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{{Heart transplantation}}
{{Heart transplantation}}


'''Editor(s)-in-Chief:''' [[C. Michael  Gibson, M.S., M.D.]]; '''Associate Editor-In-Chief:''' {{CZ}}
'''Editor(s)-in-Chief:''' [[C. Michael  Gibson, M.S., M.D.]]; '''Associate Editor-In-Chief:''' {{CZ}}{{IF}}
 
==Overview==
Criteria that should be met by the recipient to make [[cardiac transplantation]] suitable include evaluation with [[cardiopulmonary]] stress testing (peak oxygen consumption), [[heart failure]] prognosis scores- Seattle Heart Failure Model (SHFM), Heart Failure Survival Score (HFSS) and Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score and diagnostic [[right heart catheterization]].


==Criteria for Cardiac Transplantation==
==Criteria for Cardiac Transplantation==
While assessment of the indications and contraindications are important first steps in evaluating the appropriateness for cardiac transplantation, the prognosis of a patient with and without transplantation is critical in making the final determination as to whether a patient is suitable for cardiac transplantation. Discussed below are criteria that are used based upon the estimation of the patient's prognosis.
While assessment of the [[Indications and usage|indications]] and [[Contraindication|contraindications]] are important first steps in evaluating the appropriateness for [[Heart transplantation|cardiac transplantation]], the [[prognosis]] of a patient with and without transplantation is critical in making the final determination as to whether a patient is suitable for cardiac transplantation. Discussed below are criteria that are used based upon the estimation of the patient's prognosis. The pre-transplantation evaluation includes-
 
===Cardiopulmonary stress testing to guide transplant listing===
 
[[Exercise capacity]] is assessed by VO2 max which represents the cardiac reserve and the peripheral manifestations in response to a reduced [[cardiac output]]. <ref name="pmid25132979">{{cite journal| author=Alraies MC, Eckman P| title=Adult heart transplant: indications and outcomes. | journal=J Thorac Dis | year= 2014 | volume= 6 | issue= 8 | pages= 1120-8 | pmid=25132979 | doi=10.3978/j.issn.2072-1439.2014.06.44 | pmc=4133547 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25132979  }} </ref>
 
A maximal [[Cardiopulmonary exercise testing|cardiopulmonary exercise test]] is
* Respiratory exchange ratio (RER) > 1.05
* Achievement of an anaerobic threshold on optimal medical treatment
 
The following cutoff values of peak oxygen consumption (VO2) are used to guide listing in various cases- <ref name="MehraCanter2016">{{cite journal|last1=Mehra|first1=Mandeep R.|last2=Canter|first2=Charles E.|last3=Hannan|first3=Margaret M.|last4=Semigran|first4=Marc J.|last5=Uber|first5=Patricia A.|last6=Baran|first6=David A.|last7=Danziger-Isakov|first7=Lara|last8=Kirklin|first8=James K.|last9=Kirk|first9=Richard|last10=Kushwaha|first10=Sudhir S.|last11=Lund|first11=Lars H.|last12=Potena|first12=Luciano|last13=Ross|first13=Heather J.|last14=Taylor|first14=David O.|last15=Verschuuren|first15=Erik A.M.|last16=Zuckermann|first16=Andreas|title=The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update|journal=The Journal of Heart and Lung Transplantation|volume=35|issue=1|year=2016|pages=1–23|issn=10532498|doi=10.1016/j.healun.2015.10.023}}</ref>
 
* Patients intolerant of a [[Beta blockers|β-blocker]]- Peak Vo 2 of ≤ 14 ml/kg/min
* In the presence of a [[Beta blockers|β-blocker]]- peak Vo 2 of ≤ 12 ml/kg/min
* Young patients (< 50 years) and women- percent of predicted (≤ 50%) peak Vo 2 and using alternate standards in conjunction with it
* Sub-maximal cardiopulmonary exercise test (RER < 1.05)- use of ventilation equivalent of [[carbon dioxide]] (Ve/Vco 2) slope of > 35
*[[Obesity|Obese]] (body mass index [<nowiki/>[[Body mass index|BMI]]] > 30 kg/m 2) patients- adjusting peak Vo 2 to lean body mass may be considered. A lean body mass–adjusted peak Vo 2 of < 19 ml/kg/min is used for listing.
 
===Use of Heart Failure prognosis scores===
 
1. ''' Seattle Heart Failure Model (SHFM)''' - An estimated 1-year survival as calculated by the Seattle Heart Failure Model (SHFM) of < 80%
 
The factors considered in this model are-
* age
* sex
*[[NYHA functional Class|NYHA]] class
* weight
*[[ejection fraction]]
*[[blood pressure]]
* medications


==Functional Capacity and Peak V02 (V02 Max)==
SHFM model has also incorporated the impact of newer HF therapies on survival, including [[Implantable cardioverter defibrillator|ICDs]] and [[Cardiac resynchronization therapy|CRT]].  
This objective metric is listed by the ACC/AHA heart failure guidelines as a critical measure in determining when to list someone for transplantation <ref>Gibbons, RJ, Balady, GJ, Bricker, JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation 2002; 106:1883.</ref><ref>Hunt, SA, Abraham, WT, Chin, MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009; 119:e391.</ref>. A normal peak V02 is > 20 ml/kg/min.  Older data from 1986 through 1989 identified and peak V02 of 14 ml/kg/min as a threshold for listing a patient <ref name="pmid1999029">{{cite journal |author=Mancini DM, Eisen H, Kussmaul W, Mull R, Edmunds LH, Wilson JR |title=Value of peak exercise oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure |journal=[[Circulation]] |volume=83 |issue=3 |pages=778–86 |year=1991 |month=March |pmid=1999029 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=1999029}}</ref>. Those patients with a peak V02 > 14 ml/kg/min who were considered too stable for cardiac transplantation had a survival that was similar to that of patients with a peak V02 <u><</u> 14 ml/kg/min who were transplanted.  It should be noted that peak V02 is variable, and should be re assessed periodically.  It should also be noted that gender, age, comorbidities, and a patient's level of conditioning should be taken into account when interpreting the peak V02.  If a patient is consistently in the peak V02 range of 10-12 ml/kg/min, then transplantation should be considered.


==Transplant Criteria==
2. '''Heart Failure Survival Score (HFSS)''' in the high/medium risk range
'''''The ACC / AHA criteria are as follows <ref>Hunt, SA, Abraham, WT, Chin, MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009; 119:e391.</ref>:'''''
The predictors of survival in the HFSS include: <ref name="pmid25132979">{{cite journal| author=Alraies MC, Eckman P| title=Adult heart transplant: indications and outcomes. | journal=J Thorac Dis | year= 2014 | volume= 6 | issue= 8 | pages= 1120-8 | pmid=25132979 | doi=10.3978/j.issn.2072-1439.2014.06.44 | pmc=4133547 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25132979  }} </ref>
*Presence or absence of [[Coronary heart disease|coronary artery disease]]
*Resting [[heart rate]]
*[[Left ventricular ejection fraction]]
*Mean arterial blood pressure
*Presence or absence of an intraventricular conduction delay on [[The electrocardiogram|ECG]]
*Serum [[sodium]]
*VO2max.


====Absolute Indications====
3. '''Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score'''
*For hemodynamic compromise due to severe [[heart failure]]
:*Refractory [[cardiogenic shock]]
:*Documented dependence on intravenous [[inotropic]] support to maintain adequate organ perfusion
:*[[Peak VO2]] less than 10 mL/kg per min with achievement of anaerobic metabolism
*Severe symptoms of ischemia that consistently limit routine activity and are not amenable to [[coronary artery bypass surgery]] or percutaneous coronary intervention.
*Recurrent symptomatic ventricular arrhythmias refractory to all therapeutic modalities


====Relative indications====
Listing patients solely on the criteria of heart failure survival prognostic scores should not be performed. <ref name="MehraCanter2016">{{cite journal|last1=Mehra|first1=Mandeep R.|last2=Canter|first2=Charles E.|last3=Hannan|first3=Margaret M.|last4=Semigran|first4=Marc J.|last5=Uber|first5=Patricia A.|last6=Baran|first6=David A.|last7=Danziger-Isakov|first7=Lara|last8=Kirklin|first8=James K.|last9=Kirk|first9=Richard|last10=Kushwaha|first10=Sudhir S.|last11=Lund|first11=Lars H.|last12=Potena|first12=Luciano|last13=Ross|first13=Heather J.|last14=Taylor|first14=David O.|last15=Verschuuren|first15=Erik A.M.|last16=Zuckermann|first16=Andreas|title=The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update|journal=The Journal of Heart and Lung Transplantation|volume=35|issue=1|year=2016|pages=1–23|issn=10532498|doi=10.1016/j.healun.2015.10.023}}</ref>


#Peak V02 of 11 to 14 mL/kg per minute (or 55 percent predicted) and major limitation of the patient's daily activities
===Role of Diagnostic Right Heart Catheterization===
#Recurrent unstable ischemia not amenable to other intervention
<ref name="MehraCanter2016">{{cite journal|last1=Mehra|first1=Mandeep R.|last2=Canter|first2=Charles E.|last3=Hannan|first3=Margaret M.|last4=Semigran|first4=Marc J.|last5=Uber|first5=Patricia A.|last6=Baran|first6=David A.|last7=Danziger-Isakov|first7=Lara|last8=Kirklin|first8=James K.|last9=Kirk|first9=Richard|last10=Kushwaha|first10=Sudhir S.|last11=Lund|first11=Lars H.|last12=Potena|first12=Luciano|last13=Ross|first13=Heather J.|last14=Taylor|first14=David O.|last15=Verschuuren|first15=Erik A.M.|last16=Zuckermann|first16=Andreas|title=The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update|journal=The Journal of Heart and Lung Transplantation|volume=35|issue=1|year=2016|pages=1–23|issn=10532498|doi=10.1016/j.healun.2015.10.023}}</ref>
#Recurrent instability of fluid balance/renal function not due to patient noncompliance with medical regimen


===="Insufficient" indications====
* Right heart catheterization (RHC) should be performed on all adult candidates in preparation for listing for cardiac transplantation and periodically (every 3-6 months, especially in the presence of reversible pulmonary hypertension or worsening symptoms of heart failure) until transplantation.
#Low left ventricular ejection fraction
* A [[vasodilator]] challenge should be administered if-
#History of functional class II or IV symptoms of HF
** the pulmonary artery systolic pressure is ≥ 50 mm Hg and
#Peak [[VO2]] greater than 15 mL/kg per minute (or greater than 55 percent predicted) without other indications
** Either the transpulmonary gradient is ≥ 15 or the pulmonary vascular resistance (PVR) is > 3Wood units while maintaining a systolic arterial blood pressure > 85 mm Hg
* When an acute vasodilator challenge is unsuccessful, the patient should be hospitalized with continuous hemodynamic monitoring and treated pharmacologically till the PVR declines.
*[[Pulmonary hypertension|Pulmonary Hypertension]] is considered irreversible if-
** Medical therapy fails to optimize the [[hemodynamics]]
** If the left ventricle cannot be effectively unloaded with mechanical adjuncts, like an [[intra-aortic balloon pump]] ([[Intra-aortic balloon pump|IABP]]) and/or [[left ventricular assist device]] (LVAD)


==Donor Criteria==
==Donor Criteria==

Latest revision as of 17:13, 8 July 2020

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Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D.; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [1]Ifrah Fatima, M.B.B.S[2]

Overview

Criteria that should be met by the recipient to make cardiac transplantation suitable include evaluation with cardiopulmonary stress testing (peak oxygen consumption), heart failure prognosis scores- Seattle Heart Failure Model (SHFM), Heart Failure Survival Score (HFSS) and Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score and diagnostic right heart catheterization.

Criteria for Cardiac Transplantation

While assessment of the indications and contraindications are important first steps in evaluating the appropriateness for cardiac transplantation, the prognosis of a patient with and without transplantation is critical in making the final determination as to whether a patient is suitable for cardiac transplantation. Discussed below are criteria that are used based upon the estimation of the patient's prognosis. The pre-transplantation evaluation includes-

Cardiopulmonary stress testing to guide transplant listing

Exercise capacity is assessed by VO2 max which represents the cardiac reserve and the peripheral manifestations in response to a reduced cardiac output. [1]

A maximal cardiopulmonary exercise test is

  • Respiratory exchange ratio (RER) > 1.05
  • Achievement of an anaerobic threshold on optimal medical treatment

The following cutoff values of peak oxygen consumption (VO2) are used to guide listing in various cases- [2]

  • Patients intolerant of a β-blocker- Peak Vo 2 of ≤ 14 ml/kg/min
  • In the presence of a β-blocker- peak Vo 2 of ≤ 12 ml/kg/min
  • Young patients (< 50 years) and women- percent of predicted (≤ 50%) peak Vo 2 and using alternate standards in conjunction with it
  • Sub-maximal cardiopulmonary exercise test (RER < 1.05)- use of ventilation equivalent of carbon dioxide (Ve/Vco 2) slope of > 35
  • Obese (body mass index [BMI] > 30 kg/m 2) patients- adjusting peak Vo 2 to lean body mass may be considered. A lean body mass–adjusted peak Vo 2 of < 19 ml/kg/min is used for listing.

Use of Heart Failure prognosis scores

1. Seattle Heart Failure Model (SHFM) - An estimated 1-year survival as calculated by the Seattle Heart Failure Model (SHFM) of < 80%

The factors considered in this model are-

SHFM model has also incorporated the impact of newer HF therapies on survival, including ICDs and CRT.

2. Heart Failure Survival Score (HFSS) in the high/medium risk range

The predictors of survival in the HFSS include: [1]

3. Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score

Listing patients solely on the criteria of heart failure survival prognostic scores should not be performed. [2]

Role of Diagnostic Right Heart Catheterization

[2]

  • Right heart catheterization (RHC) should be performed on all adult candidates in preparation for listing for cardiac transplantation and periodically (every 3-6 months, especially in the presence of reversible pulmonary hypertension or worsening symptoms of heart failure) until transplantation.
  • A vasodilator challenge should be administered if-
    • the pulmonary artery systolic pressure is ≥ 50 mm Hg and
    • Either the transpulmonary gradient is ≥ 15 or the pulmonary vascular resistance (PVR) is > 3Wood units while maintaining a systolic arterial blood pressure > 85 mm Hg
  • When an acute vasodilator challenge is unsuccessful, the patient should be hospitalized with continuous hemodynamic monitoring and treated pharmacologically till the PVR declines.
  • Pulmonary Hypertension is considered irreversible if-

Donor Criteria

  1. Brain death declared
  2. Age <45 (special exceptions)
  3. No pre-existent heart disease
  4. Few coronary artery disease risk factors
  5. No untreated acute infections
  6. No systemic malignancy
  7. No cardiac trauma
  8. Normal ECG
  9. Normal echocardiogram
  10. Negative HIV and Hepatitis screen

References

  1. ↑ 1.0 1.1 Alraies MC, Eckman P (2014). "Adult heart transplant: indications and outcomes". J Thorac Dis. 6 (8): 1120–8. doi:10.3978/j.issn.2072-1439.2014.06.44. PMC 4133547. PMID 25132979.
  2. ↑ 2.0 2.1 2.2 Mehra, Mandeep R.; Canter, Charles E.; Hannan, Margaret M.; Semigran, Marc J.; Uber, Patricia A.; Baran, David A.; Danziger-Isakov, Lara; Kirklin, James K.; Kirk, Richard; Kushwaha, Sudhir S.; Lund, Lars H.; Potena, Luciano; Ross, Heather J.; Taylor, David O.; Verschuuren, Erik A.M.; Zuckermann, Andreas (2016). "The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update". The Journal of Heart and Lung Transplantation. 35 (1): 1–23. doi:10.1016/j.healun.2015.10.023. ISSN 1053-2498.


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