Heart transplantation criteria

Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D.; Associate Editor-In-Chief:

Criteria for Cardiac Transplantation
While assessment of the indications and contraindications are important first steps in evaluating the appropriateness for cardiac transplantation, the prognosis of a patient with and without transplantation is critical in making the final determination as to whether a patient is suitable for cardiac transplantation. Discussed below are criteria that are used based upon the estimation of the patient's prognosis.

Functional Capacity and Peak V02 (V02 Max)
This objective metric is listed by the ACC/AHA heart failure guidelines as a critical measure in determining when to list someone for transplantation. A normal peak V02 is > 20 ml/kg/min. Older data from 1986 through 1989 identified and peak V02 of 14 ml/kg/min as a threshold for listing a patient. Those patients with a peak V02 > 14 ml/kg/min who were considered too stable for cardiac transplantation had a survival that was similar to that of patients with a peak V02 < 14 ml/kg/min who were transplanted. It should be noted that peak V02 is variable, and should be re assessed periodically. It should also be noted that gender, age, comorbidities, and a patient's level of conditioning should be taken into account when interpreting the peak V02. If a patient is consistently in the peak V02 range of 10-12 ml/kg/min, then transplantation should be considered.

Transplant Criteria
The ACC / AHA criteria are as follows :

Absolute Indications

 * For hemodynamic compromise due to severe heart failure
 * Refractory cardiogenic shock
 * Documented dependence on intravenous inotropic support to maintain adequate organ perfusion
 * Peak VO2 less than 10 mL/kg per min with achievement of anaerobic metabolism


 * Severe symptoms of ischemia that consistently limit routine activity and are not amenable to coronary artery bypass surgery or percutaneous coronary intervention.
 * Recurrent symptomatic ventricular arrhythmias refractory to all therapeutic modalities

Relative indications

 * 1) Peak V02 of 11 to 14 mL/kg per minute (or 55 percent predicted) and major limitation of the patient's daily activities
 * 2) Recurrent unstable ischemia not amenable to other intervention
 * 3) Recurrent instability of fluid balance/renal function not due to patient noncompliance with medical regimen

"Insufficient" indications

 * 1) Low left ventricular ejection fraction
 * 2) History of functional class II or IV symptoms of HF
 * 3) Peak VO2 greater than 15 mL/kg per minute (or greater than 55 percent predicted) without other indications

Donor Criteria

 * 1) Brain death declared
 * 2) Age <45 (special exceptions)
 * 3) No pre-existent heart disease
 * 4) Few coronary artery disease risk factors
 * 5) No untreated acute infections
 * 6) No systemic malignancy
 * 7) No cardiac trauma
 * 8) Normal ECG
 * 9) Normal echocardiogram
 * 10) Negative HIV and Hepatitis screen