Prophylactic aortic arch debranching during type A aortic dissection repair

Abstract

They refer to data of the International Society for Heart and Lung Transplantation (ISHLT), which reported a significantly improved survival after cardiac retransplantation [3]. Regarding those patients who were more than 12 months from the initial transplant procedure and underwent redo HTX between 2002 and 2005, these patients experienced a 1year survival rate of approximately 85%, the same as primary transplants performed during the same time period. However, these survival data refer to recently performed transplantations in a selected patient population. Looking at the overall results of the ISHLT database, repeat transplantation has been identified as a significant risk factor for long-term mortality after HTX. These results have also been confirmed by other authors [4]. One important step towards a reasonable allocation of donor hearts was the decision against redo transplantation in acute organ failure. For the establishment of evidence based criteria for redo HTX a working group has analysed the results of the ISHLT database. Based on these results they have elaboratedandpublishedindicationsandcontraindicationsfor repeat HTX. Exclusion criteria were any kind of malignancy, severe pulmonary hypertension, concomitant end-organ failure (renal, hepatic, pulmonary), and evidence of patient non-compliance. Relative contraindications were severe peripheral vascular disease, severe osteoporosis as well as the patients’ general physical status [5]. These evidence based criteria are helpful. However, they cannot replace the individual decision in every potential candidate for repeat heart transplantation. As Leach and Evanspoint out,retransplantation remainstheonlydefinitive treatment option for coronary artery vasculopathy. Therefore, a decision against repeat HTX might result in the death of the patient. Repeat transplantation belongs to those indications for HTX that are associated with an increased risk of mortality, comparable to patients with temporary circulatory support, ventricular assist device support or ventilatory support [3]. Although, in all these patients the risk of mortality after HTX is significantly elevated, they are not generally excluded from this therapeutic option. According to our opinion, the final decision and responsibility as to whether or not a patient is a suitable candidate for HTX has to remain in the hands of the transplant surgeon. The decision should be based on evidence based criteria as well as on patient related individual risk factors.