From the Guidelines
Heart transplantation is indicated for selected patients with advanced heart failure (stage D) despite guideline-directed medical therapy (GDMT) to improve survival and quality of life, as stated in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.
Indications for Heart Transplantation
The indications for heart transplantation include:
- Refractory cardiogenic shock requiring mechanical circulatory support
- Dependency on intravenous inotropic medications (such as dobutamine or milrinone)
- Persistent NYHA class III-IV symptoms despite optimal medical therapy
- Peak oxygen consumption (VO2) less than 14 mL/kg/min with cardiac limitation
- Severe cardiac dysfunction with left ventricular ejection fraction typically below 25%
Patient Selection
Patients should have significant functional limitations with a poor quality of life despite maximized guideline-directed medical therapy, which includes beta-blockers (carvedilol, metoprolol succinate), ACE inhibitors or ARBs, aldosterone antagonists, and SGLT2 inhibitors at target doses.
Contraindications
Contraindications that would preclude transplantation include active malignancy, severe irreversible pulmonary hypertension (pulmonary vascular resistance >5 Wood units), recent stroke, active infection, significant comorbidities limiting survival, ongoing substance abuse, or poor psychosocial support.
Rationale for Heart Transplantation
The rationale for heart transplantation is to improve survival and quality of life in these critically ill patients, as the procedure offers a 1-year survival rate of approximately 85-90% and a median survival exceeding 12 years, which is substantially better than the natural history of end-stage heart failure.
Additional Considerations
According to the American Heart Association, mechanical circulatory support (MCS) can be considered for transplant-eligible patients with end-stage heart failure who are failing optimal medical, surgical, and/or device therapies and are at high risk of dying before receiving a heart transplantation 1.
From the Research
Indications for Heart Transplant
The primary indication for a heart transplant is advanced heart failure that is unresponsive to optimal medical therapy [(2,3,4)]. Patients with end-stage heart failure who remain symptomatic despite optimal medical therapy are considered candidates for heart transplantation 4.
Patient Selection
Patient selection for heart transplantation involves a comprehensive evaluation, including assessment of prognosis, contraindications, and potential benefits [(2,4)]. Risk stratification is essential to identify patients who are most likely to benefit from heart transplantation 4.
Contraindications
Common contraindications for heart transplantation include significant pulmonary hypertension, active infection, and severe renal or hepatic dysfunction 4. However, some patients with previously considered contraindications, such as diabetes, HIV, and pretransplant malignancy, may now be considered for heart transplantation 2.
Alternative Therapies
For patients who are ineligible for heart transplantation, alternative therapies such as palliative care, exercise-based cardiac rehabilitation, device therapy, and mechanical circulatory support may be considered 5. These therapies can improve quality of life, reduce hospitalizations, and potentially improve mortality 5.
Key Considerations
- Heart transplantation is the treatment of choice for patients with advanced heart failure who remain symptomatic despite optimal medical therapy [(2,3,4)].
- Patient selection involves a comprehensive evaluation, including assessment of prognosis, contraindications, and potential benefits [(2,4)].
- Alternative therapies are available for patients who are ineligible for heart transplantation 5.