[The timing of cardiac transplantation]

The considerable progress realised over the last 20 years in the domain of cardiac transplantation has had, as a corollary, an ever increasing demand and a cruel shortage of available grafts, responsible for a high mortality of some of the candidates on the waiting list. This situation justifies a review of the objective criteria of eligibility for a more pertinent attribution of donor organs. A review of the recent literature suggests a logical process in the evaluation of candidates. The first step consists of optimisation of medical therapy. This allows classification of patients with respect to the clinical condition obtained, which may be "critical", "unstable" or "stable" and thereby retain the indication for transplantation in the first two groups in the absence of a contra-indication. The timing of the transplantation is more difficult to determine for the 60% or so of patients with a low ejection fraction and who have been stabilised. The measurement of peak VO2 on exercise, which appears to be the most powerful prognostic variable in these patients, with respect to a normal subject of the same age, allows identification of urgent indications for transplantation. Moreover, a 3 monthly follow-up of peak VO2 of patients on the waiting list or deferred also enables reconsideration of their inscription or non-inscription.