Heart Transplantation

Heart failure is a major public health problem with significant associated morbidity and mortality. Heart transplantation remains the standard of care for highly selected patients with end-stage heart failure and absence of contraindications to transplantation. This chapter discusses indications and contraindications for transplantation; recipient evaluation, selection, and management; donor selection; timing of the procedure and surgical technique; medical management, including immunosuppression, prevention and treatment of infections, and other standard or preventive therapy; late complications; and functional status and long-term survival. Tables describe patient referral to a specialized center for heart transplantations; guidelines of indications for cardiac transplantation; organ dysfunction; pretransplantation evaluation; waiting lists; therapeutic options for patients with advanced or refractory heart failure; treating highly sensitized patients; suggested vaccinations; guidelines for donor hearts with severe infection; high-risk donor behavior; hemodynamic effect of commonly used parenteral agents; frequency of follow-up evaluations; revised International Society for Heart and Lung Transplantation (ISHLT) formulation for diagnosis of cardiac allograft rejection and suggested treatment; function of immunosuppressive agents; administration, dosing, monitoring, and adverse effects of commonly used immunosuppressants; common agents that interfere with tacrolimus and cyclosporine; cytomegalovirus prophylaxis and valganciclovir based on estimated renal function; cumulative morbidity rates in adult heart transplant survivors; and therapies to prevent and treat osteoporosis posttransplantation. Figures depict the progression of heart failure; change in functional status over time in patients with chronic heart failure; US heart transplantations in 2012; percentage of US adult wait-listed patients who received a donor heart transplant within a year and donation rates by state; bicaval surgical technique; endomyocardial biopsies; timeline of infection following solid-organ transplantation; cardiac allograft vasculopathy; and squamous cell carcinomas in a heart transplant patient. Graphs show adult worldwide heart transplantation volume from 1982 to 2010; changing characteristics of US adult heart transplant recipients; relative risk of death and development of cardiac allograft vasculopathy; posttransplantation immunosuppression at 1 and 5 years in the ISHLT Registry; older donor age and risk of developing cardiac allograft vasculopathy; freedom from malignancy in the ISHLT Registry; employment status of adult heart transplant recipients; adult heart transplant survival; and patient survival among US heart transplant recipients by gender and race. This review contains 18 highly rendered figures, 20 tables, and 109 references.