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The indication for heart transplantation is defined as : “End-stage heart disease not remediable by more conservative measures.”

The ACC/AHA guidelines include the following indications for cardiac transplantation:

Indications in appropriate patients:

  • For hemodynamic compromise due to HF
    • Refractory cardiogenic shock ( Cardiac index below 1.8 L/min/m2). The normal range of cardiac index in rest is 2.6–4.2 L/min/m2.
    • Documented dependence on IV inotropic medication support to maintain adequate organ perfusion
    • Peak Vo2 less than 10 mL/kg per min with achievement of anaerobic metabolism.
  • Persistent New York Heart Association functional class IV heart failure (HF) symptoms refractory to maximal medical therapy (left ventricular ejection fraction <20 percent; peak Vo2 <12 mL/kg/min).
  • Severe symptoms of ischemia/ intractable angina that consistently limit routine activity and are not amenable to coronary artery bypass surgery or percutaneous coronary intervention.
  • Recurrent/ malignant ventricular arrhythmias refractory to all therapeutic modalities

In unhospitalized patients the following req have been recommended for consideration for cardiac transplantation:

  • Hx of repeated hospitalizations for heart failure
  • Need for ventricular assist device or artificial heart to support circulation
  • Increasing types, dosages, and complexity of medications
  • A reproducible VO2 of less than 14 mL/kg per minute.

Patients are stratified into low, medium, and high risk of death without transplant in Heart Failure Survival Score. Predictors include: presence or absence of coronary aa disease, resting heart rate, LVEF, mean arterial blood pressure, presence or absence of an intraventricular conduction delay on EKG, serum sodium, peak VO2.

Seattle Heart Failure Model: incorporates the use of medications and devices and predicts the associated change in survival.

Insufficient indications:

Low left ventricular ejection fraction (<20%)

History of functional class II or IV symptoms of HF

Peak Vo2 greater than 15 mL/kg per minute (or greater than 55 percent predicted) without other indications.

Contraindications:

  • non-reversible pulmonary vascular resistance greater than 4- 6 Wood units (normal < 1.5). Increased risk of right ventricular failure in immediate postoperative period. Donor right ventricle is subjected to marked increase in workload.
  • Active malignancy. Patient with h/o cured malignancy and those who develop cardiomyopathy due to chemo are considered reasonable candidates for transplantation.
  • Active infection.
  • Physiologic age (usually exclude patients over 60-65). Up to 72 yo if less than 2 prior open heart surgeries, preserved renal function, no prior CVA, preserved hepatic function.
  • Active drug or alcohol abuse
  • DM with end organ failure.

The donor must be a similar weight and height as you/ body size. The ethnic background and sex of the donor do not matter. Donor organs are given according to the severity of illness or status level of the patient, size and blood group compatibility, HLA matching, past medical history of donor and recipient and the length of time spent on the waiting list.

 

Dr. Ben-Zur a cardiologist performs cardiac ablations in Tarzana. He serves the sherman oaks area.

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