MEDICAL SCRIPT #3: PEDIATRIC HEART TRANSPLANTATIONS 1

Medical Script #3: Pediatric Heart Transplantations

Jennifer Eazell

University of La Verne
MEDICAL SCRIPT #3: PEDIATRIC HEART TRANSPLANTATIONS 2

Table of Contents

Heart Transplantations……….……………………..………..……………….……………..……3

Illness/Disease/Medical Issue……………………………………………...……………..3

Etiology………………………………………...….………………………………...……3

Manifestations/symptoms of Heart Transplantations….………..……..………….……...3

Probable Tests/Procedures/Treatments.…………..…………………...………….........................4

Brief Description of Tests/Procedures/Treatments.…………………………..…….…….4

Medical Terminology Definitions (17).……………………………………………......................6

Effects of Illness on Child’s Cognitive Abilities….………..………………………..……….…..7

Specific Research Relating to Possible Cognitive Delays………………..……………....8

Methods for Assessment……………………………………………………………………….....8

Psychosocial & Coping Assessment Tool ……...………………………………………..8

Significance of Assessment Tool……………………………………………...………....9

Child Life Intervention………………………………………………………………………..…10

Intervention Used & Benefits of the Intervention…………...…………………………..10

Research on Therapeutic Intervention……………………………………………..…….10

Specific Verbiage Used………………………………………………………………………….10

Developmentally Appropriate Conversation with Child/Family…………………….….10

Psychosocial Component………………………….………………………………………….…11

Family/Patient Intervention……………………………………………………………………..14

References……………………………………………………………………………………....18
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Pediatric Heart Transplantations

Illness/Disease/Medical Issue

In Hockenberry and Wilson’s book Wong’s Nursing Care of Infants and Children (2015),

Pediatric Heart Transplantations are described as having two forms: Orthotopic Heart

Transplantation and Heterotopic Heart Transplantation. Orthotopic Heart Transplantation is

when the recipient’s heart is removed and replaced with a new heart from a donor that has

experienced brain death, but whose heart is healthy. Heterotopic Heart Transplantation is when

the recipient’s heart is left in place but a new heart from a donor is implanted into the recipient’s

chest in order to act as an additional pump, or “a ‘piggyback’ heart” (Hockenberry &Wilson,

2015). Both forms of heart transplantation are done to help treat heart failure in infants or

children as a result of diseases such as Congenital Heart Defects, Hypoplastic Left Heart

Syndrome, and Cardiomyopathy.

Etiology

Heart Transplantations are generally performed as a result of different types of heart

failure, such as Congenital Heart Defects, Cardiomyopathy, and Hypoplastic Left Heart

Syndrome. Some possible causes of cardiomyopathy and other heart defects, according to

Wong’s Nursing Care of Infants and Children (2015), are genetics, metabolic abnormalities at

birth, infections, various deficiencies, and collagen vascular disease (Hockenberry &Wilson).

Manifestations/symptoms of Heart Transplantation

The general and potential manifestations/symptoms of Heart Transplantations, according

to the article Cardiac Patient Page on the American Heart Association website by Jurt et al

(2002), are described as follows:

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Before/Without Transplant (i.e. Heart Failure): After/With Transplant:

 Shortness of breath Possible Signs of Infection/Rejection:

 Poor exercise tolerance  Fever

 Cough  Sore throat

 Fatigue  Shortness of breath

 Fluid Retention  Cough

 Change in sputum

 Cold sores

 Flu-like symptoms

 Redness, swelling, or drainage from Incision

 Weight gain

 Fatigue

Probable Tests/Procedures/Treatments

Brief Description of Tests/Procedures/Treatments

According to the handout Pediatric Organ Transplantations by Parker (2016), most heart

transplant procedures involve replacing the recipient’s heart with a cadaveric donor’s heart (Also

known as an Orthotopic Heart Transplant), whereas in other situations the recipient’s heart is not

replaced but is combined with a cadaveric heart (also known as a heterotopic heart transplant),

which is more rare. The step-by-step procedural breakdown of these surgeries are outlined as

follows, according to Hockenberry and Wilson’s book Wong’s Nursing Care of Infants and

Children (2015), the UCSF Medical Center website article Heart Transplant Procedure, the

Oxford Medical Journals website article Heterotopic heart transplantation: experimental

development and clinical experience (2000):

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Orthotopic Heart Transplant
1. Careful Cardiac Evaluation to access whether
any other medical or surgical options can be
used to help with the child’s cardiac issues
2. Other organ systems are evaluated to determine
if the body is strong enough for the transplant
3. Psychological Assessment and Support Services
are provided.
4. Incision along chest and opening of the
breastbone.
5. Main arteries are detached from recipient’s heart
and connected to a heart and lung bypass machine.
6. The recipient’s heart is removed except for the
back half or the atria and then the donor heart is
sewn to the back of the recipient’s heart.
7. The donor’s aorta and pulmonary arteries are
connected to the recipient’s main arteries that were
previously attached to the heart and lung bypass
machine.
8. New heart should begin to pump blood.
9. Chest and breastbone are closed.
5
Heterotopic Heart Transplant
1. Careful Cardiac Evaluation to access
whether any other medical or surgical
options can be used to help with the child’s
cardiac issues
2. Other organ systems are evaluated to
determine if the body is strong enough for
the transplant
3. Psychological Assessment and Support
Services are provided.
4. Incision along chest and opening of the
breastbone.
5. Recipient’s heart remains in the chest and
the donor heart is placed to the right of and
parallel to the recipient’s heart.
6. The left atria and aorta are connected end-
to-side. A pulmonary shunt is placed to the
recipient’s right atrium using the donor’s
pulmonary artery.
7. After all connections are made from the
donor’s heart to the recipient’s heart, cardiac
pressure and blood flow is accessed.
8. The two hearts should begin to pump as one
and circulate blood throughout the body. The
donor heart serves as a support system for the
recipient’s weaker heart.
9. Chest and breastbone are closed.
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Medical Terminology:

(According to Merriam-Webster.com):

 Cardiomyopathy- any of several structural or functional diseases of heart muscle marked

especially by hypertrophy and obstructive damage to the heart (Merriam-Webster, 2016).

 Myocardium- the middle muscular layer of the heart wall (Merriam-Webster, 2016).

 Hypoplastic- a condition of arrested development in which an organ or part remains below

the normal size or in an immature state (Merriam-Webster, 2016).

 Congenital Heart Defect- a defect of the heart existing since birth (Merriam-Webster, 2016).

 Cardiopulmonary bypass- a procedure that allows blood to flow past a blocked blood

vessel to reach the heart (Merriam-Webster, 2016).

 Echocardiogram- a visual record made by echocardiography; or the use of ultrasound to

examine the structure and functioning of the heart or abnormalities and disease (Merriam-

Webster, 2016).

 Cardiac Catheterization- a medical procedure in which a thin, flexible plastic tube

(catheter) is inserted through an artery or vein (in the arm or leg) and passed into the heart for

the diagnosis and treatment of heart conditions (Merriam-Webster, 2016).

 Mechanical Circulatory Supports (or mechanical heart)- a mechanism designed to

maintain the flow of blood to the tissues of the body especially during surgical operations on

the heart (Merriam-Webster, 2016).

 Orthotopic- of or relating to the grafting of tissue in a natural position (Merriam-Webster,

2016).

 Heterotopic- occurring in an abnormal place (Merriam-Webster, 2016).

 Ventricular Assist Devices- a device that is implanted in the chest or upper abdomen to
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assist the left or right ventricle in pumping blood in a damaged or weakened heart (Merriam-

Webster, 2016).

 Extracorporeal membrane oxygenation- treatment providing respiratory and circulatory

support for a patient that involves pumping blood from the body and through a membrane

oxygenator to exchange carbon dioxide for oxygen and a heat exchanger to cool or warm the

blood before returning it to the body (Merriam-Webster, 2016).

 Pulmonary vascular resistance- a resistance to blood flow through blood vessels and

especially arterioles (Merriam-Webster, 2016).

 Endomyocardial biopsy- the removal of tissues, cells, or fluids from the endocardium and

the myocardium (Merriam-Webster, 2016).

 Immunosuppressants- a suppression (as by drugs) of natural immune responses (Merriam-

Webster, 2016).

 Hypertension- high blood pressure (Merriam-Webster, 2016).

 Renal Dysfunction- relating to or involving the kidneys being unable to function in a normal

way (Merriam-Webster, 2016).

 Congestive Heart Failure- heart failure in which the heart is unable to maintain an adequate

circulation of blood in the bodily tissues or to pump out the venous blood returned to it by the

veins (Merriam-Webster, 2016).

 Rejection- an immune response in which foreign tissue (as of a skin graft or transplanted

organ) is attacked by immune system components (as antibodies, T cells, and macrophages)

of the recipient organism (Merriam-Webster, 2016).

Effects of Illness on Child’s Cognitive Abilities

Specific Research Relating to Possible Cognitive Delays

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Lasting manifestations of Heart Transplants could very much include cognitive delays as

a possible residual effect As Todaro et al’s Review on Cognitive and Psychological Outcomes of

Pediatric Heart Transplantation (2000) notes, open-heart surgery can cause a number of risk

factors potentially having a significant impact on cognition. These risk factors include the

potential for long durations in a hypoxic state, deep hypothermic arrest procedures, and long

durations of cardiopulmonary bypass. Todaro et al’s thorough research review (2000)

demonstrates that decreased oxygenation level to the brain during heart transplant surgery can

greatly effect the cognitive functioning as well as other valuable developmental processes. The

research concludes that some recipients are at a risk for cognitive delays as a result of heart

transplantations; and as a result, it is crucial that child receive proper developmental

interventions before and after surgery to help progress their development and to help them to

reach their fullest potential (Todaro et al, 2000).

Methods for Assessment:

Psychosocial & Coping Assessment Tool (modified from assessment forms provided by Dr.

Leslie Young, 2016):

Patient’s Name: ____________ Age: ________ Developmental Age:________

Sex: M F Diagnosis: Heart Transplant
Date of Admittance: ________________ Isolation: Yes No
Can infant attend the playroom? Yes No Can siblings attend playroom? Yes No
Any Special Needs: _________________________________________________
Psychosocial Issues:
 Family Structure- Nuclear, Single Parent, Divorced, Blended Family, or Other: ___________
 Language Spoken by Child (if none, then NA): _____________________
 Language Spoken by family: _____________________________________
 Foster Child: Yes No
 Family at Bedside: Yes No
 Siblings: Yes No Names/Ages: _______________________________
_____________________________________________________________
 Siblings’ developmental considerations:____________________________________________________
________________________________________________________________
________________________________________________________________
 Other: _______________________________________________________
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Temperament (Check all that apply):

___ Flexible ___Feisty
___Introverted ___Slow-to-warm-up/Fearful
___Stranger Anxiety ___Easy to Engage
___Agitated ___Extroverted
___Withdrawn ___Inactive ___Active
___Other: _______________________________________________________

Medical Services:
 First Hospital Experience: Yes No
 Previous Hospital Experience: __________________________________

Child Life Intervention(s): Needed: \ Provided: X

___Induction to Services
___Building Rapport- relationships trust
___Personal & Family-centered care
___Provide emotional support for child or family
___Procedural Teaching- Child or Family
___Diagnosis Teaching- Child or Family
___Procedural Support
___Participation in Therapeutic/Child Development Program
___Bedside interaction, interventions
___Greif/Loss support and education
___Pain management- distraction and diversion
___ Sibling and child interventions
___Therapeutic Interventions/media
___Infant & Toddler Care plans- Looking at the whole child’s development
___School Age & Adolescent Care plans
___Discharge Process- Continuum of Care Plans (i.e., Sibling Community Supports, Infant Community Resources
for developmental stimulation, etc.)

Additional Information:

_____________________________________________________________________________________________

_______________________________________________________________

Significance of Assessment Tool

The above assessment is a valuable tool for determining a number of factors that can

greatly help develop future interventions with the family and child. The information most

beneficial in the assessment that can help to determine what therapeutic interventions to conduct

later are questions relating to previous hospitalization history, developmental age versus

chronological age, physical and medical capabilities, the presence of and developmental age of

siblings, family dynamic, family makeup/background, any cultural or religious considerations,

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and temperament of the child. The more background information you can assess from the

observation and meeting with the family, the better able you can serve this child in a unique and

individualistic manner that is best for that specific child and family.

Child Life Intervention

Intervention Used & Benefits

Medical Play could prove extremely beneficial for a child experiencing a heart transplant.

Overall, the process can be very scary and intimidating for kids so by familiarizing the child with

the procedure through medical play with a doll that has a donor heart and a native heart that you

can interchange may be able to soothe children’s anxiety and confusion by familiarize the child

with the procedure in a nonthreatening way. of the Intervention

Research on Intervention

As Margaret Adams article A Hospital Play program: Helping Children with Serious

Illness (1976) notes, hospitalization of children for life-threatening illnesses can be an extremely

stressful, confusing, anxiety-ridden, and scary experience. Play can not only be a valuable tool

for relieving anxiety and stress in an environment but it can also help children explore and better

understand their feelings (Adams, 1976). Medical Play, through a heart transplant doll, in

particular can not only help to lesson anxiety and stress in a situation but it can also help to

provide valuable information for a child who is trying to understand their upcoming surgery.

Medical Play can be a beneficial tool for children receiving heart transplants because it can help

the child better understand their heart transplant surgery in a far less threatening and more

familiar way.

Specific Verbiage Used

Developmentally Appropriate Conversation with Child/Family

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 Developmental Stage: 2 month old female infant, 28 year old mother, and a 6 year old male

sibling

 Interactive Component: Medical Play Bear- Heart Transplantation (Native heart velcroed in

bear and donor heart in medical bag ready to replace the native heart)

 Situation: An infant is born with a congenital heart defect and was taken into emergency

surgery at birth. She has since been placed on a transplant list. Today, the mother is being

scheduled for the next day. A Child Life Specialist is called in to inform the mother and

sibling about the surgery, and to help explain how the surgery will work.

 Conversation:

CL: Good Afternoon, may I come in?

Mom: Sure, of course.

CL: Hi there, I’m Jennifer, and I’m a Child Life Specialist. I am here to help explain to you and

your son what is happening to little Maya. Is that ok with you?

Mom: Sure, that’s no problem. Thank you! I’m Daisy and this is Cameron. Say hi, Cameron.

Cameron: Hiii

CL: Well, hello, it’s a pleasure to meet you. So have you heard what is happening to Maya,

Cameron and why she needs to stay here in the hospital a little while longer?

Cameron: Not really. She needs surgery so the doctors can fix her heart. Is it broken? Like the

time I broke mama’s hot cocoa cup?

CL: It’s not broken like that but close. Her heart is not working any more and she is going to

have a special surgery to get a new one. Does that make sense?

Cameron: Oh. Yeah! Like the time I Gameboy stopped working and momma had to buy me a

new one.
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CL: Right! It’s more like that. 

Cameron: What’s in your bag?

CL: Oh, this? [pulls out medical play bear] This is my bear friend, Samuel. He needs a heart

transplant too. Can you help me? Can you be the doctor and do surgery on Samuel the bear for

me?

Cameron: Yea!

CL: Perfect. [hands bear to Cameron] So to start, you need to make a large opening in the chest.

[Cameron pulls on the Velcro flap on the chest.] Good. Now, do you see his heart? That is the

one that is not working. Can you take it out?

Cameron: Uh-huh.

CL: Great! Next, we need to “transplant” or put the new heart in. It’s in the little medical bag

here. [Cameron takes the medical bag, opens it, and pulls out the heart.] Good. You got it! Now

what do you think you do?

Cameron: Put the new heart in the beary bear.

CL: Good. Lastly, we need to close the opening nice and tight. [Cameron closes the Velcro flap.]

Great! Good Job! So this is what the doctors are going to do to your baby sister too.

Cameron: That’s it?

CL: Well, yes that’s how the doctors do the “transplant”, or surgery. But, your sister will need

some time here at the hospital after the surgery to see how she’s doing. Sometimes, the new

hearts don’t work so if that happens, doctors and your mom will have to see if there is anything

more they can do.

Cameron: What about another heart! Can she get another if this one doesn’t work?

CL: Maybe but it could be hard. You would probably have to go back on the list and wait again
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if that’s what your mom and the doctors decide to do.

Cameron: Oh… ok…

CL: Are you feeling a little better now? Do you understand now why the doctors need to take

sister to surgery?

Cameron: Yep, she needs a new heart.

CL: That’s right. Well, I’ll check on you later. Have a great day, Cameron and Daisy. 

Psychosocial Component

One psychosocial issue that a teen could have after discharge is self-esteem and body image

issues. The heart transplant will leave a large scar on their chest so it is likely that they will be

hyperaware and highly self-conscious of others seeing it at school, or anywhere else where they

think their peers may see it and judge them for it. Teens’ emotional development at their age is

general highly dependent on looks and their peers approval so without their support they will

likely grow anxious, withdrawn, and self-conscious of their appearance, specifically of their scar.

It is important to talk with teens and parents about this issue. Additionally, one particular

struggle that will take years to adapt to, if they ever fully adapt to it, is the forever need to take

immunosuppressant drugs t protect their immune system from infection and rejection. The will

have to take medicine daily for the rest of their lives which is a huge adjustment. This is an

important component of post-hospitalization and post-transplant care that child and families will

need to be aware of in order to continue it the rest of their lives. A thorough discussion on the

importance of taking immunosuppressant drugs and the life-threatening consequences if they are

not taken will likely be helpful for the parents but further intervention, education, and support

will be needed for the teen during this adjustment period in order to help them cope. Journaling,

Painting, and Drawing can all be recommended to children and families undergoing this struggle
MEDICAL SCRIPT #3: PEDIATRIC HEART TRANSPLANTATIONS 14

in order to help alleviate stress and encourage emotional expression.

Family/Patient Intervention

Script for Suggested Intervention #1- Music & Art Therapy:

Developmental age: Teen (Brielle), Mom (Candice)

CL: Hi there, may I come in?

Candice: Of course! Brielle is just waking up from a nap.

CL: Hey, Brielle. Good afternoon. Have a nice nap?

Brielle: Yep. *yawn*

CL: Are you ready to be discharged soon?

Brielle: Oh, yea. So ready.

Candace: We both are!

CL: Great, so I just wanted to share an activity with you both that you can do now Brielle and

that you can also do when you get home. Does that sounds ok with you?

Brielle: Sure.

CL: [pulls out music player and sketchbook] So, I know how you love to draw. And that you

love music. But did you know both those things are can be really good for you, emotionally and

physically?

Brielle: Not really… [grabs music player and sketchbook from CL, plugs in one headphone and

opens up the sketchbook]

CL: Music can serve as a huge stress relief so can help relax you physically if you start feeling

overwhelmed with school. Also, music and drawing both can help express your emotions

[(Young, 2015).] So if you are having a bad day, or you are feeling badly about your scars, music

and drawing can really help to re-center yourself.

MEDICAL SCRIPT #3: PEDIATRIC HEART TRANSPLANTATIONS 15

Brielle: I never thought of it like that. Thank you!

CL: You’re welcome, Brielle. I’ll check back on you later. Bye, Candice!

Candice and Brielle: Bye, thank you!

Script for Suggested Intervention #2- Literature Therapy

Developmental Age: 7-year-old boy named Colin; 42-year-old mom named Janie

CL: Hi Colin. How you doing today buddy?

Colin: I’m doing ok. I wanna go home.

Janie: Yea, he’s had a rough morning. He keeps asking me what the kids at school will say

about his scar. He thinks they might tease him.

Colin: Yea. They’re gonna be mean.

CL: I’m sorry, Colin. I know it’s scary and hard sometimes because you don’t know what kids

might say. I want you to know that you are not alone though, and if you’re having a bad day just

take out this book [CL brings out book about superheroes with scars].

Colin: I love books! Can we read it now??

CL: Of course!

[CL reads book to Colin then gives it to him so he can look at the pictures]

CL: Do you feel better now?

Colin: Yea I do!

CL: How come?

Colin: ‘Cause like the book says, it’s ok to be sad sometimes but scars are what make us strong!

Like superheroes! It means we are … what was it the book said at the end?

CL: “That we are stronger than whatever tried to stop us.” Just like the superhero in the book!

He was stronger than the bad guy and won the fight, even though he got a scar on his chest.
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Colin: Yea!! That’s me! 

CL: That’s right. Books can really help people feel better when they are feeling done because

they can help people feel like they aren’t alone. That other people go through similar things and

that they get sad sometimes too but they also grow from it too [(Young, 2015).] Just like you

when you become a superhero today! Scar and all!

Colin: Yea I AM a superhero!!! Zoom Zoommm!

Script for Suggested Intervention #3- Game Therapy:

Developmental ages: 10-year-old girl named Olivia with mother and father present

CL: Hi there, Olivia. How you doing today?

Olivia: I’m doing good.

CL: Glad to hear that. So, I hear you are getting released from the hospital soon? Are you

excited?

Olivia: I am! I’m ready to be home in my own room.

CL: I bet! OK, so I brought something here with me. It’s a gift for you to take home and play

with your brothers and sisters and mom and dad. It can help provide time for everyone to be

together and help you cope with adapting to new routines by adding a little fun [(Young, 2015)].

If you want to make a weekly family game night, that could help keep you all together despite a

busy school schedule and after school life with the kids/brothers/sisters.

Olivia: Ohhh can we play it now to?

CL: Of course!

[CL pulls out Exploding Kittens Card Game, and family proceeds to play and laugh for quite a

while]
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Olivia: Thanks! That was awesome!

Mom: Yes, thank you so much! We really appreciate it. That really is a fun game! And so funny!

We are really going to enjoy that at home.

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References

Assessment and Documentation in Child Life (2015). (Handout provided in ASCL 530 A from

Dr. Leslie Young)

Heart Transplant Procedure. (n.d.). Retrieved November 12, 2016, from

https://www.ucsfhealth.org/conditions/heart_transplant/procedure.html

Hockenberry, M. J., & Wilson, D. (2015). Wong's nursing care of infants and children. St.

Louis: Elsevier-Mosby.

Jean Piaget Cognitive Development (2015). (Handout provided in ASCL 530 A from Dr. Leslie

Young)

Jurt, U. & Others (2002). Heart Transplant: What to Expect. Circulation, 106(14), 1750-1752.

doi:10.1161/01.cir.0000031169.85931.4d

Kadner, A., Chen, R. H., & Adams, D. H. (2000). Heterotopic heart transplantation:

Experimental development and clinical experience. European Journal of Cardio-

Thoracic Surgery, 17(4), 474-481. doi:10.1016/s1010-7940(00)00362-6

Leslie’s Favorites- Game Therapy (2015). (Handout provided in ASCL 530 A from Dr. Leslie

Young)

Literature Therapy (2015). (Discussion and Handout provided in ASCL 530 A from Dr. Leslie

Young)

Merriam-Webster.com. Retrieved November 14, 2016, from http://www.merriam-

webster.com/dictionary

Music and Movement Therapy for Child Life Specialists (2015). (Handout provided in ASCL

530 A from Dr. Leslie Young)

Pediatric Organ Transplantation (2016). (Handout provided in ASCL 530 by Michelle Parker)
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The Impact of Hospitalization on Various Stages of Development (2015). (Handout provided in

ASCL 530 A from Dr. Leslie Young)

Todaro, J. F., Fennell, E. B., Sears, S. F., Rodrigue, J. R., & Roche, A. K. (2000). Review:

Cognitive and psychological outcomes in pediatric heart transplantation. Journal Of

Pediatric Psychology, 25(8), 567-576. doi:10.1093/jpepsy/25.8.567