Introduction to heart failure

Heart failure (HF) has significant public health impact and is associated with decreased quality of life, substantial resource utilization, and decreased life expectancy . HF is classified according to symptoms and anatomic considerations (see Tables 1–3 ).

Stage D HF is defined as advanced progression of disease despite maximal therapies.

Indications for heart transplantation ( Fig. 1 )

The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines include the following indications for cardiac transplantation :

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  Refractory cardiogenic shock requiring intra-aortic balloon pump (IABP) counterpulsation or left ventricular assist device (LVAD)

  
  
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  Cardiogenic shock requiring continuous intravenous inotropic therapy

  
  
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  Peak VO ₂ (VO ₂ max) less than 10 mL/kg/min

  
  
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  New York Heart Association (NYHA) class of III or IV despite maximized medical and resynchronization therapy

  
  
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  Recurrent life-threatening left ventricular arrhythmias despite an implantable cardiac defibrillator, antiarrhythmic therapy, or catheter-based ablation

  
  
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  End-stage congenital HF with no evidence of pulmonary hypertension

  
  
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  Refractory angina without potential medical or surgical therapeutic options

Patients with end-stage heart failure who have failed medical management and other specialized interventions progress to OHT, MCS implantation, or palliative care.

The European Society of Cardiology also describes a series of features that should be met before patients are considered for heart transplantation :

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  Severe symptoms, with dyspnea at rest or with minimal exertion (NYHA class III or IV)

  
  
• •
  

  Episodes of fluid retention (pulmonary or systemic congestion, peripheral edema) or of reduced cardiac output at rest (peripheral hypoperfusion)

  
  
• •
  

  Objective evidence of severe cardiac dysfunction (at least one of the following):

  
  
  
  
  • –
    

    Left ventricular ejection fraction less than 30%

    
    
  • –
    

    Pseudonormal or restrictive mitral inflow pattern on Doppler echocardiography

    
    
  • –
    

    High left and/or right ventricular filling pressure severely impaired functional capacity demonstrated by one of the following: inability to exercise

    
    
  • –
    

    6-min walk test distance less than 300 m (or less in women or patients who are age 75 and older) or peak oxygen intake less than 12–14 mL/kg/min;

  
  
  
  
• •
  

  One or more hospitalizations for HF in the past 6 months.

Indications for heart transplantation ( Fig. 1 )

The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines include the following indications for cardiac transplantation :

• •
  

  Refractory cardiogenic shock requiring intra-aortic balloon pump (IABP) counterpulsation or left ventricular assist device (LVAD)

  
  
• •
  

  Cardiogenic shock requiring continuous intravenous inotropic therapy

  
  
• •
  

  Peak VO ₂ (VO ₂ max) less than 10 mL/kg/min

  
  
• •
  

  New York Heart Association (NYHA) class of III or IV despite maximized medical and resynchronization therapy

  
  
• •
  

  Recurrent life-threatening left ventricular arrhythmias despite an implantable cardiac defibrillator, antiarrhythmic therapy, or catheter-based ablation

  
  
• •
  

  End-stage congenital HF with no evidence of pulmonary hypertension

  
  
• •
  

  Refractory angina without potential medical or surgical therapeutic options

Patients with end-stage heart failure who have failed medical management and other specialized interventions progress to OHT, MCS implantation, or palliative care.

The European Society of Cardiology also describes a series of features that should be met before patients are considered for heart transplantation :

• •
  

  Severe symptoms, with dyspnea at rest or with minimal exertion (NYHA class III or IV)

  
  
• •
  

  Episodes of fluid retention (pulmonary or systemic congestion, peripheral edema) or of reduced cardiac output at rest (peripheral hypoperfusion)

  
  
• •
  

  Objective evidence of severe cardiac dysfunction (at least one of the following):

  
  
  
  
  • –
    

    Left ventricular ejection fraction less than 30%

    
    
  • –
    

    Pseudonormal or restrictive mitral inflow pattern on Doppler echocardiography

    
    
  • –
    

    High left and/or right ventricular filling pressure severely impaired functional capacity demonstrated by one of the following: inability to exercise

    
    
  • –
    

    6-min walk test distance less than 300 m (or less in women or patients who are age 75 and older) or peak oxygen intake less than 12–14 mL/kg/min;

  
  
  
  
• •
  

  One or more hospitalizations for HF in the past 6 months.

Contraindications to heart transplantation

Contraindications to transplantation have evolved since the advent of heart transplantation, with many centers expanding criteria for acceptance . Conventional contraindications to transplantation are listed below :

Absolute contraindications:

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  Systemic illness with a life expectancy <2 years despite orthotopic heart transplantation (OHT):

  
  
  
  
  • –
    

    Active or recent solid organ or blood malignancy within 5 years

    
    
  • –
    

    AIDS with frequent opportunistic infections

    
    
  • –
    

    Systemic lupus erythematosus, sarcoidosis, or amyloidosis that has multisystem involvement and is still active

  
  
  
  
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  Irreversible renal or hepatic dysfunction in patients considered for OHT alone

  
  
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  Significant obstructive pulmonary disease (FEV1 < 1 L/min)

  
  
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  Fixed pulmonary hypertension:

  
  
  
  
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    Pulmonary artery systolic pressure > 60 mmHg

    
    
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    Mean transpulmonary gradient > 15 mmHg

    
    
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    Pulmonary vascular resistance > 6 Wood units

  
  

Relative contraindications:

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  Age > 72

  
  
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  Any active infection (with exception of device-related infection in VAD recipients)

  
  
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  Active peptic ulcer disease

  
  
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  Severe diabetes mellitus (DM) with end-organ damage (neuropathy, nephropathy, or retinopathy)

  
  
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  Severe peripheral vascular or cerebrovascular disease:

  
  
  
  
  • –
    

    Peripheral vascular disease not amenable to surgical or percutaneous therapy

    
    
  • –
    

    Symptomatic carotid stenosis

    
    
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    Ankle brachial index < 0.7

    
    
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    Uncorrected abdominal aortic aneurysm > 6 cm

  
  
  
  
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  Morbid obesity (body mass index > 35 kg/m ² ) or cachexia (body mass index < 18 kg/m ² )

  
  
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  Creatinine > 2.5 mg/dL or creatinine clearance < 25 mL/min

  
  
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  Bilirubin > 2.5 mg/dL, serum transaminases > 3×, INR > 1.5 off warfarin

  
  
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  Severe pulmonary dysfunction with FEV1 < 40% normal

  
  
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  Recent pulmonary infarction within 6–8 weeks

  
  
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  Difficult to control hypertension

  
  
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  Irreversible neurologic or neuromuscular disorder

  
  
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  Active mental illness or psychosocial instability

  
  
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  Drug, tobacco, or alcohol abuse within 6 months

  
  
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  Heparin-induced thrombocytopenia within 100 days