Conventional criteria for HTx and clinical indicators that should prompt consideration for referral to a transplant centre. Adapted with permission.42
| Conventional criteria for HTx: |
|---|
| > impaired left ventricle systolic dysfunction |
| > NYHA III or IV symptoms |
| > receiving optimal medical treatment (target or maximum tolerated doses of beta-blockers, ACEi, MRA) |
| > CRT, ICD or CRTD (if indicated) |
| > evidence of poor prognosis: |
| – cardiorespiratory exercise testing (VO 2 max <12 mL/kg/min if on beta-blockade, <14 mL/kg/min if not on beta-blockade, ensuring respiratory quotient ≥1.05) |
| – markedly elevated BNP (or NT-proBNP) serum levels despite full medical treatment |
| – using established composite prognostic scoring system (eg HFSS or SHFM). |
| Clinical indicators that should prompt consideration for referral: |
| > two or more admissions for treatment of decompensated HF within the last 12 months |
| > persistent overt HF despite optimal medical treatment |
| > SHFM score indicating ≥20% 1-year mortality |
| > echocardiographic evidence of right ventricular dysfunction or increasing PA pressure on optimal medical therapy |
| > anaemia, involuntary weight loss, liver dysfunction or hyponatraemia attributable to HF |
| > deteriorating renal function attributable to HF or inability to tolerate diuretic dosages sufficient to clear congestion without change in renal function (refer before creatinine clearance falls below 50 mL/min or the eGFR drops below 40 mL/min/1.73 m 2) |
| > significant episodes of ventricular arrhythmia despite full pharmacological and device treatment |
| > increasing plasma BNP or NT-proBNP levels despite adequate HF treatment |
| > refractory angina where debilitating, significant and recurrent myocardial ischaemia is evident and is not amenable to revascularisation or full anti-anginal treatment |
| > restrictive or hypertrophic cardiomyopathy with persisting NYHA III/IV symptoms refractory to conventional treatment ± recurrent admissions with decompensated HF. |
| Clinical indicators that should prompt urgent inpatient referral for HTx: |
| > the need for continuous inotrope infusion (± IABP to prevent multiorgan failure |
| > persistent circulatory shock due to a primary cardiac disorder |
| > no scope for revascularisation in the setting of persistent coronary ischaemia. |
| Relative (R) and absolute (A) contraindications for transplantation: |
| > microvascular complications of diabetes (excluding non-proliferative retinopathy) (A) |
| > active malignancy other than localised non-melanoma skin cancer (A) |
| > extracardiac vascular disease (peripheral or cerebrovascular) (R) |
| > sepsis and active infection (A); chronic viral infections (R) |
| > recent pulmonary embolism (A) due to the risks of RV failure post-operatively |
| > autoimmune disorders (R) |
| > aggressive skeletal myopathies (A) |
| > substance misuse (tobacco or excessive alcohol consumption) (R) |
| > a history of non-adherence to treatment or follow-up (R) |
| > those with a BMI >32 kg/m 2 are advised to loose weight (R) |
| > age is not a contraindication, but age <75 years is associated with lower risk |
| > multiple prior sternotomies increases the risk, but is not a contraindication. |
ACEi = angiotensin-converting enzyme inhibitor; BNP = B-type natriuretic peptide; CRT = cardiac resynchronisation treatment; CRTD = cardiac resynchronization therapy defibrillator; eGFR = estimated glomerular filtration rate; HF = heart failure; HFSS = heart failure survival score; HTx = heart transplantation; IABP = intra-aortic balloon pump; ICD = implantable cardioverter defibrillator; MRA = mineralocorticoid receptor antagonist; NT-proBNP = N-terminal pro-B-type natriuretic peptide; NYHA = New York Heart Association; PA = pulmonary artery; SHFM = Seattle heart failure model.