When is a heart transplant recommended for patients with end-stage heart failure?

Heart Transplantation for End-Stage Heart Failure

Heart transplantation is recommended for patients with end-stage heart failure who have severe symptoms, poor prognosis, and no remaining alternative treatment options despite optimal medical and device therapy. 1

Indications for Heart Transplantation

Heart transplantation remains the gold standard treatment for carefully selected patients with end-stage heart failure, offering significantly improved survival, exercise capacity, quality of life, and return to work compared to conventional treatment 1, 2.

Specific indications include:

• End-stage heart failure with severe symptoms and poor prognosis despite optimal medical and device therapy 1
• Patients with >2 months of severe symptoms despite optimal medical and device therapy with one or more of the following 1:
  • Left ventricular ejection fraction <25% and peak VO2 <12 mL/kg/min
  • ≥3 heart failure hospitalizations in previous 12 months without obvious precipitating cause
  • Dependence on intravenous inotropic therapy
  • Progressive end-organ dysfunction due to reduced perfusion

Patient Selection Criteria

Suitable candidates should be:

• Motivated, well-informed, and emotionally stable 1
• Capable of complying with intensive post-transplant treatment 1
• Without contraindications that would compromise outcomes 1

Contraindications

Absolute contraindications include:

• Active infection 1
• Severe peripheral arterial or cerebrovascular disease 1
• Current alcohol or drug abuse 1
• Pharmacologically irreversible pulmonary hypertension (LVAD should be considered with subsequent re-evaluation) 1
• Cancer (collaboration with oncology specialists required to stratify recurrence risk) 1
• Irreversible renal dysfunction (creatinine clearance <30 mL/min) 1
• Systemic disease with multi-organ involvement 1
• Other serious co-morbidity with poor prognosis 1
• Pre-transplant BMI >35 kg/m² (weight loss recommended to achieve BMI <35 kg/m²) 1
• Inadequate social support 1

Mechanical Circulatory Support as Bridge to Transplant

For patients awaiting heart transplantation who are deteriorating or at high risk of death, mechanical circulatory support should be considered 1:

• Left ventricular assist devices (LVADs) should be considered in patients with end-stage heart failure with reduced ejection fraction (HFrEF) despite optimal medical and device therapy who are eligible for heart transplantation 1
• This approach can improve symptoms, reduce hospitalization risk, and prevent premature death while waiting for a donor heart 1
• LVADs can also serve as a bridge to candidacy (BTC) to improve end-organ function in patients initially ineligible for transplantation 1

Expected Outcomes

Heart transplantation offers significant survival benefits:

• In-hospital mortality rate <5% 1
• 1-year survival rate approaching 85% 1
• 5-year survival rates of 75-80% 1, 3
• Marked improvement in quality of life 1, 4

Clinical Pitfalls and Considerations

• Timely referral is crucial - patients should be referred for transplant evaluation before end-organ damage becomes irreversible 5
• Some contraindications are temporary and treatable - patients with HIV, hepatitis, Chagas disease, and tuberculosis can be considered as candidates with appropriate management 1
• Limited donor availability remains a major challenge, necessitating careful patient selection 2
• Long-term immunosuppression complications include infection, hypertension, renal failure, malignancy, and coronary artery vasculopathy 1, 2
• Mechanical circulatory support technology is advancing rapidly and may become competitive with heart transplantation for selected patients, though long-term results are still pending 3

Algorithmic Approach to Evaluation

1. Confirm end-stage heart failure despite optimal medical and device therapy 1
2. Assess functional capacity, symptom severity, and prognosis 4
3. Screen for contraindications 1
4. For eligible patients, list for transplantation 1
5. For deteriorating patients awaiting transplantation, consider mechanical circulatory support 1
6. For patients with reversible contraindications (e.g., pulmonary hypertension), consider LVAD as bridge to candidacy 5

Heart transplantation decisions should be made by a multidisciplinary transplant team at centers experienced in advanced heart failure management 6.