Cardiac transplantation

Cardiac transplantation is now an accepted therapeutic option for patients with end-stage myocardial failure. Provided donor and recipient are appropriately selected and adequately matched, expected survival rates at one and five years are 85% and 65%, respectively. Two major challenges are encountered in clinical heart transplantation. The first is monitoring immunosuppression for adequate prevention of acute rejection and surveillance for side effects. The endomyocardial biopsy remains the gold standard for rejection surveillance, but since it is an invasive procedure which can only be performed at arbitrary time intervals, the search for non-invasive methods continues. The approach to immunosuppression currently practised by most centers is that of combination drug therapy, which allows low doses with decreased potential for side effects. At Stanford, immunosuppression is usually initiated with OKT3, corticosteroids, and cyclosporine, and maintained with a combination of steroids, cyclosporine, and azathioprine. The most frequently encountered complications include bacterial and opportunistic infections, cyclosporine nephrotoxicity, and malignancy. The second challenge is accelerated coronary disease, which has emerged as the major factor limiting long-term survival. It is usually clinically silent and often presents with sudden death, acute myocardial infarction, or progressive unexplained graft failure. Coronary arteriography is currently the only method for premorbid diagnosis, and retransplantation the only effective therapy.