What happens if a newly transplanted heart simply won't start beating? (don't need answer fast!)

As heart transplants have become more and more common, I’ve been wondering about this. It’s not as if there’s a second heart in case the first one won’t work. There’s a living person on the operating table with a hole in the chest, and no heart. What would happen?

Obviously, the patient dies. Shit happens.

(If anyone can think of any exceptions, then we can argue if that’s fighting the OP’s hypothetical.)

So perhaps OP is asking, what else happens? Do the doctors and assistants panic? Is there pandemonium in the OR? What actions do they take to try to get the heart started? Does the lead surgeon heroically donate his own heart? At what point do they give up? At what point is the living person on the operating table with a hole in the chest declared a dead person on the operating table with a hole in the chest? Do they sew the hole back up anyway? Do they have their lawyers and insurance companies on speed-dial?

How common would that be? I would expect not very. Healthy hearts (and of course they’re going to use a healthy heart for a transplant) don’t just stop beating, or fail to start.

Based on my experience (watching medical dramas on television) the doctor will manually pump the heart or even use the defibrillator to jump-start it.

A similar question would be relevant in non-transplant cases: What happens if the surgeons stopped a patient’s heart to do open-heart surgery, and they did whatever they went in for, and then when they were done, the heart failed to restart?

Here’s my guess for both of these situations: During the surgery, they patient was hooked up to a machine that keeps the blood circulating. They usually disconnect that machine after the heart starts up again, but in this case they would keep it connected, and the patient is still alive. The next question is how long that situation can be maintained.

At least two weeks. But probably no longer than a month.

Sometimes the hearts just don’t start. A lot of research has gone into trying to figure out why. Some good theories, some less so. But after sufficient attempts to jumpstart the heart, correct any possible chemical imbalances, pumping the heart and body full of various pharmaceuticals that might fix it, etc eventually the patient is declared dead. Maintenance for a few days on artificial heart/oxygenation systems is now possible but not super common at this point.

I suppose by that time, installing an artificial heart would not be a viable option?

I know someone this happened to. His heart did not restart after a bypass operation. Whatever they did (adrenalin? defibrillation? I don’t know) they eventually restarted it. He suffered brain damage from a short time of low oxygen. He was in the middle of writing a book about his life’s research. He could not continue. His teaching suffered and his department eventually forced him into early retirement. That was in the 1980s and he died about a year ago, so survived the experience by more than 30 years. In ordinary conversation you would not notice a deficiency.

BTW the electronic shock machines (defibilators) normally don’t start a heart that is not beating but they can be used for that. They are mostly used to restore proper heart rhythm

Do VIPs have several hearts on ice so the surgeons can keep trying until one starts?

No.

The number of people on the transplant list exceeds the number of available organs. When a heart becomes available it’s only good for a few hours. It would be completely unethical to reserve 2 or more hearts for 1 person when there are other people also waiting for a life saving transplant.

Ethical issues aside, it’s highly unlikely that you have more than one heart that are:
-available simultaneously
-in the same area of the country
-that are both compatible for the same recipient

In the case at St Luke’s in Houston in 2015, a new heart could not be shocked into rhythm (because the defibrillator in the operating room didn’t work). The surgeons manually pumped the heart for 10 or 20 minutes while the back-up plan was enacted. Unfortunately, the new heart was damaged by the delay.
The back-up plan was that the patient was placed on Extracorporeal Membranous Oxygenation (ECMO)- an artificial lung device to oxygenate the blood outside of the body and then return it to the body, and also on a Left Ventricular Assist Device (LVAD) and a Right Ventricular Assist Device (LVAD)- mechanical pumps that assist the ventricles to pump, or “Heart-lung bypass”.
Since obtaining another human heart was unlikely, the next step was to place a mechanical heart; more specifically a SynCardia total artificial heart.
The man in this story had many complications and ultimately died. https://features.propublica.org/heart-transplants/heart-transplants-baylor-st-lukes-death-lee-lewis/
This case and a couple more caused the program to lose funding, to be shut down for a while, lots of people were fired, and lawsuits filed. https://www.propublica.org/series/heart-failure/p2