Selection and management of patients for cardiac transplantation

The limited availability of donor hearts for cardiac transplantation has focused interest on the provision of alternative therapies and on the establishment of more objective criteria for determining which candidates will benefit. Indications now emphasize exercise capacity and reevaluation on optimal medical therapy rather than ejection fraction or previous history. Pharmacologic and mechanical bridges to transplantation are increasingly used for the growing population of hospitalized candidates. Preserving the option of outpatient transplantation prior to deterioration will require better assessment of sudden death risk and hemodynamic risk. Patients with advanced heart failure form a unique population, rarely represented in large trials, for whom prognosis and therapy continue to improve.