Heart transplantation indications
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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]
Indications
In order for a patient to be recommended for a heart transplant they will generally have advanced, irreversible heart failure with a severely limited life expectancy.[1] It is important to note that the life expectancy of heart failure has improved over the past two decades due to improvements in both medical therapy (ACE Inhibition, beta-blockers, aldosterone antagonists and device therapy such as automatic implantable cardiac defibrillators AICDs and cardiac resynchronization. Thus, patients should not be considered for cardiac transplantation unless they have failed aggressive medical and device therapy.
Systolic Heart Failure with a Left Ventricular Ejection Fraction less than 35%
- Due to either:
- Ischemic cardiomyopathy
- Dilated cardiomyopathy
- Valvular heart disease
- Hypertensive heart disease
- Etiologies which are excluded are amyloid, HIV, and cardiac sarcoma
Ischemic Coronary Artery Disease with Refractory Angina
- Ischemia which is not amenable to percutaneous or surgical revascularization (coronary artery bypass graft surgery CABG) and is refractory to maximally tolerated medical and/or device therapy
Intractable life-threatening Arrhythmias
- Ventricular arrhythmias which are not controlled by an implantable cardioverter-defibrillator and are refractory or not amenable to electrophysiologic guided single or combination medical therapy
- Patients that are not a candidate for catheter ablation therapy
Cardiomyopathies
- Restrictive and Hypertrophic Cardiomyopathies with NYHA Class IV heart failure symptoms that persist despite maximal medical therapy, myomectomy, alcohol septal ablation, mitral valve replacement
- Non-dilated cardiomyopathies such as arrhythmogenic right ventricular cardiomyopathy
Congenital Heart Disease
- CHD resulting in New York Heart Association functional class IV Heart Failure not amenable to surgery.
- Severe symptomatic cyanotic congenital heart disease.
- Presence of some degree of pulmonary hypertension with the potential risk of developing fixed and irreversible elevation of pulmonary vascular resistance (PVR)
General Considerations
According to The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation, the following general considerations should be taken into account to finalise the listing of a patient with relevant indications for heart transplant [2]
- Cardiopulmonary stress testing to guide transplant listing
- Use of heart failure prognosis scores - An estimated 1-year survival as calculated by the Seattle Heart Failure Model (SHFM) of < 80% or a Heart Failure Survival Score (HFSS) in the high/medium risk range should be considered as reasonable cut points for listing
- Role of diagnostic right heart catheterization- should be performed on all adult candidates in preparation for listing for cardiac transplantation and periodically until transplantation
- Comorbidities and their implications for heart transplantation listing
- Age (< 70 years), obesity ((BMI) > 35 kg/m 2 is associated with a worse outcome), and cancer
- Diabetes- End-organ damage and persistent poor glycemic control (glycosylated hemoglobin [HbA 1c] > 7.5% or 58 mmol/mol) are contraindications
- Renal dysfunction- irreversible renal dysfunction ( eGFR < 30 ml/min/1.73 m 2) is a relative contraindication
- Peripheral vascular disease- Clinically severe symptomatic cerebrovascular disease may be considered a contraindication.
- Assessment of frailty
- Mechanical circulatory support for bridge to candidacy
- Tobacco use, substance abuse, and psychosocial evaluation in candidates
- Substance abuse
- Psychosocial evaluation
- Guidance for screening grids and serial pre-transplant evaluation
- Dynamic listing and new donor allocation algorithms
- Retransplantation- indicated for those patients who develop significant CAV with refractory cardiac allograft dysfunction, without evidence of ongoing rejection
References
- ↑ Steinman TI, Becker BN, Frost AE, Olthoff KM, Smart FW, Suki WN, Wilkinson AH (2001). "Guidelines for the referral and management of patients eligible for solid organ transplantation". Transplantation. 71 (9): 1189–204. PMID 11397947. Unknown parameter
|month=ignored (help) - ↑ 2.0 2.1 Mehra MR, Canter CE, Hannan MM, Semigran MJ, Uber PA, Baran DA; et al. (2016). "The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update". J Heart Lung Transplant. 35 (1): 1–23. doi:10.1016/j.healun.2015.10.023. PMID 26776864.