Update on heart transplantation: a consensus document

Heart transplantation (HT) remains the reference therapy for selected eligible patients with advanced heart failure (HF), recent developments in drug and device therapies notwithstanding. The majority of heart transplants are performed in Europe and the USA. However, the rate of heart transplants varies greatly among European countries, ranging from <1 to >10 per million population per annum. Due to donor organ shortage, durable mechanical circulatory support (MCS) became a practical solution for many advanced HF patients, either as a bridge to transplant or as destination therapy. The aim of the present consensus document is to provide a perspective on important issues regarding HT, in particular patient selection, pre-transplant work-up, matching of donor heart and recipient, strategies of bridging patients to transplant with temporary or durable MCS, as well as how to increase the donor organ pool. Furthermore, surgical techniques and complications are discussed, as well as immediate post-transplant, and long-term management including the main aspects of long-term follow up such as rejection surveillance, personalized immunosuppression and managing comorbidities. Cellular and antibody mediated rejection, early cardiac allograft failure, and indications for retransplantation are described. An emphasis is given on the most important post-HT complications, such as cardiac allograft vasculopathy, infections and malignancies. Finally, the need for tailored physical rehabilitation and psychosocial support, and impact of post-transplant status on reproductive health are discussed.