Heart Transplant Program

Heart transplantation remains an excellent option for patients who have exhausted all medical and surgical therapies for congestive heart failure. It continues to be limited by donor availability, but short- and long-term results are outstanding, with an expected 60 percent survival at ten years.

Heart transplant eligibility criteria:

• End-stage cardiac disease as a result of poor cardiac function or uncontrollable ventricular arrhythmias that can no longer be treated with medications and/or other surgeries
• Absence of serious systemic illness or other medical conditions that may affect immediate or long-term survival
• Age 68 or less with a high likelihood of becoming healthy, productive, functional individuals with a life expectancy of at least five to 10 years
• Full understanding of transplant procedure, its limitations and long-term compliance to follow-up requirements
• Strong social support network, especially family
• Free from active drug, nicotine or alcohol abuse
• Weight less than 135 percent of IBW

Indications for heart transplant

• Poor 12-24 month prognosis without heart transplantation (based on combination of variables)
• LV dysfunction without CAD LVEF < 20-25 percent, LV diameter > 7 cm, poor right heart pressures (CVP > 12, PCWP > 18, PAS > 50, CI < 2.2) on medical therapy, poor exercise tolerance (VO2 max < 14 ml/kg/min), advanced symptoms
• LV dysfunction secondary to CAD (not amenable to further revascularization) - more liberal criteria than above based on individual assessment
• Hypertrophic cardiomyopathy, congenital heart disease, valvular heart disease, etc.
• NYHA Class III-IV or intractable severe angina that is not amenable to other therapies
• Refractory ventricular dysrhythmias

Absolute contraindications for heart transplant

• Intrinsic renal dysfunction: renal ultrasound will be obtained if creatinine clearance < 50 ml/min to assess for structural abnormalities. Note: heart-kidney transplantation may be considered in carefully selected patients.
• Irreversible liver disease
• Pulmonary dysfunction (COPD) which is severe
• Recent pulmonary embolus
• Complicated diabetes mellitus (poor control, retinopathy, neuropathy, nephropathy)
• Active severe infection
• Advanced peripheral vascular disease/diffuse atherosclerosis
• CNS (dementia, active seizure disorder, stroke with poor rehabilitation)
• Cardiac amyloid
• Patient > 68 years will not be evaluated for heart transplant at Emory University Hospital
• Active substance abuse (nicotine, ETOH, illicit drugs)
• Severe psychiatric dysfunction
• Malignancy with high risk of recurrence
• Non-compliance with medical regimen

Relative contraindications for heart transplant

• Uncontrolled hypertension
• If age > 60, renal function and relative contraindications evaluated carefully
• Obesity (> 135 percent IBW)
• Active systemic illness that would limit long-term survival
• Inadequate transportation to and from medical appointments
• Inadequate financial resources to support post-transplant needs
• Inadequate support system including family and friends

Patients awaiting cardiac transplant will be listed in one of three active categories: Status 1A, Status 1B, or Status 2. The following guidelines describe the clinical circumstances that determine under which category the patient will be listed.

Status 1A

• Mechanical devices (VAD for < 30 days, ECMO, IABP, ventilator)
• VADs > 30 days with device-related complications
• High-dose single inotropes with pulmonary artery catheter
• Dobutamine at 7.5 mcg
• Milrinone at .5 mcg
• Multiple inotropes with pulmonary artery catheter

Status 1B

• VAD for > 30 days
• Inotropic support (regardless of location of patient-ICU without PA catheter, floor or home)

Status 2

• All other patients actively listed for heart transplant

Donor hearts are matched to recipients according to blood type and body size. Available donor hearts will be allocated using the following algorithm:

The United Network for Organ Sharing (UNOS) computer will identify all Status 1A patients of the proper blood type and body size in Georgia. The Status 1A patient who has waited the longest as a 1A will receive the donor heart.

In the event there are no Status 1A patients listed in Georgia, the donor heart will go to the Status 1B patient in Georgia who has been listed the longest as a 1B.

If there are no patients in Georgia of the proper blood type and body size listed as Status 1B, the donor heart will go to the patient who has been listed the longest as a Status 2 in Georgia.

If there are no patients listed as Status 2 in Georgia for that particular blood type and body size, the donor heart will go to the patient in the region who has been listed the longest as a Status 1A.