Heart Transplantation

1

What is the gold standard therapy for end-stage heart disease?

Heart transplantation remains the gold standard therapy for end-stage heart failure. The most common technique is to place the heart in its anatomical or orthotopic position. Ventricular assist devices (VADs) have become more popular either as a bridge-to-transplant or as a destination-therapy for those who are not transplant candidates, with promising results.

2

Who were the pioneers in developing heart transplantation?

In 1905, Alexis Carrel and Charles Guthrie performed a heart transplant heterotopically. Vladmir Demikhov was successful in transplanting hearts both heterotopically and orthotopically.

In the 1960s, Norman Shumway and Richard Lower refined the techniques of orthotopic heart transplantation, which have served as the basis for modern clinical operative techniques.

3

Who performed the first human-to-human heart transplant? When?

Christian Barnard performed the first human-to-human heart transplantation in December 1967 (in Cape Town, South Africa). In 1968, Norman Shumway performed the first successful human-to-human heart transplantation in the United States.

4

Who performed the first successful heart-lung transplant? When?

In 1981, Bruce Reitz at Stanford performed the first successful heart-lung transplantation in a human. The patient was a 21-year-old woman with pulmonary hypertension secondary to an atrial septal defect.

5

How many heart transplants are performed annually? Is the number increasing or decreasing?

According to the most recent International Society for Heart and Lung Transplantation Registry in 2015, a total of 4477 heart transplants (3817 adult) were performed at 252 centers worldwide. The number has remained relatively stable for several years, with subtle fluctuations, despite the increase in the number of patients on the waitlist. The limiting factor is the number of donors.

6

What are the anastomoses required to perform a heart transplant?

Aorta, pulmonary artery, left atrium, and either right atrium or vena cavae (superior vena cava [SVC] and inferior vena cava [IVC]). The preferred method at most centers is the bicaval technique, in which SVC and IVC are anastomosed separately, rather than anastomosing the right atrium to right atrium (biatrial technique). It is thought that the incidence of postoperatively tricuspid regurgitation and atrial arrhythmias are less with the bicaval technique.

7

What are the indications and contraindications for heart transplant?

Indications:

• New York Heart Association class III or IV heart failure refractory to medical therapy with expected 2-year survival <60%

• Debilitating angina with no interventional or surgical options

• Ventricular arrhythmias refractory to medical treatment, implantable cardioverter-defibrillator, or surgical therapy

• VO ₂ max up to 14 mL/kg/min

Contraindications:

• Irreversible pulmonary hypertension (PVR <6 Wood units)

• Severe obstructive or restrictive lung disease

• Advanced age (generally older than 70 years)

• Obesity

• Unresolved recent malignancy

• Active infection

• Significant systemic disease or end-organ dysfunction (e.g., end-stage liver failure, end-stage renal failure, severe peripheral vascular disease)

• Lack of psychosocial well-being or support, including active substance abuse

• Medical noncompliance

8

What are acceptable donor selection criteria?

• Age <55 years

• No history of chest trauma or cardiac disease

• No prolonged hypotension or hypoxemia

• Normal electrocardiogram, echo, and/or coronary angiogram

• Negative hepatitis B and C serology

• Negative HIV serology