance under physical stress.

During this test:

• The patient walks on a treadmill or rides a stationary bike
• Heart rhythm, blood pressure, and oxygen levels are monitored

This test is especially recommended if the following symptoms are present:

• Shortness of breath
• Chest pain
• Dizziness
• Palpitations

If the person cannot exercise, medications that make the heart work faster can be given.

Screening Tests

In some cases, your doctor may recommend screening tests.

Prenatal Screening The baby’s heart is evaluated during pregnancy.

Newborn Screening Test In this test:

• The oxygen level in the baby’s blood is measured using pulse oximetry.
• Low oxygen levels can be a sign of valve disease or serious congenital heart diseases.

Post-Cancer Treatment Screening Because the risk of developing heart valve disease increases in people who have received radiation therapy, regular screening may be recommended.

Causes and Risk Factors

What Causes Heart Valve Diseases?

There are four valves in the heart, and these valves open and close to ensure that blood flows in the correct direction within the heart. Heart valve diseases occur when these valves do not work properly.

Valve diseases: Can be present at birth (congenital) or can develop later over time (acquired).

To understand heart valve diseases, it is important to understand how the heart works.

Congenital Heart Valve Diseases

Congenital heart valve diseases occur due to problems that arise while the baby’s heart is developing in the womb. These valve problems can be seen alone or together with other congenital heart diseases.

Congenital valve diseases can range:

• From mild problems
• To life-threatening conditions that can completely block blood flow.

The most common congenital valve problems are:

• Atresia: The valve has not formed at all, and blood flow is completely blocked.
• Stenosis (narrowing): The valve is very narrow and does not allow adequate blood passage.
• Regurgitation (insufficiency): Blood leaks backward because the valve leaflets are not of normal size or shape.

Some congenital valve diseases are inherited (genetic). That is, they can occur due to genes passed down from the mother or father.

For example: Bicuspid aortic valve is a valve disease that can be genetically transmitted and can lead to aortic stenosis.

Acquired Heart Valve Diseases

Heart valve diseases can also develop as age advances, due to certain medications used, or medical proceduresperformed.

Risk Factors

Risk factors for heart valve diseases include:

Age Advanced age can increase the risk, especially if there are unhealthy lifestyle habits.

Family History Some valve diseases can run in families. For example:

• Mitral valve prolapse
• Bicuspid aortic valve Additionally, having a family history of early-onset coronary heart disease can also increase the risk.

Lifestyle Lifestyle factors that lead to other heart diseases can also pose a risk for valve diseases:

• Lack of physical activity
• Unhealthy diet
• Smoking
• Obesity

Medical Devices Devices like a pacemaker or defibrillator can sometimes rub against the valves, causing:

• scar tissue formation
• or stretching of the valves.

Other Diseases Some diseases can increase the risk of valve disease:

• Hypertension
• Diabetes
• Autoimmune diseases (e.g., lupus)
• Other heart diseases

Cancer Treatment Radiation therapy used for cancer can cause the heart valves to:

• thicken
• or experience problems like narrowing.

Sex (Gender) Some valve diseases are more common in men. For example:

• Aortic valve stenosis is more common in men than in women.

Research and Genetics

Family history and inherited genes can increase the risk of developing heart valve disease. Researchers are specifically studying gene mutations that cause valve diseases such as the bicuspid aortic valve.

Can Heart Valve Diseases Be Prevented?

Not all congenital valve diseases can be prevented, but the risk can be reduced in some cases.

During pregnancy:

• Taking necessary vitamins
• Protecting against infections like rubella is important.

Preventing Acquired Valve Diseases Your doctor may recommend the following precautions:

Heart-Healthy Lifestyle

• Healthy diet
• Regular physical activity
• Healthy weight
• Quitting smoking
• Stress management

Good Oral and Skin Hygiene This helps prevent the endocarditis infection, which can affect heart valves.

Regular Use of Medications It is important to regularly use medications prescribed to prevent a heart attack, hypertension, or heart failure.

Also, if there is a throat infection (strep infection), the treatment must be completed. Because if left untreated, rheumatic fever can develop, and this condition can damage the heart valves.

Treatment

Heart valve disease is generally a lifelong condition. Although many people have valve disease, they may not experience symptoms for a long time. However, the disease can progress over time, and if left untreated, it can lead to heart failure or other life-threatening problems.

Your doctor will usually recommend lifestyle changes and medication therapy first. These methods can help control symptoms and delay the progression of the disease. However, in the advanced stages, valve repair or valve replacement may be necessary.

Even after valve repair or replacement is performed, medication use and regular doctor check-ups are necessary.

Heart-Healthy Lifestyle Changes

Lifestyle is very important in the treatment of heart valve diseases.

Recommended changes include:

• Heart-healthy diet
• Maintaining a healthy body weight
• Stress management
• Regular physical activity
• Quitting smoking

You must consult your doctor before starting a new exercise program.

Medication Therapy

Your doctor may prescribe medications to reduce symptoms, slow the progression of the disease, or treat other heart problems accompanying the valve disease.

These may include:

• Blood pressure medications
  • Diuretics
  • Vasodilators
  • These medications reduce the pressure on the heart, allowing it to work less.
• Heart rate regulating medications
  • They help the heart work more efficiently by controlling the heart rhythm.
• Blood thinners
  • Used to prevent or treat the formation of blood clots.
• Antibiotics
  • To treat infections that cause heart inflammation (endocarditis)
  • To prevent rheumatic fever
• Prostaglandin
  • It can be used in newborns to keep certain heart pathways open and maintain blood circulation.

Heart Valve Repair

When new symptoms appear or existing symptoms worsen, your doctor may recommend valve repair.

Methods used in valve repair:

• Repairing or reshaping the valve leaflets
• Closing tears
• Reattaching the leaflets
• Separating fused leaflets These procedures are called valvuloplasty.

Other methods:

• Balloon valvuloplasty: A balloon is used to widen the valve opening.
• Stent placement: To increase blood flow or support a leaking valve
• Placement of a special device for mitral regurgitation
• Removal of calcium buildups
• Repair of valve support structures
• Annuloplasty: Strengthening or tightening the valve ring

Valve repair can reduce symptoms, but sometimes the problem can reoccur.

Possible complications:

• Valve damage or leak
• Blood vessel injury
• Cardiac tamponade (compression)
• Stroke

Heart Valve Replacement

In some cases, the valve cannot be repaired and valve replacement is necessary.

The surgeon replaces the damaged valve with one of the following types of valves:

• Mechanical Valve
  • Made from durable materials
  • Very long-lasting
  • However, it requires lifelong use of blood-thinning medication
• Biological Valve (Tissue Valve)
  • Usually made from animal tissue
  • The need for blood thinners is less
  • However, it does not last as long as a mechanical valve and may need to be replaced again in the future

Doctors decide which valve is more appropriate based on the following factors:

• Age
• Risk factors
• Other diseases

Catheter-Based Valve Replacement Some valves can be replaced using a catheter method without open-heart surgery.

The most common example: TAVR / TAVI (Transcatheter Aortic Valve Replacement) In this method:

• A thin catheter is advanced to the heart through a blood vessel
• A new valve is placed It is especially used in the treatment of aortic stenosis.

Problems That May Occur If Left Untreated

Untreated heart valve diseases can lead to serious complications:

• Acute respiratory distress syndrome (ARDS)
• Arrhythmias
• Blood clots
• Sepsis and bloodstream infections
• Aortic aneurysm or rupture
• Heart failure
• Infective endocarditis
• Liver damage
• Pulmonary hypertension
• Stroke
• Cardiac arrest

Pregnancy and Heart Valve Diseases

Many women with heart valve disease can have a healthy pregnancy and give birth to healthy children. However, some valve diseases can make getting pregnant difficult or lead to complications during pregnancy.

Therefore, if you are pregnant or planning to become pregnant, it is very important to consult your doctor to ensure the safety of you and your baby throughout the pregnancy.

Before Getting Pregnant

If possible, you should talk to your healthcare provider about your heart valve disease and current symptoms before getting pregnant.

Some valve diseases can make pregnancy high-risk. For example:

• Valve narrowing (stenosis)
• Having had valve replacement surgery

In these situations, special monitoring and care may be required during pregnancy and childbirth.

Your doctor may recommend the following tests before pregnancy:

• Echocardiography
• Stress test

If the disease is severe, it may need to be treated before pregnancy.

Medication Use During Pregnancy

Some medications are not safe during pregnancy.

For example:

• Blood-thinning medications

Therefore, your doctor:

• During the pregnancy planning period
• May recommend safer alternative medications for you to use during pregnancy.

Possible Risks During Pregnancy

Severe or untreated heart valve disease during pregnancy can increase the risk of certain complications.

These may include:

• Arrhythmia (heart rhythm disorder)
• Blood clot formation
• Miscarriage
• Premature birth
• Need for a cesarean delivery
• Postpartum hemorrhage

Genetic Risk

Some heart valve diseases can be inherited and passed on to your child.

Therefore, talking to your doctor about your disease helps you better understand the potential risks for your baby..