Who is eligible for a heart or heart-lung transplant? How do I assess suitability for transplantation?

Cardiac and pulmonary transplantation are potential options for selected patients with end stage cardiac or pulmonary disease, unresponsive to conventional medical or surgical therapies. The majority of patients referred for cardiac transplantation have end stage cardiac failure as a consequence of ischaemic heart disease or cardiomyopathy, although some patients are referred whose cardiac failure follows valvular or congenital heart disease. There are four lung transplant procedures, namely, heart-lung transplantation, bilateral lung transplantation, single lung transplantation and living related lobar transplantation.

With increasing numbers of centres performing cardiac transplantation worldwide, fewer combined heart-lung transplant procedures are being performed. Therefore, the indications for this operation have been redefined and by and large, heart and lung transplantation is now reserved for patients with Eisenmenger syndrome who have a surgically incorrectable cardiac defect. Broadly speaking, patients with suppurative lung disease, e.g. cystic fibrosis and bronchiectasis, require bilateral lung transplantation. Single lung transplantation is usually inappropriate for this group because of the concern of contamination of the allograft from sputum overspill from the native remaining lung in an immunocompromised patient. Single lung transplantation has been successfully applied to patients with end stage respiratory failure due to restrictive lung conditions, e.g. pulmonary fibrosis, and to selected patients with emphysema. In living related lobar transplantation a lower lobe is taken from two living related donors, the transplant recipient undergoes bilateral pneumonectomy and subsequent re-implantation of a lower lobe into each hemithorax. Encouraging results for this procedure have been described in adolescents with cystic fibrosis.

Cardiac transplantation – indications

1. Prognosis less than 12 months
2. Inability to lead a satisfactory life because of physical limitation caused by cardiac failure
3. New York Heart Association class III or IV
4. Non-transplant cardiac surgery considered unfeasible
5. Heart failure resulting from one of the following:
   • Ischaemic heart disease
   • Cardiomyopathy
   • Valvular heart disease
   • Congenital heart disease.

Lung transplantation – indications

1. Severe respiratory failure, despite maximal medical therapy
2. Severely impaired quality of life
3. Patient positively wants a transplant.

Only patients who have deteriorating chronic respiratory failure should be accepted on to the transplant waiting list. In practice, the forced expiratory volume in one second is usually less than 30% of the predicted value.

Careful psychological assessment is necessary to exclude patients with intractable psychosocial instability that may interfere with their ability to cope with the operation and to comply with the strict post operative follow up and immunosuppressive regimes. In most centres, the upper age limit is 60 years for cardiac transplantation and for single lung transplantation and 50 years for heart-lung and bilateral lung transplantation.

Contraindications for cardiac and lung transplantation

1. Psychosocial instability and poor compliance
2. Infection with hepatitis B or C virus or with human immunodeficiency virus
3. Active mycobacterial or aspergillus infection
4. Active malignancy (patient must be in complete remission for more than five years after treatment)
5. Active peptic ulceration
6. Severe osteoporosis
7. Other end-organ failure not amenable to transplantation e.g. hepatic failure or renal failure (creatinine clearance <50mls/min).>

Incremental risk factors for pulmonary transplantation include previous thoracic surgery and pleurodesis and patients are not accepted on to the waiting list who are on long term prednisolone therapy in excess of 10mg/d. Additional contraindications for cardiac transplantation include pulmonary vascular resistance greater than 3 Wood units and severe lung disease.