Year released: 2016
Society: International Society for Heart and Lung Transplantation (ISHLT)
The ISHLT issued a 10-year update to the first-ever International Listing Criteria for Heart Transplantation that was published in 2006.
The 2016 guidelines provide new recommendations for clinical evaluations of transplantation candidates and psychosocial factors that may affect transplantation success. The revised guidelines also eliminate a section on how patients are placed on, and removed from, the list for transplantation.
HF prognosis scores
The updated guidelines recommend against using heart failure (HF) survival prognostic scores as the sole determinant of whether patients are placed on the transplantation list, suggesting instead that several factors be considered when making this choice.
HF survival prognosis scores can be used in conjunction with cardiopulmonary exercise testing to assess prognosis and make determinations about listing ambulatory patients for transplantation. In addition, estimated 1-year survival as determined by the Seattle Heart Failure Model (SHFM) in the high- to medium-risk range should be classified as acceptable cut points for listing.
Effect of BMI
The 2006 guidelines stated that a body mass index (BMI) greater than 30 kg/m2 (or percent ideal body weight > 140%) correlated with worse outcomes after transplantation. The 2016 guidelines increase the BMI threshold to 35 kg/m2.
Several reports published since the first guideline was written review the effect of BMI on outcomes after heart transplantation, according to the authors who developed the guideline. A BMI in the obese range that is less than 35 kg/m2 has not been “convincingly associated” with greater mortality after transplantation, although patients with a BMI greater than 35 kg/m2 experienced longer wait times and were less likely to find an appropriate donor. In addition, some reports demonstrated a rise in morbidity and mortality among these patients after transplantation.
As a result, the guidelines have been updated to recommend that patients reach a BMI of 35 kg/m2 or less to be listed for transplantation. The percent ideal body weight greater than 140% parameter was eliminated from the guideline because BMI is the framework used most frequently, according to the authors.
The 2006 guidelines recommended a psychosocial evaluation before listing a patient for transplantation, including an evaluation of a patient’s sources of support at home and in the community. The 2016 update adds to this, stating that any individual whose social support system is inadequate, so that compliance with posttransplantation care may not be achievable, should be classified as having “a relative contraindication to transplantation.”
The original guidelines classify mental retardation or dementia as potential contraindications for transplantation. The update states that the advantages associated with heart transplantation in patients with significant cognitive-behavioral issues or dementia have not been determined; relevant health issues include self-injurious behavior and the “inability to ever understand and cooperate with medical care.” These issues also present “the potential for harm,” according to the update, and transplantation in patients with these issues cannot be advised.
The 2016 guidelines state that patients with certain infectious diseases, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV) and tuberculosis (TB), are considered candidates for transplantation. The update provides protocols to follow for patients with one of these infectious diseases who are otherwise considered candidates for transplantation.
The updated guidelines add several recommendations, including the stance that retransplantation is advisable in patients who have substantial cardiac allograft vasculopathy (CAV) with refractory cardiac allograft dysfunction and no signs pointing to ongoing acute rejection, although this update does discuss the risk associated with retransplantation in the first 6 months of the original transplant.
Mehra MR, et al. J Heart Lung Transplant. 2016;doi:10.1016/j.healun.2015.10.023.
Cardiology Today coverage: https://www.healio.com/cardiology/hf-transplantation/news/online/%7b4d2d1928-2465-40de-8915-16f8daaf7764%7d/society-updates-listing-criteria-for-heart-transplantation