Heart transplantation

Indications

• Cardiogenic shock requiring mechanical circulatory device
• Persistent severe symptomatic heart failure refractory to medical management
• VO2 ≤12 if on beta-blockers, ≤14 if intolerant to beta-blockers
• Persistent severe angina refractory to medical and percutaneous management
• Life-threatening arrhythmias refractory to less invasivemanagement
• Certain patients with amyloidosis
• Certain patients with congenital heart disease

Contraindications

• Psychosocial concerns that may limit adherence
• Multiorgan failure
• Poor life expectancy

Rejection

• 90% is asymptomatic, so requires monthly biopsies for the first few years
• When symptomatic
  • Non-specific fatigue
  • Diarrhea
  • Abdominal pain
  • Heart failure if causing graft dysfunction
  • Low voltage ECG or arrhythmias
  • Echo with evidence of tissue edema

Prognosis

• Median survival 15 years if they survive the first year
• Malignancy
  • Usually skin cancer
• Cardiac allographic vasculopathy (CAV)
  • Immune-mediated coronary disease
  • Diffuse, not patchy, and therefore not amenable to traditional interventions
  • Prevent with pravastatin
  • Treat with sirolimus
• Hypertention
• Chronic kidney disease from tacrolimus
• Dyslipidemia
• Diabetes