[Indications for heart transplantation, preoperative assessment and treatment]

Heart transplantation [HTx] is a therapeutic option for an end-stage congestive cardiomyopathy. At the present time five and ten years' survival results after cardiac transplantation can be compared to those of coronary bypass surgery in patients with a three-vessel disease. Ten-year survival after coronary surgery in patients with a three-vessel disease and impaired left-ventricular function is 64%, without decreased left-ventricular function 72%, and after HTx between 60 and 70%. In spite of good results HTx remains a therapeutic possibility only for well-selected candidates with an expected survival of less than twelve months. Symptoms and signs for a poor prognosis are: functional NYHA-class III-IV, cardiothoracic ratio > 0.55, walking distance of less than 300 m in the 6-minute walk test, VO2 max. of < 14 ml/kg, cardiac index < 2.25 l/min/m2, pulmonary capillary wedge pressure > 16 mmHg. A syncope of any origin is, in patients with functional class III-IV, associated with a 1-year sudden-death incidence of 45%. Because of a high daily variability, ventricular ectopy alone is of limited prognostic value. Secondary pulmonary hypertension is a common finding in end-stage congestive heart failure. A mean pulmonary artery pressure above 55 mmHg and a transpulmonary gradient of > 12 mmHg are associated with a poor prognosis. If pulmonary vascular resistance exceeds 4 Wood units (320 dyn.sec.cm-5), reversibility has to be proved, using sodium nitroprussid or prostaglandine E1. An irreversible pulmonary vascular resistance above 8-Wood units (640 dyn.sec.cm-5) is an absolute contraindication for HTx; lung or heart-lung transplantation are the only