Key differences in new guidelines for heart transplantation
Wednesday, February 17, 2016
The International Society for Heart and Lung Transplantation (ISHLT) has published new guidelines for heart transplantation candidacy that address many of the important and relevant issues associated with transplantation.
ISHLT published the first International Listing Criteria for Heart Transplantation in 2006. The ISHLT has since commissioned a focused update on areas of increasing importance not fully addressed in the first edition, such as congenital heart disease (CHD), restrictive cardiomyopathy and infectious disease.
These updated guidelines should help physicians determine which patients may be suitable candidates for heart transplantation. Let's take a look at some of the key differences.
The 2006 guidelines said patients with certain medical conditions, such as human immunodeficiency virus (HIV), tuberculosis, Chagas disease or hepatitis, should not be considered for heart transplantations. The updated guidelines allow these patients to become candidates provided the applicants meet other transplantation criteria.
The 2006 guidelines suggested a body mass index (BMI) of 35 or less for consideration for a heart transplant. The current guidelines increased the threshold to a BMI of 30 or less.
The new guidelines update the use of the Heart Failure Survival Score (HFSS), which estimates all-cause mortality for patients with heart failure and is used to determine eligibility for heart transplantation. In light of recent studies that raise concerns about the system's accuracy, the updated guidelines say that clinicians should list patients for heart transplantation based solely on the criteria of heart failure survival prognostic scores only when prognosis is unclear.
The ISHLT now recommends all adult heart transplant candidates undergo right-heart catheterization (RHC) in preparation for listing and every year until transplantation. RHC measures pulmonary artery occlusion pressure and cardiac output.
The updated guidelines now recommend consideration of mechanical circulatory support to determine transplantation candidacy for patients with potentially treatable or reversible co-existing conditions, including renal failure, cancer and obesity, and in patients who use tobacco or have pharmacologically irreversible pulmonary hypertension. The ISHLT recommends re-evaluation before reaching a decision.
The new guidelines recommend a psychosocial evaluation before listing. The evaluation should assess the patient's ability to give informed consent, and to comply with drug therapy and other instructions. The guidelines point out that poor compliance with drug regimens is a risk factor for graft rejection and mortality.
The updated guidelines recommend evaluation of the support systems existing in the patient's home or community. Insufficient support systems in the outpatient setting may be a relative contraindication to transplant.
ISHLT recommends against heart transplantation for those patients with severe cognitive-behavioral disabilities or dementia, specifically those who demonstrate self-injurious behavior or who will never be able to understand and cooperate with medical care.
Dr. Mandeep R. Mehra, professor of medicine at Harvard Medical School, and medical director of the Heart and Vascular Center at Brigham and Women's Hospital chaired the revision project. In her comments on the updated guidelines, Mehra says: "There are many controversial issues in the guidelines that we have tackled head on, including heart transplantation in previously denied conditions (HIV, hepatitis amyloidosis, certain congenital heart diseases) that we now allow or recommend more lenient listing.
"The 2006 guidelines were particularly important in that we recommended against an age limit for transplantation or time dependency for patients with previously healed cancers (e.g. waiting a minimum of five years for freedom from cancers). The new guidelines not only update several of these prior issues, but also tackle the most controversial topics of our times."
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