Wider Eligibility for Heart Transplantation in New Guidelines

Marlene Busko

January 13, 2016

ADDISON, TX — The 2016 International Society for Heart Lung Transplantation (ISHLT) listing criteria for heart transplantation updates the criteria issued in 2006, adds recommendations for patients who were previously deemed ineligible, and even touches on marijuana use[1].

The new guidelines, led by writing committee chair Dr Mandeep M Mehra (Brigham and Women's Hospital, Boston, MA), were published online January 7, 2016 in the Journal of Heart and Lung Transplantation.

"In the past 10 years, much has changed" when assessing whether a patient is a candidate for a heart transplant, Mehra told heartwire from Medscape. More patients qualify now.

For example, "mechanical circulatory support with left ventricular assist devices [LVADs] is allowing us to assess patients . . . with what used to be considered relative contraindications," Mehra noted. Patients with treatable low-grade cancer or some very frail patients may benefit from an LVAD, which could be used as a bridge until they become suitable heart-transplant candidates.

The upper age and weight cutoffs have been relaxed. "Carefully selected patients >70 years of age may be considered for cardiac transplantation," according to the guidelines. "Dick Cheney was transplanted [when he was] past the age of 70," Mehra observed, adding that frailty may be a better measure of outcome than chronological age.

The report recommends that patients lose enough weight to have a body-mass index (BMI) below 35 (as opposed to below 30) before they are listed for a heart transplant. Nevertheless, "the average person gains anywhere from 12 to 30 pounds in the first year after transplantation," so adverse effects such as sleep apnea, arthritis, or infections are magnified in obese patients, Mehra said.

Listing for a heart transplant should not be based solely on heart-failure survival scores, since these scores have inherent limitations, the report warns.

Infections, Amyloidosis, and Congenital Heart Disease

Mehra drew to attention to three report sections on infections, amyloidosis, and congenital heart disease. "[Clinicians] should not automatically eliminate patients with HIV or hepatitis C" from being listed for a heart transplant, he said. The guidelines discuss measures that centers that perform these transplants in these patients need to take.

Patients with Chagas disease may be eligible for a heart transplant, but they are also prone to recurrence of this disease. "A growing number of Hispanic patients in the United States have been exposed to Chagas disease," Mehra observed. "Thus, all centers should develop protocols for screening of candidates and surveillance after transplantation for reactivation of the disease," the guidelines advise.

"The old dictum used to be that if you transplant a patient with amyloidosis, it is likely that the amyloidosis will recur," Mehra noted. But now the guidelines describe how carefully selected patients with transthyretin-related (TTR), amyloid-light-chain (AL), or familial-TTR cardiac amyloidosis may be candidates for a heart transplant.

Adults who had congenital heart disease and now have failing surgical repairs, such as "a patient who has a normal functioning heart but develops gastrointestinal or even lung problems as a result of a failing Fontan [procedure]" may be suitable candidates for a heart transplant, Mehra said.

Last, the guidelines note that little is known about how marijuana use may affect a heart transplant. "Whether candidates on medical marijuana or those who obtain it through other legal means should receive organ transplantation is at best an issue for which no clear direction exists," according to the guidelines. Heavy use could impair patients' cognitive ability, which could lead to nonadherence to medication, and there have been isolated reports of fungal infections.

Mehra has previously reported consulting for research with Thoratec, Heartware, St Jude Medical, Boston Scientific, Medtronic, Johnson & Johnson, Teva, and Stealth Biopeptides. Disclosures for the coauthors are recorded in the ISHLT office.

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