Class of recommendation I, level of evidence C
Heart transplantation is an accepted treatment for end-stage HF. Although controlled trials have never been conducted, there is consensus that transplantation, provided proper selection criteria are applied, significantly increases survival, exercise capacity, return to work, and quality of life compared with conventional treatment.
- Patients with severe HF symptoms, a poor prognosis, and with no alternative form of treatment should be considered for heart transplantation.
- The introduction of new techniques and more sophisticated pharmacological treatment has modified the prognostic significance of the variables traditionally used to identify heart transplant candidates (peak VO2).
- The patient must be well informed, motivated, emotionally stable, and capable of complying with intensive medical treatment.
- Apart from the shortage of donor hearts, the main challenge of heart transplantation is prevention of rejection of the allograft, which is responsible for a considerable percentage of deaths in the first post-operative year.
- The long-term outcome is limited predominantly by the consequences of long-term immunosuppression therapy (infection, hypertension, renal failure, malignancy, and CAD).
- Heart transplantation should be considered in motivated patients with end-stage HF, severe symptoms, no serious co-morbidity, and no alternative treatment options.
- The contraindications include: current alcohol and/or drug abuse, lack of proper cooperation, serious mental disease not properly controlled, treated cancer with remission and < 5 years follow-up, systemic disease with multiorgan involvement, active infection, significant renal failure (creatinine clearance < 50 ml/min), irreversible high pulmonary vascular resistance (6–8 Wood units and mean transpulmonary gradient >15 mmHg), recent thromboembolic complications, unhealed peptic ulcer, evidence of significant liver impairment, or other serious co-morbidity with a poor prognosis.