Cardiac Transplant

Indications (Circulation, 2010) [MEDLINE]


  • Cardiogenic Shock Requiring Intravenous Support or Circulatory Support (Inatraortic Balloon Pump, Left Ventricular Assist Device) to Maintain Adequate Organ Perfusion
  • Persistent NYHA Class IV Heart Failure Symptoms Refractory to Medical/Surgical Therapy (Including Use of Support Devices)
    • Cardiopulmonary Exercise Testing and Heart Failure Prognosis Scoring are Recommended
      • Peak Oxygen Consumption (VO2) Thresholds Suggesting Listing for Cardiac Transplant (These Apply Regardless of the Use of Cardiac Resynchronization Therapy)
        • Patient on β-Blocker: peak VO2 ≤12 mL/kg/min
        • Patients Intolerant of β-Blockers: peak VO2 ≤14 mL/kg/min
        • Young Patient (<50 y/o) or Female: peak VO2 <50% predicted
      • Sub-Maximal Cardiopulmonary Exercise Testing (Respiratory Exchange Ratio <1.05)
        • Ventilation Equivalent of Carbon Dioxide (VE/VCO2) Slope >35
      • Prognosis Scoring
        • Seattle Heart Failure Model (SHFM) Estimated 1-Year Survival of <80%
        • Heart Failure Survival Score (HFSS) in the Medium/High Risk Range
  • Intractable/Severe Anginal Symptoms in Patients with Coronary Artery Disease Not Amenable to Percutaneous/Surgical Reascularization, Including Severe Transplant Coronary Artery Disease (Cardiac Allograft Vasculopathy)
  • Intractable Life-Threatening Arrhythmias Unresponsive to Medical Therapy/Catheter Ablation/Surgery/Automatic Implantable Cardioverter-Defibrillator
  • Selected Patients with Restrictive/Hypertrophic Cardiomyopathy and NYHA Class III-IV Heart Failure
    • Work-Up Should Identify Etiology and Exclude Constrictive Pericarditis
    • Consideration Should Include Presence of Prognostic Factors, Such as Atrial Enlargement, Left Ventricular Systolic Dysfunction, Low Cardiac Output, and Pulmonary Hypertension
    • In Patients with Hepatic Dysfunction, Liver Biopsy May Be Required to Exclude Hepatic Fibrosis/Cirrhosis
    • Bridging with Left Ventricular Assist Device (or Total Artificial Heart) May Be Utilized
    • Selected Patients with Cardiac Amyloidosis (Those without Extracardiac Amyloid with Organ Dysfunction) May Be Candidates for Cardiac Transplantation
    • Patients with Refractory Severe Heart Failure from Non-Obstructive Cardiomyopathy (Especially Those with Left Ventricular Dilation and Systolic Dysfunction) May Be Considered for Cardiac Transplant
  • Other Non-Dilated Cardiomyopathy
    • Arrhythmogenic right ventricular cardiomyopathy
    • Left ventricular noncompaction
  • Congenital Heart Disease
    • Groups Who May Be Considered
      • NYHA Class IV Heart Failure Not amenable to Palliative or Corrective Surgery
      • Severe Symptomatic Cyanotic Heart Disease Not Amenable to Palliation
      • Post-Fontan Procedure with Refractory Heart Failure, Persistent Protein-Losing Enteropathy, and/or Plastic Bronchitis Despite Optimal Therapy
      • Pulmonary Hypertension with Potential Risk of Developing Fixed, Irreversible PVR Elevation Which Would Preclude Cardiac Transplant in the Future
    • Patients with Significant Irreversible Pulmonary Vascular Obstructive Disease (Eisenmenger Syndrome with Severe Symptoms Despite Therapy) May Be Considered for Combined Heart-Lung Transplant
    • Cardiac Transplant Alone Should Not Be Performed in the Presence of Severe Hypoplasia of the Central/Branch Pulmonary Arteries or Veins


  • Patients with Heart Failure Causing Major Limitation of Daily Activities Despite Optimal Therapy (Including a β-Blocker) with Peak VO2 of 13-14 mL/kg/min (or <55% predicted)
  • Recurrent Unstable Ischemia Not Amenable to Other Interventions
  • Recurrent Instability of Fluid Balance/Renal Function Not Due to Patient Noncompliance

Insufficient Indications

  • Low Left Ventricular Ejection Fraction
  • History of NYHA Class III-IV Symptoms of Heart Failure
  • Peak VO2 >15 mL/kg/min (or >55% predicted) Without Other Clinical Indications for Cardiac Transplant

Contraindications (International Society for Heart Lung Transplantation, ISHLT, Criteria) (J Heart Lung Transplant, 2016) [MEDLINE]


  • Active Substance Abuse
    • Alcohol Abuse (see Ethanol, [[Ethanol]])
    • Drug Abuse
    • Tobacco Abuse (see Tobacco, [[Tobacco]])
  • Inability to Comply with Drug Therapy
  • Irreversible Pulmonary Hypertension (PVR >3 WU)
    • However, there is Variation Among Centers as to the the Exact PVR Threshold is Acceptable
    • In Addition, Heart-Lung Transplantation May Be Considered in Cases with Pulmonary Hypertension with PVR >3 WU
    • After LVAD, Hemodynamics Should Be Evaluated After 3-6 mo to Ascertain Reversibility of the Pulmonary Hypertension (Class IIa Recommendation, Level of Evidence C)
  • Multisystem Disease with Severe Extracardiac Organ Dysfunction
    • Amyloidosis (see Amyloidosis, [[Amyloidosis]]): in some cases
  • Severe Symptomatic Cerebrovascular Disease (Class IIb Recommendation, Level of Evidence C)
  • Systemic Illness with Life Expectancy <2 yrs Despite Cardiac Transplant


  • Acute Pulmonary Embolism (within 6-8 wks) (see Acute Pulmonary Embolism, [[Acute Pulmonary Embolism]])
  • Age >70 y/o
    • However, Selected Patients >70 y/o May Be Considered (Class IIb Recommendation, Level of Evidence C)
  • Chronic Kidney Disease (with GFR <30 mL/min) (Class IIa Recommendation, Level of Evidence C) (see Chronic Kidney Disease, [[Chronic Kidney Disease]])
  • Diabetes Mellitus with End-Organ Damage Other than Non-Proliferative Retinopathy or Poor Control (HbA1c >7.5%) Despite Optimal Therapy (Class IIa Recommendation, Level of Evidence C) (see Diabetes Mellitus, [[Diabetes Mellitus]])
  • Drug/Alcohol Abuse (within 6 mo)
  • Frailty (Class IIb Recommendation, Level of Evidence C): unclear role in assessing transplant candidacy
    • 3 of 5 Symptoms
      • Fatigue
      • Low Level of Physical Activity
      • Muscle Loss
      • Slow Walking Speed
      • Unintentional Weight loss of ≥10 lbs within the Past Year
  • Inadequate Social Support or Cognitive-Behavioral Disability/Dementia Which Might Prevent Medical Compliance (Class IIa Recommendation, Level of Evidence C)
  • Infection
    • However, Selected Patients with Infection May Be Considered
  • Neoplasm
    • However, Selected Patients with Neoplasms May Be Considered
  • Obesity (BMI >35 kg/m2) (Class IIa Recommendation, Level of Evidence C) (see Obesity, [[Obesity]])
  • Other Conditions Which Would Limit Rehabilitation Potential
    • Peripheral Arterial Disease (PAD) Not Amenable to Revascularization (Class IIb Recommendation, Level of Evidence C) (see Peripheral Arterial Disease, [[Peripheral Arterial Disease]])
  • Tobacco Abuse (within 6 mo)


Cardiovascular Complications

  • xxxx

Other Complications

  • xxxx


  • Selection of cardiac transplantation candidates in 2010. Circulation. 2010 Jul;122(2):173-83 [MEDLINE]
  • The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update. J Heart Lung Transplant. 2016;35(1):1 [MEDLINE]