CARDIAC TRANSPLANTATION
CARDIAC TRANSPLANTATION
Since the first human heart transplant in 1967, the techniquehas become an accepted form of treatment forpatients dying of heart failure and for whom no other formof treatment offers any help. The current annual rate ofcardiac transplantation worldwide is approximately 3000.The number of patients requiring transplantation eachyear in the USA alone is estimated to be 35 000-70000. The shortfall is mainly due to the shortage of donor hearts, and is responsible for the plateauing of the transplantation ratein the USA and Europe. Cardiac transplantation will notbecome the panacea of heart failure treatment, and selectionof recipients will necessarily remain strict.
Indications
The vast majority of patients who undergo cardiactransplantation have either terminal idiopathic dilatedor ischaemic cardiomyopathy. Other indications includeperipartum cardiomyopathy, congenital heart disease andcardiac tumours. The patient must have reached end-stageheart failure and have a very limited life expectancy. Thebest available method of measuring the prognosis of thesepatients is estimation of their cardiac reserve Contraindications to transplantation of the heart aloneinclude increased pulmonary vascular resistance, bloodgroup incompatibility, or any coexisting systemic illnessthat may significantly limit life expectancy.
Surgery
There are two main surgical procedures:
• Orthotopic transplantation.
The recipient's heart (exceptthe venous attachment side of the atria) is excised andreplaced by the donor's heart. This is the commonestprocedure
.• Heterotopic transplantation.
The recipient's heart isnot excised and the donor's heart is anastomosed side toside to the corresponding atria and great vessels of therecipient's heart.Contrary to popular belief, the surgery itself is simpler thanmost open heart surgical procedures. The main operative problem is the preservation of the donor heart duringtransit.
Management
By far the most difficult part of cardiac transplantation isthe postoperative care. The two major complications aregraft rejection and infection, which account for most of theearly mortality. There is as yet no early and accurate noninvasivemethod of detecting rejection. Apart from clinicalsuspicion and loss of R wave in the ECG, the most reliablemethod of diagnosing rejection is by percutaneous endomyocardialbiopsy.Immunosuppressive regimens include combinations ofciclosporin, azathioprine, corticosteroids, cyclophosphamide,antithymocyte globulin (ATG), use of monoclonalantibody against the CD3 molecule on mature T cells, andoccasionally vincristine or methotrexate. The need for immunosuppressionmeans that patients are at increased riskfrom bacterial infection. Opportunistic fungal infectionsand reactivation of primary viral infection (notably cytomegalovirus)occur.
Prognosis
Current survival rates of cardiac transplantation are as good as those of renal transplantation, with overall 1-and 5-year survival rates of about 80% and 70%, respectively,for orthotopic transplantation. The survival rate for heterotopic transplantation is less good, with a 5-yearsurvival of about 50%. Factors that negatively influence prognosis include major HLA mismatch, prolonged cold preservation of the donor heart, the presence of preformed circulating antibodies and advanced donor age.
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