Who needs a transplant and when?

PURPOSE OF REVIEW: Heart transplantation remains the treatment of choice for patients with advanced heart failure. We review the current definition of optimal therapy, prediction of prognosis and revisit contraindications for transplant. RECENT FINDINGS: Clinical trials of eplerenone and ivabradine were associated with improved prognosis, whereas others (nesiritide) were disappointing. Advances in cardiac resynchronization therapy and ventricular assist devices (VAD) have resulted in an expansion of their indications. Advances in catheter ablation for ventricular tachycardia have made this an uncommon indication for heart transplantation. Surgical ventricular reconstruction and mitral valve intervention have not resulted in survival benefit. Bypass surgery was associated with a lower mortality from cardiovascular causes. Prognostic risk scores have been developed in heart failure patients; however, ongoing refinements are needed. Selected patients with diabetes, HIV and pretransplant malignancy, now have favourable outcomes after heart transplantation. VAD as bridge to candidacy is an option in heart failure patients with 'fixed' pulmonary hypertension. Alternate listing strategies have also been studied to provide high-risk patients with an opportunity for heart transplantation. SUMMARY: Heart failure patients should be on current optimal medical and device therapy with a poor prognosis before consideration for heart transplantation. An individualized approach to heart transplantation assessment is recommended.