CARDIAC TRANSPLANTATION FOR END-STAGE HEART-DISEASE

Orthotopic heart transplantation (OHT), first accomplished in 1967, is currently performed in over 2000 patients per year at hundreds of cen ters worldwide. Selection criteria include end-stage heart failure wit h a limited life expectancy, intractable angina due to inoperable coro nary artery disease, malignant ventricular arrhythmias refractory to m aximal therapy, and unresectable cardiac tumors. While early immunosup pression was based on azathioprine and steroids, the current success o f OHT is based on the addition of cyclosporine A (CyA) to this regimen . At Columbia-Presbyterian Medical Center, steroids and azathioprine a re given perioperatively, and cyclosporine (OKT3 in patients with rena l dysfunction) begun postoperatively. Survival rates at our institutio n parallel those reported by other centers, with 1- and 5-year actuari al survival of 85% and 70%, respectively. The most frequent causes of early mortality are allograft rejection and infection, while graft cor onary artery disease (CAD) is responsible for most deaths occurring af ter the first post-transplant year. Regular endomyocardial biopsy is u sed to monitor for rejection, which occurs in 55% of patients within t he first year. Mild or asymptomatic rejection is managed with oral ste roids, followed by intravenous steroids and/or OKT3 or anti-thymocyte globulin (ATG) in refractory cases. Graft CAD occurs in 45% of patient s surviving 3 years, and may require retransplantation. Heart transpla ntation is a proven, effective form of cardiac replacement. The recent trend of increasingly critically ill transplant candidates, however, has driven the costs of OHT to unprecedented levels. This issue, as we ll as the continuing organ shortage and current developments in mechan ical cardiac assistance and xenotransplantation will undoubtedly assur e a continually evolving role for cardiac transplantation in the treat ment of endstage heart disease.