Chapter 91 ■ Heart Transplantation

Cardiac allotransplantation is now an established therapeutic modality for end-stage heart disease (1). Although the operative procedure remains essentially unchanged, recent advances in mechanical assist technology and significant advances in the medical therapy of congestive heart failure have changed heart transplantation from an “operation” to a definitive therapy among competing therapies in integrated heart failure management programs. Ventricular assist devices (VAD), cardiac resynchronization therapy, nontransplant surgical procedures, and novel molecular strategies have further complicated the process of patient selection for transplantation. This discussion will review the current status of clinical cardiac transplantation, describe the diagnostic algorithms of the acute decompensated heart failure patient that determine appropriate patient selection for cardiac transplantation, and identify the major perioperative risk factors for acute allograft loss and the clinical strategies designed to attenuate these risks.