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First performed in humans in 1966 by Barnard, but initial results poor because of rejection. Explosive growth in numbers in the mid to late 1980s with the introduction of better immunosuppression. Approx. 3500 worldwide per year. 1 year survival is now approx. 80%, with ongoing 4% / year. Repeat heart transplants do worse.
- Usually NYHA class IV (or III) symptoms associated with LVEF < 20%. Although there is persistent evidence that heart transplantation prolongs life and improves its quality in critically ill patients, this effect is less clear in ambulatory New York Heart Association class III patients. For some authors, the time has come for a clinical trial comparing the results of transplantation as opposed to medical treatment in the low- or mid-risk population of patients with heart failure.
- Usually free of other organ dysfunction.
- Not morbidly obese.
- Preoperative pulmonary vascular resistance (PVR) is an independent risk factor for early death after heart transplantation. Risk of early death may be increased three fold. Right ventricular dysfunction accounts for approximately 50% of cardiac complications and 20% of early deaths post transplant. PVR > 5 W.U. is local cut off. Other centres 6 W.U. falling to 3 W.U. with maximal pulmonary vasodilation. Transpulmonary pressure gradient of > 15 mmHg, or PAP < 50 / 25. This is not an absolute contraindication; a bigger heart may be used to offset the PAHT. Some authors suggest that if the PAP is elevated, then it should be reassessed every 3-6 months while the patient is on the waiting list.
Post operative complications
- Cardiac failure due to prolonged X clamp time and protection issues. This may affect the right ventricle more than the left. Right ventricular failure may necessitate measures to reduce the afterload on this ventricle. This may include hyperventilation, avoidance of high levels of PEEP, use of milrinone, NO and prostaglandin E1. In addition an intra aortic balloon pump may be used.
- Bleeding from prolonged cardiopulmonary bypass depleting the coagulation factors and the multiple suture lines.
- Renal dysfunction / failure may occur for a variety of reasons, including prolonged cardiopulmonary bypass and use of cyclosporin.
- Cardiac tamponade.
- Multi-organ failure due to sustained low cardiac output and/or non-pulsatile flow on cardiopulmonary bypass.
- Arrhythmias, both atrial and ventricular, are common post transplantation. 10 - 25 % will require permanent pacemaker implantation.
- For a variety of reasons, tricuspid insufficiency is the most common valvular problem in heart transplant recipients. Size mismatch and the biatrial cuff, together with repeated endomyocardial biopsy (from a week post transplantation) possibly contributing.
- Acute and hyperacute rejection. In most heart transplantation programs, the percentage of deaths attributed to acute rejection ranges from 11 to 14% with a mean incidence of "treatable" rejection episodes of 0.6 to 1.2.
- Infection, some of which is opportunistic, related to the immunosuppression regimen.
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- Date last published: 29 January 2008
- Document type: Clinical Guideline
- Services responsible: Paediatric Intensive Care Unit
- Editor: John Beca
- Review frequency: 2 years
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