[Heart transplantation]

Heart transplantation is presently the only treatment capable of substantially changing the natural history of endstage heart failure, achieving a 5-year survival rate of 60%. The relative scarcity of available donors is the main limitation to this procedure. The standard surgical technique is that referred to as "orthotopic", described by Shumway and Lower. Research efforts now focus on the design of more efficient methods of preservation that will permit longer storage periods once the grafts have been harvested. Rejection and infection are the most common causes of post-transplantation mortality. The "attenuation" of the immune response to prevent graft loss is achieved by administration of drugs such as cyclosporine A, azathioprine, steroids and antilymphocytic globulins, which constitute the basis for most immunosuppression protocols. Despite numerous proposals of methods for detecting rejection, endomyocardial biopsy continues to be the fastest and most efficient procedure and constitutes a standard tool for monitoring rejection. Graft vascular pathology or chronic rejection is the greatest threat to long-term survival of transplant recipients, 30% of whom are affected by this process after 5 years. Prospects for the future point in three different directions: research to design more powerful and selective immunosuppressive drugs, the development of totally implantable and autonomous artificial ventricular assist systems and the use of xenografts that have undergone genetic manipulations that eliminate interspecies immunological barriers.