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Selecting patients for heart transplantation: which patients are too well for transplant?
M C Deng1, J M A Smits, M Packer
1Heart Failure Center, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, Milstein Hospital Building Room 5-407, 177 Fort Washington Avenue, New York, NY 10032, USA. md785@columbia.edu
Insights
Cardiac transplantation criteria need reevaluation. Patients with advanced heart failure may be too well for transplant if they have low risk scores, high oxygen consumption, or specific clinical indicators, guiding better treatment selection.
Area of Science:
- Cardiology
- Transplantation Medicine
- Heart Failure Management
Background:
- Cardiac transplantation is a critical therapy for end-stage heart failure.
- Its role requires redefinition in contemporary medical and surgical contexts.
- Lack of randomized trials necessitates analysis of existing data to refine patient selection.
Purpose of the Study:
- To redefine the role of cardiac transplantation.
- To identify clinical profiles of patients potentially too well for transplant.
- To inform optimal treatment strategies for advanced heart failure.
Main Methods:
- Analysis of early breakthrough studies and recent observational cohort studies.
- Review of studies on alternative therapies for advanced heart failure.
- Characterization of patient profiles based on specific clinical parameters.
Main Results:
- Identified profiles of patients who may be considered too well for cardiac transplantation.
- Key indicators include low Heart Failure Survival Score, high peak oxygen consumption (>14-18 mL/kg/min), LVEF <20% alone, NYHA class III-IV symptoms alone, ventricular arrhythmias alone, no prior neurohormonal blockade, and no prior transplant evaluation.
- These findings aid in distinguishing transplant candidates from those better suited for other advanced therapies.
Conclusions:
- Cardiac transplantation criteria require refinement based on current evidence.
- Identifying patients who are 'too well' for transplant ensures appropriate allocation of resources and timely access to alternative treatments.
- A structured evaluation process can optimize patient management and psychological well-being.
Abstract:
In the context of contemporary medical and surgical therapy, the revolutionary procedure of cardiac transplantation should be redefined in its relative role. Based on the assumption that its goal is to prolong life while improving its quality, and in the absence of randomized clinical trial data testing its benefit, data from early breakthrough studies, more recent observational cohort studies, and studies testing other therapies in advanced heart failure must be analyzed to characterize clinical profiles of patients who should be considered too well for cardiac transplantation at specific stages of their disease processes. These profiles likely include advanced heart failure with (1) low risk according to the Heart Failure Survival Score, (2) peak oxygen consumption greater than 14 to 18 mL/kg/min without other indications, (3) left ventricular ejection fraction less than 20% alone, (4) history of New York Heart Association class III to IV symptoms alone, (5) history of ventricular arrhythmias alone, (6) no previous attempt at comprehensive neurohormonal blockade, and (7) no structured cardiac transplantation evaluation in a designated cardiac transplantation center. The evaluation may identify the potential transplant candidate, who could be placed on a national potential transplant candidate list, combining the psychologic benefit of acceptance by the program with an ongoing openness to the diversity of advanced heart failure treatment modalities.