Heart failure is quickly becoming the most pressing health problem in India. Millions of people in India live with heart failure disease. In addition there is numerous unreported cases. Even though there are good treatments that relieve symptoms and improves prognosis, not all get the treatment they should. Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of ventricles to pump blood. Heart failure is often a long-term (chronic) condition, but it can sometimes develop suddenly. It can be caused by many different heart problems. The condition may affect only the right side or the left side of the heart. These are called right-sided HF or left-sided HF. More often, both sides of the heart are involved. India has a long way to go before we can match the demand for heart transplants in the country. There is a dire need to aggressively spread awareness about the colossal gap that exists between the organ donors and those who need it in India. Though there are more than 10 lakh people suffering from end-stage organ failure, only around 3,500 organ transplants are performed every year. Most of those who manage to make it to the list eventually don’t survive the wait which is a minimum of 3-4 months. This scenario proves to be especially fatal for those who are battling with end-stage heart failure.
Cardiac transplantation represents the most effective long-term treatment strategy for advanced heart failure; however, the supply of donor hearts is limited.It has been a gold standard treatment for end stage heart failure.
- Cardiogenic shock requiring mechanical assistance.
- Refractory heart failure with continuous inotropic infusion.
- NYHA functional class 3 and 4 with a poor 12 month prognosis.
- Progressive symptoms with maximal therapy.
- Severe symptomatic hypertrophic or restrictive cardiomyopathy.
- Medically refractory angina with unsuitable anatomy for revascularization.
- Life-threatening ventricular arrhythmias despite aggressive medical and device interventions.
- Cardiac tumors with low likelihood of metastasis.
- Hypoplastic left heart and complex congenital heart disease
- Patients should receive maximal medical therapy before being considered for transplantation. They should also be considered for alternative surgical therapies including CABG, valve repair / replacement, cardiac septalplasty, etc.
- VO2 has been used as a reproducible way to evaluate potential transplant candidates and their long term risk. Generally a peak VO2 >14ml/kg/min has been considered “too well” for transplant as transplantation has not been shown to improve survival over conventional medical therapy. Peak VO2 10 to 14 ml/kg/min had some survival benefit, and peak VO2 <10 had the greatest survival benefit.
- Absolute contraindications
- Systemic illness with a life expectancy <2 y despite HT, including
- Active or recent solid organ or blood malignancy within 5 y (eg. leukemia, low-grade neoplasms of prostate with persistently elevated prostate-specific antigen)
- AIDS with frequent opportunistic infections
- Systemic lupus erythematosus, sarcoid, or amyloidosis that has multisystem involvement and is still active
- Irreversible renal or hepatic dysfunction in patients considered for only HT
- Significant obstructive pulmonary disease (FEV1<1 L/min)
- Fixed pulmonary hypertension
- Pulmonary artery systolic pressure >60 mm Hg
- Mean transpulmonary gradient >15 mm Hg
- Pulmonary vascular resistance >6 Wood units
- Relative contraindications
- Age >72 y
- Any active infection (with exception of device-related infection in VAD recipients)
- Active peptic ulcer disease
- Severe diabetes mellitus with end-organ damage (neuropathy, nephropathy, or retinopathy)
- Severe peripheral vascular or cerebrovascular disease
- Peripheral vascular disease not amenable to surgical or percutaneous therapy
- Symptomatic carotid stenosis
- Ankle brachial index <0.7
- Uncorrected abdominal aortic aneurysm >6 cm
- Morbid obesity (body mass index >35 kg/m2) or cachexia (body mass index <18 kg/m2)
- Creatinine >2.5 mg/dL or creatinine clearance <25 mL/min*
- Bilirubin >2.5 mg/dL, serum transaminases >3×
- Severe pulmonary dysfunction with FEV1<40% normal
- Recent pulmonary infarction within 6 to 8 wk
- Difficult-to-control hypertension
- Irreversible neurological or neuromuscular disorder
- Active mental illness or psychosocial instability
- alcohol abuse within 6 mo
- induced thrombocytopenia within 100 d
Cardiac transplantation can be done in an orthotopic or heterotopic fashion(18,19). The gold standard technique is biatrial approach but now a days bicaval approach is practiced more often. Recepient’s cardiectomy is done and donor heart is implantated starting from left atrium aorta, pulmonary artery inferior vena cava and then superior vena cava in bicaval approach or right atrium to recepient’s right atrium in biatrial approach. Total transplantation is done when disparity is more between recipient’s and donor left atrial size(20).
Here are the key sites of their action and their side effects.
Acts on cyclophilin receptors and main side effects are hypertension, seizures,hyperlipidemia, renal insufficiency, microangiopathic hemolytic anemia gingival hyperplasia and increase in hair growth.
acts on FKBP-12 receptors and its side effects are hypertension, seizures, hyperlipidemia, renal insufficiency, microangiopathic hemolytic anemia hyperglycemia and hair loss.
acts through purine synthesis inhibition and its side effects are leukopenia, thrombocytopenia, anemia pancreatitis and myelodysplastic syndrome.
inhibits inosine mono phosphatase dehydrogenase (IMDPG) and its adverse effects are nausea, diarrhea, weight loss leukopenia, thrombocytopenia, anemia and hyperkalemia
inhibit “target of rapamycin” (m-TOR) via FKBP-12 and the side effects are delayed wound healing, hepatic vein thrombosis, interstitial pneumonitis, lymphocele, anemia hypertriglyceridemia renal insufficiency and proteinuria.