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]Ifrah Fatima, M.B.B.S[2]
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-
- age
- sex
- NYHA class
- weight
- ejection fraction
- blood pressure
- medications
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]
- 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. [2]
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 (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-
- Medical therapy fails to optimize the hemodynamics
- If the left ventricle cannot be effectively unloaded with mechanical adjuncts, like an intra-aortic balloon pump (IABP) and/or left ventricular assist device (LVAD)
Donor Criteria
- Brain death declared
- Age <45 (special exceptions)
- No pre-existent heart disease
- Few coronary artery disease risk factors
- No untreated acute infections
- No systemic malignancy
- No cardiac trauma
- Normal ECG
- Normal echocardiogram
- Negative HIV and Hepatitis screen
References
- ↑ 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.
- ↑ 2.0 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.