Heart Transplantation and LVAD Therapy
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Direct answer
Heart transplantation and left ventricular assist devices are the two main options for advanced heart failure that persists despite optimal medical therapy. A bridge to transplant LVAD keeps a suitable candidate alive until a donor heart is available, whereas destination therapy is permanent support for patients who cannot be transplanted. Late graft failure is driven mainly by cardiac allograft vasculopathy, while acute rejection is detected by endomyocardial biopsy.
What you must remember
- Transplant indications: advanced heart failure refractory to optimal therapy, with inotrope dependence, recurrent admissions, refractory arrhythmias or a low peak oxygen uptake.
- Contraindications: fixed, high pulmonary vascular resistance, active infection or malignancy, irreversible end-organ failure and poor psychosocial support.
- LVAD indications: bridge to transplant, destination therapy for those ineligible for transplant, bridge to decision and bridge to recovery.
- Right heart failure: the right ventricle may fail after LVAD implantation, so right heart function and pulmonary pressures are assessed before the device is placed.
- Pump complications: continuous-flow devices carry risks of pump thrombosis, stroke, driveline infection and gastrointestinal bleeding from acquired von Willebrand syndrome.
- Acute cellular rejection: a T-cell mediated process graded on endomyocardial biopsy and usually treated with pulse steroids.
- Cardiac allograft vasculopathy: diffuse concentric intimal thickening of donor coronary arteries, the main cause of late graft loss, and often silent because the graft is denervated.
- Immunosuppression: tacrolimus-based regimens with mycophenolate and steroids, with everolimus used as an alternative in allograft vasculopathy.
A candidate pathway for advanced heart failure
A 48-year-old man with dilated cardiomyopathy has needed inotropes for six weeks and has had recurrent admissions despite optimal therapy. The steps below show how to decide between transplant, a device, and no advanced therapy.
- Confirm advanced disease: Document inotrope dependence, recurrent admissions or a low peak oxygen uptake, and confirm that medical therapy has been optimised. Without these features, referral is premature.
- Screen for contraindications: Measure pulmonary vascular resistance by right heart catheterisation, and exclude active infection, malignancy, active substance use and irreversible renal or hepatic failure.
- Decide between transplant and device: A suitable candidate is referred for transplant listing, and an LVAD serves as a bridge while the donor search proceeds. Destination therapy is used when transplant is not an option.
- Check right ventricular reserve before implantation: A failing right ventricle after LVAD implantation carries high morbidity, so right heart function is assessed and temporary right support is considered when needed.
- Plan lifelong surveillance: After transplant, monitor for rejection with biopsy and echo, check for allograft vasculopathy with coronary imaging, and adjust immunosuppression. After LVAD, watch for pump thrombosis, bleeding and driveline infection.
Where the examiner sets the traps
Advanced heart failure questions usually test the difference between bridge and destination therapy, and the late complication of the graft.
- Trap: treating a transplant recipient's silent ischaemia as normal Correct: the denervated graft often gives no angina, and allograft vasculopathy is found only by surveillance coronary imaging.
- Trap: calling destination therapy a temporary measure Correct: destination therapy is permanent support for patients not eligible for transplant, whereas a bridge to transplant is temporary.
- Trap: attributing late graft failure to acute rejection Correct: cardiac allograft vasculopathy is the main cause of late graft loss, while acute rejection is most common in the early period after transplant.
Frequently asked questions
What are the indications for heart transplantation?
The main indications for heart transplantation are advanced heart failure that persists despite optimal medical therapy, with features such as inotrope dependence, recurrent admissions or a low peak oxygen uptake. Refractory arrhythmias and cardiogenic shock may also justify referral for transplant assessment.
What is a bridge to transplant LVAD?
A bridge to transplant LVAD is a left ventricular assist device implanted to keep a suitable candidate alive while awaiting a donor heart. Destination therapy, by contrast, is permanent support for patients who are not transplant candidates.
What is cardiac allograft vasculopathy?
Cardiac allograft vasculopathy is diffuse concentric intimal thickening of the donor coronary arteries, and it is the leading cause of late graft failure after heart transplantation. Because the transplanted heart is denervated, ischaemia often produces no angina, so surveillance coronary imaging is essential.
How is acute cardiac rejection detected after heart transplantation?
Acute cardiac rejection after heart transplantation is detected by endomyocardial biopsy, which is graded histologically and usually treated with pulse steroids for significant grades. Echocardiography and clinical review support surveillance, but biopsy remains the reference standard for rejection.