Advanced heart failure, a distinct syndrome, is characterized by refractoriness to conventional therapy and represents a vexing clinical dilemma that is associated with an increased symptom burden, frequent hospitalization, a poor quality of life and high risk of death. Such individuals do not tolerate neurohormonal antagonists at recommended doses, exhibit cardiorenal syndrome, maintain markedly poor cardiac reserve on cardiopulmonary stress testing, and typically display a low cardiac output state with elevated pulmonary pressures. In general, therapeutic targets shift away from disease modifying neurohormonal therapy to surgical options that attend directly to the myocardial stress and strain relationship. Most often, prolonged circulatory assistance using mechanical pumps or cardiac transplantation is required to reliably improve quality of life and long-term survival.
A decade after Norman Shumway had accomplished the technique of a successful heart transplant in canines, Christiaan Barnard successfully performed the first human to human transplant on December 3, 1967. Now, 5 decades later, this surgery has become entrenched in the standard armamentarium for treating patients with advanced heart failure who are otherwise healthy enough to receive such a life altering treatment. Globally, >150,000 patients have undergone cardiac transplantation with a 1 year survival >80% and median survival of nearly 11 years. These gains have been ushered in due to advances in immunosuppression and identification and management of allograft rejection, as well as a comprehensive appreciation for late complications including accelerated coronary artery disease, malignancy, and renal failure.
CANDIDATES FOR CARDIAC TRANSPLANTATION
The demand for cardiac transplantation outstrips the availability of organ donors. Hence, attention to the optimal utility, equitable allocation, and patient autonomy must dominate the decisions to identify and list candidates for transplantation. Simultaneously, attempts at expanding the donor pool have surfaced. However, vigilance to evaluating candidates most likely to have a successful outcome from transplantation takes pre-eminence. In 2006, the International Society for Heart and Lung Transplantation identified a set of criteria to guide listing of patients. These criteria were updated in 2016 and include additional attention to the growing epidemiology of candidates suffering from congenital heart disease, restrictive and infiltrative cardiomyopathy (such as amyloidosis), and chronic infections in recipients (such as Chagas’ disease, tuberculosis and hepatitides). Selected general principles for listing candidates for cardiac transplantation are enumerated in Table 255-1.
TABLE 255-1Principles for Listing Candidates for Cardiac Transplantation |Favorite Table|Download (.pdf) TABLE 255-1 Principles for Listing Candidates for Cardiac Transplantation
|Principle ||Comment |
|Advanced Disease Severity ||Refractory heart failure with a VO2 of <14 mL/kg/min (<12, if on beta blockers) or percent predicted VO2 <50%; combination of intolerance to disease modifying therapy, cardiorenal syndrome, use of inotropic therapy to maintain stability or need for a left ventricular assist system. |
|Co-Morbidity ||Age is not an absolute contraindication, but frailty should be considered a relative contraindication; a BMI > 35 kg/m2...|