EINEMANN REVIEWS Cardiovascular Surgery, Vol. 3, NC>. 1, pp. l--14, 1995 Copyright @ 1995 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0967~.?1~~4i% $lO,oo t- O.OiJ Cardiac transplantation: a review M.Yeatman, J. A. Smith, J. J. Dunning, S.R.Large andJ. Wallwork The Transplant Unit, Papworth Hospiital, Cambridge CB3 &IRE,UK Cardiac transplantation is currently a highly successful treatment for selected patients with end-stage cardiac failure. The long-term results are limited by the development of coronary artery vasculopathy, infection and malignancy. The activity of transplantation programmes worldwide is severely limited by the availability of donor organs. Further refinements of immunosuppressive agents are likely to result in improved prevention of both acute and chronic rejection. The donor pool is unlikely to be significantly extended as a result of measures to increase donor organ supply. Alternative methods to allograft transplantation need further investigation to increase the number of therapeutic options available for those patients with end-stage heart failure. Keywords: cardiac transplantation, indications, management, immunosuppression, graft rejection;, complications Introduction During the past two decades heart transplantation has become the treatment of choice for selected patients with end-stage heart failure. It is one of the most conspicuous success stories of 20th century medicine, and more than 26000 heart transplants have been performed worldwide with the 1, 5, and lo-year survival figures now approaching 80%, 65%, and 43% respectively’. By contrast, the l-year survival for patients treated medically with end-stage heart failure (New York Heart Association, NYHA class IV symp- toms, and ejection fractions of less than 0.2) is only 40%” 3. The success of cardiac transplantation is the result of improvements in preoperative evaluation, surgical care, immunosuppressive treatment, and the management of postoperative infection. Quality of life, general health and social rehabilitation are excellent in the majority of cardiac transplant recipients. The proportion of patients returning to work after transplantation is similar to that following coronary artery bypass grafting4 and quality of life does not differ significantly from that of the general population516. Correspondence to: Mr J. Wallwork CAFtCJlOVASCUMR SURGERY FEBRUARY 1995 VOL 3 NO1 1 Major problems that remain to be o\,crcome in the 1990s include the chronic shortage of organ donors (20-40% of patients listed for cardiac transplantation die before a suitable organ can be f’ounJ)P~8, the lack of specific, non-toxic immunosuppression, and late allo- graft failure from graft atherosclerosxs. This article reviews the current status of cardiac transplantation and examines hisrorical developments, worldwide activity, donor organ selection and procure- ment, criteria for recipient selection. rechniques of cardiac transplantation, immunosuppressive therapies, results, complications, and future developments. Refer- ence will be made to the experience of the Transplant Unit at Papworth Hospital over the last !5 years. History of cardiactransplantation The current success of heart transplantation IS based upon a long progression of experimenta{ arld clinical advances. The first heart transplant was performed in 1905 by Carrel and Guthrie’ when they- transplanted the heart of a puppy into the neck of a larger dog. The heart beat for 2 hours before the experiment was terminated. Mann and co-workers in 1933’” and Marcus et al. 1951l’ developed canine cervical hetero- topic models which functioned for up to 41‘ minutes. Histological examination of the excised hearts demons- trated infiltration with lymphocytes, large mononuclear cells and polymorphonuclear cells, suggesting that graft failure resulted from undefined factors relating to tissue