Selection and management of patients for cardiac transplantation

Each month in the United States, approximately 170 patients undergo cardiac transplantation and 300 new candidates are listed. Provision of alternative therapies, identification of the patients who truly have no other option, and management of those candidates until transplantation is performed has created a challenging area of investigation. The results of heart failure trials conducted in populations with milder heart failure may not always extend to advanced heart failure, to which some prognostic and therapeutic principles are unique. Many patients with low ejection fractions and a history of severe heart-failure symptoms can nonetheless enjoy quality of life and survival equivalent to those of patients who have received transplants. Improvements in our ability to design optimal medical therapy and to identify risk factors for early mortality will allow many patients with advanced heart failure to defer or avoid transplantation, and enable the majority of candidates to remain stable until transplantation can be performed.