Role of cardiac transplantation in the management of congestive heart failure

T he successful treatment of end-stage congestive heart failure by transplantation has not received wide acceptance until recently. Cardiac transplantation originated with Carel and Guthrie in 1905 [1]. These innovative experimenters reported successful heterotopic procedures in dogs, resulting in the awarding of the Nobel Prize in medicine to Carel in 1912. Following this pioneering work, there were only scattered reports in the literature regarding cardiac transplantation. The modern era of heart transplantation was initiated by Shumway, professor of cardiac surgery at Stanford University Medical Center. In 1960, Shumway and Lower, chairman of cardiac surgery at the Medical College of Virginia, reported the first successful orthotopic cardiac transplantation procedure performed in the canine model [2]. The initial clinical heart transplantation procedure was performed in 1967 by Bernard in Capetown, South Africa [3]. This sparked an initial enthusiasm resulting in the performance of more than 150 transplant procedures over the next two years. However, because the one-year survival rate was less than 20 percent, enthusiasm in the medical community and among the public rapidly faded. However, Shumway believed that this operation could restore patients to a full life and be a therapeutic adjunct to the treatment of end-stage congestive heart failure. He continued his cardiac transplantation program, with a gradual increase in patient survival [4]. After the introduction of cyclosporin, a potent immunosuppressive agent, survival further increased, resulting in a revival of cardiac transplantation as a therapeutic procedure both in the United States and around the world. The current one-, two-, and three-year survival rates with cyclosporin are 80, 78, and 70 percent, respectively. Fiveyear follow-up in cyclosporin-treated patients is unavailable. This renewed interest in transplantation resulted in the proliferation of more than 30 transplant centers, which performed 270 transplantation procedures in 1984. Most patients currently referred for cardiac transplantation have terminal cardiac disease due to primary cardi0myopathy or ischemic heart disease with global left ventricular function. Recipient selection is an important aspect in any program. The upper age limit for transplant recipients has been increased due to better immunosuppression. Most institutions now accept patients for potential transplantation up to the age Of 55. All patients have class IV symptoms and have an expected survival of less than one year. These patients, however, should be otherwise healthy without irreversible end-organ disease. Patient compliance, motivation, and strong family support represent important psychosocial criteria. Contraindications to heart transplantation include systemic disease, irreversible end-organ disease, pneumonia, and recent pulmonary infarction. This latter contraindication represents a temporary one, until chest roentgenography shows resolution of the infarct area. Additional contraindications include a history of alcohol or drug abuse, mental illness, or cancer. Elevation of pulmonary vascular resistance above 8 Wood units also represents a contraindication to orthotopic cardiac transplantation, but may actually be an indication for heart-lung transplantation. Cardiac donors are limited to younger persons, usually less than 35 years of age for males and 40 years of age for females. This limitation is based upon retrospective analysis of donor age that revealed a significant correlation between the development of coronary atherosclerosis in the grafted heart and the age of the donor. In addition, the donor should have no evidence of systemic infection, chest trauma, or prolonged cardiac arrest. Potential heart donors should be hemodynamically stable without high-