Click here to view next page of this article


Heart Transplantation

The acceptable age for transplant candidacy includes individuals from newborn age up to age 60 years routinely and age 65 years in unusual circumstances. Patients selected must experience symptoms that place them in Class IV of the New York Heart Association classification or must have angina pectoris that is severely limiting their lifestyle in a setting where revascularization is not an option. Certain individuals can be considered for transplantation before experiencing Class IV symptoms if they have life-threatening cardiac arrhythmias refractory to medical and surgical therapies. Patients undergo a careful screening process to ensure suitable extracardiac and psychosocial health status. Fixed, irreversible deficits in extracardiac organ function contraindicate transplantation, because they would not be expected to be corrected by improved cardiac function. Psychosocial screening is important to ensure a proper support structure for the patient and strict compliance with prescribed medical regimens.

Patients must have end-stage heart disease not amenable to conventional medical or surgical therapies. From a hemodynamic standpoint, the most critical predictor of operative risk at the time of transplantation is the pulmonary vascular resistance. There must be no active malignancy or infection in a potential recipient. Active peptic ulcer is a contraindication, at least in programs in which corticosteroids form a part of the immunosuppressive.

Operative Technique

Coordination of the retrieval and implantation portions of the transplant procedure is critical to minimize cardiopulmonary bypass time and graft ischemia time and to optimize function of the graft. When the surgeon has visually inspected the donor heart, preparation of the recipient may proceed. The recipient is cannulated for cardiopulmonary bypass with an aortic cannula in the usual position and right-angle.


Cyclosporine-based immunosuppression is performed using one of two protocols in most programs. Triple therapy, introduced by the author and his colleagues in 1983, consists of the combination of cyclosporine, azathioprine, and prednisone and remains the mainstay of immunosuppressive.

Allograft Rejection.

The diagnosis of cardiac rejection depends on an index of suspicion associated with new-onset cardiac arrhythmia, hypotension, or fever. Associated symptoms may include fatigue, malaise, and shortness of breath.


Several measures of prophylaxis against infection have proved highly useful in the management of these postoperative transplant recipients. All patients who are seronegative for cytomegalovirus.

Transplant Coronary Artery Disease.

A dreaded sequel of cardiac transplantation is that of transplant coronary artery disease. This entity continues to plague cardiac transplant recipients and is expected to become an increasing problem in


The 1994 report of the Registry of the International Society of Heart and Lung Transplantation documents that the explosive growth in heart transplantation that occurred in the late 1980s has