Indications and selection criteria for cardiac transplantation

Assessment of indications for cardiac transplantation is a complex process including first a comparison of expected survival of a patient with end-stage heart disease, mostly ischemic or dilative cardiomyopathy, allocated either to conventional medical or surgical therapy or to cardiac transplantation, second the expected increase in exercise tolerance and quality of life after transplantation. Furthermore the exclusion of contraindications is required: severe irreversible secondary organ damage (especially of kidneys and liver), malignant tumors and systemic malignancies, severe pulmonary hypertension, florid infections, unstable psychosocial conditions of the patient and his surrounding. Although a considerable number of clinical, electrocardiographic, echocardiographic and hemodynamic factors have been defined as indicating very poor prognosis, there exists no prognostic index combining all these factors into a precise prediction of survival of an individual patient with end-stage cardiac failure. Whereas high survival rates have been concordantly documented for the first years after transplantation, the long-term prognosis cannot be estimated as yet with equally sufficient certainty, due to increasing observation of vasculopathies and of progressive myocardial (mostly diastolic) dysfunction of transplanted hearts. These problems suggest to continue with very careful selection of candidates for transplantation. Even in the case of cardiac decompensation and poor prognostic factors, usually a single examination of the patient is not sufficient, but rather a thorough observation of the patient over a period of time including an evaluation of the rate of clinical and hemodynamic decline and of the response to medical therapy.