Heart failure module 6: surgical management

Released1 November 2017     Expires: 01 November 2019      Programme:

Patient selection

Good cardiac transplant candidates have advanced and severely symptomatic heart failure but without end organ complications or co-morbidities that are associated with unacceptably high peri-operative risk or adversely affect long-term outcome.

The criteria for heart transplantation are:9

  • left ventricular systolic dysfunction
  • New York Heart Association (NYHA) class III or IV
  • optimal medical and device therapy (if indicated)
  • evidence of a poor prognosis
      – reduced VO2 max on cardiopulmonary exercise testing
      – significantly raised natriuretic peptides
      – based on established prognostic scoring systems such as heart failure survival score (HFSS).

The paradigm for patient selection is identifying those patients with sufficiently poor prognosis to justify the increased early mortality risk in favour of excellent long-term survival. Inpatient referral may be considered for patients admitted with acute heart failure with intractable cardiogenic shock.

Clinical features that should prompt consideration for transplant are:9

  • >2 admissions with acute heart failure in last 12 months
  • persistent signs and symptoms of heart failure despite maximal therapy
  • evidence of right ventricular dysfunction or increasing pulmonary pressures
  • end organ damage
      – weight loss
      – liver dysfunction
      – anaemia
      – hyponatraemia
      – renal dysfunction preventing increasing dose of diuretics sufficient to treat congestion.

Criteria for urgent inpatient referral are:9

  • persistent cardiogenic shock due to primary cardiovascular cause
  • continuous intravenous inotropic support
  • mechanical circulatory support
  • ongoing coronary ischaemia with no revascularisation treatment options
  • no contraindication to transplantation.

Contraindications for heart transplantation are:9

  • primary end-organ damage i.e. not secondary to advanced heart failure
      – renal dysfunction
      – liver dysfunction
  • pulmonary hypertension
      – pulmonary vascular resistance >5 wood units
      – transpulmonary gradient >15 mmHg
      – pulmonary arterial systolic pressure (PASP) >60 mmHg
  • active infection or sepsis
  • recent pulmonary embolism
  • microvascular complications of diabetes other than non-proliferative retinopathy
  • obesity*
      – body mass index >32 kg/m2
  • active malignancy other than localised non-melanoma skin cancer*
  • symptomatic peripheral or cerebrovascular disease*
  • auto-immune disease*
  • infiltrative cardiac disease*
      – sarcoidosis
      – amyloidosis
  • severe skeletal myopathy with associated cardiomyopathy*
  • smoking*
  • excessive alcohol use*
  • history of non-compliance / non-adherence to treatments*

* = relative contraindications.

Patients who undergo transplantation require life-long follow up, monitoring and treatment: a stable home life with adequate social support and psychological evaluation are also important aspects of patient selection.9

Transplant assessment is summarised in table 1.9,10

Table 1. Summary of transplant assessment
Table 1. Summary of transplant assessment

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