Why transplant?

Cardiac transplantation is performed in patients with end-stage cardiac failure to enhance survival and improve the quality of life.

Identification.

First, the physician must recognize which patient is at risk for immanent death despite optimal therapy, conventional surgery, and assume cardiac transplantation will alter this prognosis. Second, the physician must exclude from consideration any patient in whom pathophysiological or psychological problem exists that will interfere with the aims of improving the quality and quantity of life for that individual.

Cause for Transplantation.

The vast majority of patients who undergo transplantation have either ischemic or idiopathic dilated cardiomyopathy and suffer from severely symptomatic CHF. Less common causes include post partum cardiomyopathy, congenital heart disease, cardiac tumors, intractable ventricular arrythmias, hypertrophic cardiomyopathy, and graft rejection.

Inclusion Criteria.

Hemodynamics.
Patients with elevated central venous pressure, pulmonary artery pressure, pulmonary capillary wedge pressure, and decresed cardiac output.
Ejection Fraction(EF).
An EF greater than 45% excludes patients from immediate concern. Patients with EF less than 10% places them in the high risk group, with some centers using 20% or less.
Exclusion of Active Myocarditis.
Biopsy results are not helpful, unless they reveal active myocarditis(treated by immunosuppresion), or infiltration which would remove the patient from transplantation candidacy.
Symptoms and Functional Capacity.
Class IV symptoms, despite cardiotonic regimen is a poor prognostic factor. Maximum oxygen consumption of less than 10ml/kg/min is also a very poor prognostic indicator.
Elevated Epinephrine Levels.
Patients who do not respond to cardiotonic regiments or continue to deteriorate despite therapeutic intervention are considered to have a maximally activated sympathetic system which places them in a high risk category.
Ventricular Arrhythmia.
Patients with high grade ventricular arrhythmia(symptomatic or not) that do not respond to anti-arrhythmic or other cardiotonic regiments are candidates to be considered.

Relative Exclusion Criteria.

Age.
Generally, 55 years has been the "preferred" cut-off age, however there are a variety of variables that can extend the cut-off.
Peripheral Vascular Disease(PVD).
PVD places patients at an increased risk for diffuse end-organ damage in the context of known drug toxicities used in post transplantation management.
Renal Dysfunction.
Prerenal azotemia alone is a risk, especially when one considers the known renal toxicity of cyclosporine. Serum creatinine greater than 2.5mg/dl or creatinine clearance of less than 30ml/min is a relative contraindication for transplantation.
Hepatic Dysfunction.
Hepatic faliure beyond the normally expected hepatic congestion secondary to heart failure and/or an underlying significant coagulapathy is a contraindication.
Diabetes Mellitus(DM).
End-organ damage is associated with a hyperglycemic state which is considered to be a risk associated with the known side-effect of cyclosporine and prednisone. Those without DM, but with significant glucose intolerance are evaluated for diabetic complications of hyperglycemia.
Peptic Ulcer Disease(PUD).
PUD is a relative contraindication due to the potential for exacerbation with post-transplant steroid therapy and fungal / viral superinfection of gastric and duodenal ulcers.

Absolute Exclusion Criteria.

Malignancy.
Any malignancy present at time of transplantation or in the near past places patients at an increased risk for exacerbation of the neoplasm during immunosuppression. Lymphomas sometimes arise de novo without past history of neoplasm.
Pulmonary Vascular Resistance(PVR).
Patient with elevated PVR and/or pulmonary hypertension do poorly post-transplantation. If the PA pressure is higher than 45mm Hg, intravenous nitroprusside is given to lower the PA pressure as well as the PVR to optimally below 2.5 Woods units.
Concurrent infection.
Infection is a absolute contraindication to transplantation due to its requirement for immunosuppression.
Collagen Vascular Disease(CVD).
CVD can cause a dangerous array of end-organ pathology that can lead to potential post-transplantation complications.
Other Irreversible Organ disease.
Disease such as emphysema and untreatable systemic illnesses such as amyloidosis are contraindications.
Marked obesity.
Obstacle in regard to postoperative morbidity and larger donor heart requirements.
Cachexia.
Associated with post operative multiple end-organ failure and is considered an absolute contraindication.

Appropriate Psychological Profile.

Patient must be emotionally stable enough to comply with extensive medical follow up required after the surgery and have a realistic attitude toward potential benefits and hazards of transplantation and immunosuppresion. History of active drug abuse, alcohol, or chronic mental illness are not compatible with transplantation.

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	Site last modified on:	March 22, 1997
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