Cardiac transplantation: indications, eligibility and current outcomes

### Learning objectives Despite advances in medical and device therapy, the prognosis and quality of life of patients with advanced heart failure (HF) remains poor. For a carefully selected group of these patients, cardiac transplantation is the treatment of choice. The first human-to-human heart transplant was performed in Cape Town on 3 December 1967 by Christiaan Barnard; the patient died 18 days later of infective complications. Outcomes were poor in the early years, but with the discovery of ciclosporin in the 1980s there was an improvement in survival which led to a peak in cardiac transplant activity in the early 1990s.1 Between 1993 and 2004, there was a reduction in the number of cardiac transplants reported to the registry of the International Society for Heart and Lung Transplantation (ISHLT); however in recent years, the numbers reported have grown to >5000 annually worldwide.1 With increasing numbers of patients now referred for consideration of transplantation, a significant imbalance between supply and demand exists.2 3 There are more candidates, and patients are increasingly complex, older,3 on mechanical circulatory support pretransplant and increasingly sensitised.1 Heart transplantation is the treatment of choice for selected patients with advanced HF who have limiting symptoms despite optimal conventional treatment and evidence of a poor prognosis. The limited number of available donor hearts restricts this treatment to a small fraction of potential recipients. Allocation of a scarce resource (the donor heart) requires two different perspectives. One is the risk and benefit for the individual patient. The second is the patient’s capacity to benefit, relative to the wider pool of potential recipients. Careful selection is crucial to ensure …