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
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
Relative
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]
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
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)
Complications
Cardiovascular Complications
xxxx
Other Complications
xxxx
References
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]
