What are the primary criteria for a heart transplant?

Heart Transplant Criteria

Heart transplantation is indicated for patients with end-stage heart disease refractory to maximal medical therapy (Class III-IV heart failure) when no other surgical procedure can restore productive life, provided they meet specific inclusion criteria and lack absolute contraindications. 1

Primary Indications

Adult Patients

• End-stage heart failure with Class III or IV symptoms despite maximal medical therapy including ACE inhibitors and diuretics 1
• Escalating medical requirements or frequent hospitalizations indicating medical therapy failure 1
• Dependence on mechanical or parenteral inotropic support 1
• Specific cardiac conditions that have successfully undergone transplantation include: 1
  • Dilated cardiomyopathy (most common)
  • Advanced valvular heart disease
  • Complex congenital heart disease
  • Hypertrophic cardiomyopathy
  • Sarcoidosis and amyloidosis (though progression may limit long-term benefit)
  • Primary unresectable cardiac tumors
  • Refractory endocarditis

Pediatric Patients

• End-stage heart disease refractory to maximal medical therapy with no available surgical alternative 1
• Cardiomyopathy or complex congenital heart disease (the two main diagnoses) 1
• Growth failure or cardiac cachexia even when symptomatic heart failure appears controlled 1
• Single ventricle physiology after Fontan repair with low output 1

Clinical Referral Triggers

Refer patients for transplant evaluation when they demonstrate: 1

• Increasing congestive failure despite maximal oral diuretics and ACE inhibitor therapy
• Cardiac cachexia or growth failure (pediatrics)
• Dependence on intravenous inotropes
• Recurrent hospitalizations for decompensated heart failure

Important Caveat

Before listing for transplant, systematically exclude reversible causes of heart failure decompensation including: 1

• Recent onset nonischemic cardiomyopathy
• Active alcohol consumption
• Major reversible myocardial ischemia
• Atrial fibrillation or other atrial arrhythmias
• Endocrine disorders
• Inadequate medical optimization (ineffective use of vasodilators/diuretics)
• Therapy with negative inotropic drugs or prostaglandin inhibitors

Absolute Contraindications (Exclusion Criteria)

The following conditions preclude heart transplantation: 1

Organ Dysfunction

• Irreversible renal dysfunction: serum creatinine >2 mg/dL or creatinine clearance <60 mL/min 1
• Irreversible hepatic dysfunction 1
• Irreversible pulmonary parenchymal disease 1

Pulmonary Hypertension

• Pulmonary vascular resistance >6 Wood units or >3.0 Wood units after treatment with vasodilators 1

Active Disease States

• Active infection 1
• Coexisting neoplasm (exception: anthracycline cardiotoxicity patients believed cured have undergone successful transplantation) 1
• Active diverticulosis or diverticulitis 1
• Active peptic ulcer disease 1
• Acute pulmonary embolism or infarction 1

Systemic and Vascular Disease

• Coexistent systemic illness with poor prognosis 1
• Severe peripheral and cerebrovascular disease 1
• Insulin-dependent diabetes with end-organ damage 1
• Myocardial infiltrative and inflammatory diseases (relative contraindication) 1

Other Contraindications

• Severe obesity 1
• Severe osteoporosis 1
• Psychosocial instability or active substance abuse (strongly associated with poor post-transplant outcomes and noncompliance) 1

Psychosocial Evaluation

Assess compliance potential and psychiatric stability as pretransplantation noncompliance strongly predicts post-transplant noncompliance, which is a major cause of late graft loss: 1

• Evaluate for depression (distinguish endogenous from exogenous)
• Assess family support adequacy
• Screen for substance abuse history
• Identify potential behavioral problems requiring intervention

All disabled patients should be evaluated individually based on their ability to comply with medical regimens rather than by societal norms 1

Expected Outcomes

Heart transplantation offers superior survival compared to medical therapy alone: 1

• In-hospital mortality: <5%
• 1-year survival: approaching 85%
• 5-year survival: 75-80%
• This compares to 30-40% annual mortality with Class IV heart failure on medical therapy alone 1