Abstract
Despite advances in medical and electrical therapies for heart failure, morbidity and mortality remain high and patients often progress to end-stage heart failure. Over the last five decades, heart transplantation is considered a standard therapy for select patients with end-stage heart failure. However, while heart transplantation has become a treatment of choice for end-stage heart failure, challenges still exist for improvement in the short- and long-term outcomes. While there is an increase in the number of patients with end-stage heart failure, the number of donor organs remains a major limiting factor. Heart transplantation candidates in the current era are also more complex: older, antigen-sensitized, and on mechanical circulatory support at the time of listing and transplant. Such potential heart transplant recipients have an increased chance of problems, including antibody-mediated rejection and primary graft dysfunction. Recent advances could address the current challenges and include: 1) attempts to expand the pool of donor hearts; 2) changes in heart transplantation allocation policy allowing for more equitable organ distribution; and 3) advances in the management of antibody sensitization. Developments in these areas could result in improved survival and quality of life for heart transplantation recipients.
Highlights
Despite advances in medical and electrical therapies for heart failure, morbidity and mortality remain high and patients often progress to end-stage heart failure
Increasing numbers are aged 65 years or more[3], have mechanical circulatory support[3], and have higher levels of antibodies to human leukocyte antigens (HLA), i.e. “sensitization”[4]. Due to all these issues, these heart transplantation (HTx) candidates of the modern era are at increased risk for poor outcomes, including primary graft dysfunction and antibodymediated rejection[1,2,5]
The latest developments might be able to counter existing problems: 1) attempts to expand the pool of potential organ donors; 2) changes in the heart transplant donor allocation policy to allow for more equitable organ distribution; and 3) management of sensitized HTx candidates
Summary
Despite advances in medical and electrical therapies for heart failure, morbidity and mortality remain high and patients often progress to end-stage heart failure. The HTx landscape have motivated efforts to improve the current system[14,15]: there is an imbalance between candidates awaiting transplantation and available donors, the sickest patients have unacceptably high mortality, and advances in mechanical circulatory support have decreased mortality in these transplant candidates These alterations have uncovered two significant difficulties with the present status criteria. Potential HTx recipients on ECMO support have increased mortality compared with candidates on inotropic support with continuous hemodynamic monitoring These two groups of patients should not have the same priority, though they do under the current three-tiered system.
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