For the first time in a decade, the International Society for Heart and Lung Transplantation have issued updated guidelines to help physicians determine which patients may be suitable candidates for heart transplantation.
Published in The Journal of Heart and Lung Transplantation, the updated guidelines are a result of a collaboration between the International Society for Heart and Lung Transplantation (ISHLT) Heart Failure and Transplantation, Pediatric and Infectious Disease Councils.
Chaired by Dr. Mandeep R. Mehra, professor of medicine at Harvard Medical School, and medical director of the Heart and Vascular Center at Brigham and Women's Hospital - both in Boston, MA - the revised guidelines for heart transplantation candidacy address some of the issues that have arisen since such guidelines were first put in place in 2006.
One key issue has been heart transplantation eligibility for patients with certain medical conditions; the 2006 guidelines stated that patients with particular illnesses should not be considered for the procedure.
However, based on recent scientific evidence, the ISHLT now state that patients with human immunodeficiency virus (HIV), hepatitis, Chagas disease or tuberculosis can now be considered suitable transplant candidates, provided they meet other criteria.
Additionally, the 2006 guidelines stated that for heart failure patients who are overweight, a body mass index (BMI) of 35 or less must be achieved before they can be considered for a heart transplant.
However, the revised guidelines now stipulate that doctors must ensure such patients reach a BMI of 30 or less, based on new evidence showing that more patients are likely to qualify for heart transplantation if they reach this goal.
New guidelines 'tackle most controversial topics of our times'
Another notable change to the 2006 guidelines involves the Heart Failure Survival Score (HFSS) - a system that is used to estimate all-cause mortality for patients with heart failure. The HFSS is used to judge a patient's eligibility for heart transplantation.
- More than 4,100 people in the US are currently on the waiting list for a heart transplant
- More than 62,000 heart transplants have been conducted in the US since 1988
- The majority of heart transplants have occurred among adults aged 50-64.
However, recent studies have raised concerns about the accuracy of the HFSS. As such, the updated guidelines state that listing patients for heart transplantation based solely on HFSS criteria should only occur if a patient's prognosis is unclear.
The ISHLT have also updated recommendations for the use of right-heart catheterization (RHC) - a test that determines how well the heart is pumping. The Society now recommend that all adult heart transplant candidates undergo RHC testing before being listed for the procedure, and such patients should be tested regularly up until the date of transplantation.
For heart failure patients with potentially reversible or treatable co-existing conditions - such as renal failure, cancer or obesity - and those who have pharmacologically irreversible pulmonary hypertension or engage in tobacco use, the ISHLT now recommend that mechanical circulatory support be considered to determine heart transplantation candidacy, with re-evaluation recommended before a decision is reached.
The updated guidelines also take patients' social support into account, noting that for individuals who are unlikely to comply with outpatient care requirements, heart transplantation may be considered a major risk.
The ISHLT also recommend against heart transplantation for patients with severe cognitive disabilities, noting that this may impact their ability to understand the procedure, adhere to medical recommendations or engage in self-injury; the benefits of heart transplantation have not been determined in such patients.
Commenting on the updated guidelines, Dr. Mehra says:
"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.
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 (e.g. waiting a minimum of 5 years for freedom from cancers). The new guidelines not only update several of these prior issues, but also tackle the most controversial topics of our times."
In November 2015, Medical News Today reported on the issue of the first ever guidelines for diagnosis and treatment of children with pulmonary hypertension, developed by the American Heart Association and the American Thoracic Society.