Cardiac Transplantation: Current Outcomes and Contemporary Controversies

Despite advances in pharmacologic and device treatment of chronic heart failure, long-term morbidity and mortality remain high, and many patients progress to end-stage heart failure. Over the last 5 decades, heart transplantation (HTx) has become the preferred therapy for select patients with end-stage heart disease. However, although HTx has become standard of care for the management of end-stage heart failure, challenges continue to exist. The number of patients with end-stage heart failure is increasing, whereas the number of donor organs remains constant and a limiting factor in HTx. Not only are there more potential heart transplantation candidates, but HTx candidates today are more complex: older, sensitized, and in need of mechanical circulatory support. Such candidates are at higher risk for poor outcomes including primary graft dysfunction and antibody-mediated rejection. This article focuses on current post-transplantation outcomes and recent advances in HTx that could address the current challenges. These advances include: 1) attempts to expand the donor pool; 2) proposed changes in HTx allocation policy for more equitable organ distribution; 3) a better understanding of the definition and management of primary graft dysfunction; and 4) advances in the management of sensitized HTx candidates. Developments in these areas could result in expansion and more equitable distribution of the donor pool and improved survival and quality of life for HTx recipients.