heart transplant

Heart transplantation is a treatment that removes an end-stage heart that cannot be recovered with maximal medication, devices, or surgery, and replaces it with a heart from a brain-dead donor. ISHLT defines it as a crucial life-extending treatment for appropriately selected patients with advanced heart failure, and recent guidelines emphasize individualized candidate evaluation and mechanical circulatory support such as VAD during waiting. Because hearts cannot be donated from living donors and have a short ischemic time, extraction, transport, and surgery must occur simultaneously nationwide as soon as a donor becomes available.

Entry points include repeated hospitalizations even with maximal treatment, hypotension and low perfusion at rest, dependence on inotropes, severe exercise intolerance, worsening renal/hepatic function, intractable ventricular arrhythmias, or uncorrectable congenital heart disease. Early evaluation before peripheral organ damage, rather than after shock, is important. Even at rest, repeated defibrillation, syncope, dyspnea, cyanosis, or decreased urine requires urgent evaluation, and hypotension, decreased consciousness, or lactic acidosis necessitate immediate transfer to a center capable of ECMO/MCS.

Evaluation is done with echocardiography, cardiac MRI, coronary and right heart catheterization, cardiopulmonary exercise peak VO2, 6-minute walk test, arrhythmias/devices, cardiac and pulmonary vascular resistance, and kidney, liver, lung, vascular, cancer, and infection assessment. HLA, PRA/DSA, blood type and size matching, nutrition, sarcopenia/frailty, cognition, mental health, substance abuse, medication adherence, and social support are integrated. Post-transplant, rejection and transplant cardiovascular disease are monitored with hemodynamics, echocardiography, myocardial biopsy, DSA, coronary angiography, and intravascular imaging.

Step 1: Advanced heart failure·candidate assessment → Reversibility, hemodynamics·organ function·pulmonary vasculature·immunity·infection·cancer·frailty·social risk are evaluated by a multidisciplinary team.

Phase 2: KONOS registration/bridge → manage urgency and matching samples, and apply GDMT, inotropes, IABP/ECMO, short-term/durable VAD in a timely manner.

Stage 3: Explantation/transplantation/ICU isolation → Minimize donor heart ischemic time, perform transplantation, and manage primary graft failure, hemorrhage, right heart failure, rejection, and infection.

Stage 4: Lifelong immune and rehabilitation follow-up → Manage biopsies/DSA, drug concentrations, CAV, infections, cancer, kidney/metabolic complications, and cardiac rehabilitation and medication adherence.