Heart transplantation criteria
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Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D.; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [1]Ifrah Fatima, M.B.B.S[2]
Overview
Criteria that should be met by the recipient to make cardiac transplantation suitable include evaluation with cardiopulmonary stress testing (peak oxygen consumption), heart failure prognosis scores- Seattle Heart Failure Model (SHFM), Heart Failure Survival Score (HFSS) and Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score and diagnostic right heart catheterization.
Criteria for Cardiac Transplantation
While assessment of the indications and contraindications are important first steps in evaluating the appropriateness for cardiac transplantation, the prognosis of a patient with and without transplantation is critical in making the final determination as to whether a patient is suitable for cardiac transplantation. Discussed below are criteria that are used based upon the estimation of the patient's prognosis. The pre-transplantation evaluation includes-
Cardiopulmonary stress testing to guide transplant listing
Exercise capacity is assessed by VO2 max which represents the cardiac reserve and the peripheral manifestations in response to a reduced cardiac output. [1]
A maximal cardiopulmonary exercise test is
- Respiratory exchange ratio (RER) > 1.05
- Achievement of an anaerobic threshold on optimal medical treatment
The following cutoff values of peak oxygen consumption (VO2) are used to guide listing in various cases- [2]
- Patients intolerant of a β-blocker- Peak Vo 2 of ≤ 14 ml/kg/min
- In the presence of a β-blocker- peak Vo 2 of ≤ 12 ml/kg/min
- Young patients (< 50 years) and women- percent of predicted (≤ 50%) peak Vo 2 and using alternate standards in conjunction with it
- Sub-maximal cardiopulmonary exercise test (RER < 1.05)- use of ventilation equivalent of carbon dioxide (Ve/Vco 2) slope of > 35
- Obese (body mass index [BMI] > 30 kg/m 2) patients- adjusting peak Vo 2 to lean body mass may be considered. A lean body mass–adjusted peak Vo 2 of < 19 ml/kg/min is used for listing.
Use of Heart Failure prognosis scores
1. Seattle Heart Failure Model (SHFM) - An estimated 1-year survival as calculated by the Seattle Heart Failure Model (SHFM) of < 80%
The factors considered in this model are-
- age
- sex
- NYHA class
- weight
- ejection fraction
- blood pressure
- medications
SHFM model has also incorporated the impact of newer HF therapies on survival, including ICDs and CRT.
2. Heart Failure Survival Score (HFSS) in the high/medium risk range
The predictors of survival in the HFSS include: [1]
- Presence or absence of coronary artery disease
- Resting heart rate
- Left ventricular ejection fraction
- Mean arterial blood pressure
- Presence or absence of an intraventricular conduction delay on ECG
- Serum sodium
- VO2max.
3. Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score
Listing patients solely on the criteria of heart failure survival prognostic scores should not be performed. [2]
Role of Diagnostic Right Heart Catheterization
- Right heart catheterization (RHC) should be performed on all adult candidates in preparation for listing for cardiac transplantation and periodically (every 3-6 months, especially in the presence of reversible pulmonary hypertension or worsening symptoms of heart failure) until transplantation.
- A vasodilator challenge should be administered if-
- the pulmonary artery systolic pressure is ≥ 50 mm Hg and
- Either the transpulmonary gradient is ≥ 15 or the pulmonary vascular resistance (PVR) is > 3Wood units while maintaining a systolic arterial blood pressure > 85 mm Hg
- When an acute vasodilator challenge is unsuccessful, the patient should be hospitalized with continuous hemodynamic monitoring and treated pharmacologically till the PVR declines.
- Pulmonary Hypertension is considered irreversible if-
- Medical therapy fails to optimize the hemodynamics
- If the left ventricle cannot be effectively unloaded with mechanical adjuncts, like an intra-aortic balloon pump (IABP) and/or left ventricular assist device (LVAD)
Donor Criteria
- Brain death declared
- Age <45 (special exceptions)
- No pre-existent heart disease
- Few coronary artery disease risk factors
- No untreated acute infections
- No systemic malignancy
- No cardiac trauma
- Normal ECG
- Normal echocardiogram
- Negative HIV and Hepatitis screen
References
- ↑ 1.0 1.1 Alraies MC, Eckman P (2014). "Adult heart transplant: indications and outcomes". J Thorac Dis. 6 (8): 1120–8. doi:10.3978/j.issn.2072-1439.2014.06.44. PMC 4133547. PMID 25132979.
- ↑ 2.0 2.1 2.2 Mehra, Mandeep R.; Canter, Charles E.; Hannan, Margaret M.; Semigran, Marc J.; Uber, Patricia A.; Baran, David A.; Danziger-Isakov, Lara; Kirklin, James K.; Kirk, Richard; Kushwaha, Sudhir S.; Lund, Lars H.; Potena, Luciano; Ross, Heather J.; Taylor, David O.; Verschuuren, Erik A.M.; Zuckermann, Andreas (2016). "The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update". The Journal of Heart and Lung Transplantation. 35 (1): 1–23. doi:10.1016/j.healun.2015.10.023. ISSN 1053-2498.