What are the criteria for eligibility for a heart transplant in a patient with advanced heart failure?

Heart Transplant Eligibility Criteria

Patients with end-stage heart failure should be considered for heart transplantation when they have severe symptoms (NYHA Class III-IV), poor prognosis, and no remaining alternative treatment options, provided they meet specific clinical thresholds and lack absolute contraindications. 1

Clinical Indications for Transplant Evaluation

Patients should be evaluated for heart transplantation when they demonstrate:

Hemodynamic and Functional Criteria

• LVEF <25% with peak VO₂ <12 mL/kg/min during cardiopulmonary exercise testing 1
• ≥3 heart failure hospitalizations in the previous 12 months without obvious precipitating cause 1
• Dependence on continuous intravenous inotropic therapy to maintain adequate organ perfusion 1
• Progressive end-organ dysfunction with worsening renal and/or hepatic function 1
• Severe hemodynamic compromise with PCWP ≥20 mmHg and SBP ≤80-90 mmHg or cardiac index ≤2 L/min/m² 1
• Refractory cardiogenic shock unresponsive to escalating medical therapy 1

Patient Characteristics Required

The European Society of Cardiology emphasizes that acceptable candidates must be 1:

• Motivated, well-informed, and emotionally stable
• Capable of complying with intensive post-transplant treatment requirements
• Free from active substance abuse and demonstrating reliable social support

Absolute Contraindications

The following conditions preclude heart transplantation 1:

Infectious and Malignant Disease

• Active infection of any kind 1
• Active malignancy (requires oncology collaboration to stratify recurrence risk; generally requires >5 years cancer-free) 1

End-Organ Dysfunction

• Irreversible renal dysfunction with creatinine clearance <30 mL/min (some centers accept <50 mL/min) 1
• Severe hepatic impairment that is irreversible 1

Vascular and Pulmonary Disease

• Severe peripheral arterial or cerebrovascular disease 1
• Pharmacologically irreversible pulmonary hypertension (LVAD should be considered first with subsequent re-evaluation for candidacy) 1

Other Absolute Contraindications

• Systemic disease with multi-organ involvement 1
• Pre-transplant BMI >35 kg/m² (weight loss to achieve BMI <35 kg/m² is recommended before listing) 1
• Current alcohol or drug abuse 1
• Uncertain social supports or inability to comply with medical regimen 1
• Uncontrolled psychiatric illness 1

Special Populations

Hypertrophic Cardiomyopathy Patients

For HCM patients, transplant evaluation is appropriate when 1:

• LVEF <50% with NYHA Class III-IV symptoms despite guideline-directed therapy 1
• Life-threatening ventricular arrhythmias refractory to maximal therapy 1
• Nonobstructive HCM with advanced heart failure (preserved EF may occasionally qualify) 1

The 2020 AHA/ACC guidelines specifically recommend cardiopulmonary exercise testing in nonobstructive HCM patients with advanced heart failure to quantify functional limitation and aid in selection 1.

Pediatric Patients

Children with HCM and restrictive physiology who are unresponsive to or inappropriate candidates for other interventions should be considered for transplantation 1.

Timing of Referral

Peak VO₂ remains the most objective assessment for timing transplant evaluation 1:

• Peak VO₂ <10 mL/kg/min with achievement of anaerobic metabolism represents an absolute indication 1
• Peak VO₂ 11-14 mL/kg/min (or <55% predicted) with major limitation of daily activities represents a relative indication 1
• Peak VO₂ >14-15 mL/kg/min generally indicates insufficient severity for transplantation unless other compelling indications exist 1

Bridge to Transplant Considerations

LVAD implantation should be considered in eligible transplant candidates with end-stage heart failure to improve symptoms, reduce hospitalization risk, and reduce premature death risk while awaiting transplantation 1. The 2016 ESC guidelines note that earlier LVAD implantation in less severely ill patients (higher INTERMACS class) shows better outcomes than continued medical therapy alone 1.

Common Pitfalls to Avoid

• Do not use ejection fraction alone as a criterion for transplant candidacy; functional capacity and hemodynamics are equally critical 1, 2
• Ensure maximal medical therapy has been instituted and maintained before evaluation, as prognosis can be favorable in some patients with severe LV dysfunction on optimal therapy 2
• Reassess pulmonary hypertension after LVAD placement in initially ineligible patients, as it may become reversible 1
• Do not list mildly symptomatic patients regardless of other factors, as this causes harm 1