Heart transplantation criteria

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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]

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 VO2max which represents the cardiac reserve and the peripheral manifestations in response to a reduced cardiac output.

• A maximal cardiopulmonary exercise test is defined as one with a respiratory exchange ratio (RER) > 1.05 and achievement of an anaerobic threshold on optimal pharmacologic therapy.

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

• 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 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-

• age
• sex
• NYHA class
• weight
• ejection fraction
• blood pressure
• medications,
• few laboratory values

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:

• Presence or absence of coronary artery disease
• Resting heart rate
• Left ventricular ejection fraction
• Mean arterial blood pressure
• Presence or absence of an intraventricular conduction delay on ECG
• Serum sodium
• VO2max.

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.

Role of Diagnostic Right Heart Catheterization

• Right heart catheterization (RHC) should be performed on all adult candidates in preparation for listing for cardiac transplantation and periodically until transplantation.
• RHC should be performed at 3- to 6-month intervals in listed patients, especially in the presence of reversible pulmonary hypertension or worsening of heart failure symptoms
• 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, hospitalization with continuous hemodynamic monitoring should be performed, as often the PVR will decline after 24 to 48 hours of treatment consisting of diuretics, inotropes and vasoactive agents such as inhaled nitric oxide
• If medical therapy fails to achieve acceptable hemodynamics, and if the left ventricle cannot be effectively unloaded with mechanical adjuncts, including an intra-aortic balloon pump (IABP) and/or left ventricular assist device (LVAD), it is reasonable to conclude that the pulmonary hypertension is irreversible

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

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