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Society updates listing criteria for heart transplantation
The International Society for Heart and Lung Transplantation has issued an update to its criteria for listing for heart transplantation.
The new guideline, an update of one from 2006, relaxed some of the recommendations of the older document in light of new evidence.
“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,” Mandeep R. Mehra, MD, professor of medicine at Harvard Medical School, medical director of the Heart and Vascular Center at Brigham and Women’s Hospital, editor-in-chief of The Journal of Heart and Lung Transplantation and chair of the task force that wrote the document, said in a press release. “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. … The new guidelines not only update several of these prior issues, but also tackle the most controversial topics of our times.”
In one change, the task force now recommends that physicians suggest a weight-loss program for overweight patients with HF to a target BMI of less than 35 kg/m2, a change from the previous target BMI of less than 30 kg/m2. “BMI in the obese range but < 35 kg/m2 has not been convincingly associated with an increase in mortality after transplantation,” they wrote.
The guideline no longer recommends listing patients solely on the criteria of HF survival prognostic scores, such as the Seattle Heart Failure Model and the Heart Failure Survival Score, because concerns about their accuracy have been raised.
Periodic right-heart catheterization, a routine procedure for adult candidates for transplantation, is no longer recommended for children who may need transplantation, the authors wrote.
A new recommendation is that “use of [mechanical circulatory support] should be considered for patients with potentially reversible or treatable comorbidities, such as cancer, obesity, renal failure, tobacco use and pharmacologically irreversible pulmonary hypertension, with subsequent re-evaluation to establish candidacy” for heart transplantation.
The new document emphasizes the issue of social support after transplantation, recommending that patients without adequate social support to achieve compliant care as an outpatient “may be regarded as having a relative contraindication to transplant.” The authors wrote that the benefit of heart transplantation in patients with severe cognitive-behavioral disabilities or dementia has not been established and could produce harm, so these patients should not be considered candidates.
A new recommendation is that some patients with HIV infection, hepatitis, Chagas disease or tuberculosis may now be considered candidates for heart transplantation, assuming certain protocols are followed carefully. – by Erik Swain
Disclosure: Disclosures and conflicts of interest for all authors have been reviewed, declared and recorded with the International Society for Heart and Lung Transplantation office.
Perspective
Back to TopThe group spelled out very well some of the more nebulous things about whether or not certain patients should be addressed. Some of that has to do with `are you sick enough,’ and I thought the recommendation for the Heart Failure Survival Score to be used as part of the process was helpful. The clarification on cardiometabolic stress testing I thought was helpful, because there is a lot of debate about beta-blockers, resynchronization therapy and other factors. They also included the disclaimer for very obese people, where we have to look differently at the BMI number, and also for people who are younger than 50 years, which were very well thought out and represents mainstream HF/transplant evaluation and care. I also thought they did a good job with restrictive and infiltrative cardiomyopathies. We have not been particularly unified in our approach to them in the past.
I don’t know that it’s going to change practice a whole lot, but it puts in print what we do and what we should be doing for these individuals. That not only helps medical professionals, but also those who perform screening and appropriate use criteria.
The criteria are as good as they can be based on current knowledge and donor availability. The hard thing about heart transplantation is that as a transplant physician, you have two distinctly different jobs. The first is to take care of the individual patient sitting in front of you. And the second is a responsibility to utilize the donated organs wisely, because there are so precious few of them. Sometimes those points are diametrically opposed. We have to consider that even if we don’t give a heart to my patient, somebody else’s patient who may do better will benefit from it. That’s why the publication of criteria like this is important. It reinforces a standard.
There are very few absolute contraindications in the document, and that’s good, because everything in medicine is relative. But it does a lot to keep improper donor utilization from being a big issue. The recommendations are more robust than they ever have been for what needs to be done for people on the transplant waiting list.
Additionally, the recommendations for ongoing assessment of non-inotropic people on the waiting list, are important from a management standpoint and an appropriate use criteria perspective. They specifically recommend those people that are what we would typically call status II, who are at home and not on an inotrope, get reassessed and reevaluated every 3 to 6 months. Things change, people get worse, people get better, and the concept of dynamic listing is incredibly important. If you’ve been on the transplant waiting list for 11 years, you probably didn’t need to be on it to start with. They did a very good job to highlight the importance of dynamic listing.