Selecting patients for heart transplantation: which patients are too well for transplant?

In the context of contemporary medical and surgical therapy, the revolutionary procedure of cardiac transplantation should be redefined in its relative role. Based on the assumption that its goal is to prolong life while improving its quality, and in the absence of randomized clinical trial data testing its benefit, data from early breakthrough studies, more recent observational cohort studies, and studies testing other therapies in advanced heart failure must be analyzed to characterize clinical profiles of patients who should be considered too well for cardiac transplantation at specific stages of their disease processes. These profiles likely include advanced heart failure with (1) low risk according to the Heart Failure Survival Score, (2) peak oxygen consumption greater than 14 to 18 mL/kg/min without other indications, (3) left ventricular ejection fraction less than 20% alone, (4) history of New York Heart Association class III to IV symptoms alone, (5) history of ventricular arrhythmias alone, (6) no previous attempt at comprehensive neurohormonal blockade, and (7) no structured cardiac transplantation evaluation in a designated cardiac transplantation center. The evaluation may identify the potential transplant candidate, who could be placed on a national potential transplant candidate list, combining the psychologic benefit of acceptance by the program with an ongoing openness to the diversity of advanced heart failure treatment modalities.