Heart transplantation: focus on donor recovery strategies, left ventricular assist devices, and novel therapies

Abstract

Heart transplantation is advocated in selected patients with advanced heart failure in the absence of contraindications. Principal challenges in heart transplantation centre around an insufficient and underutilized donor organ pool, the need to individualize titration of immunosuppressive therapy, and to minimize late complications such as cardiac allograft vasculopathy, malignancy, and renal dysfunction. Advances have served to increase the organ donor pool by advocating the use of donors with underlying hepatitis C virus infection and by expanding the donor source to use hearts donated after circulatory death. New techniques to preserve the donor heart over prolonged ischaemic times, and enabling longer transport times in a safe manner, have been introduced. Mechanical circulatory support as a bridge to transplantation has allowed patients with advanced heart failure to avoid progressive deterioration in hepato-renal function while awaiting an optimal donor organ match. The management of the heart transplantation recipient remains a challenge despite advances in immunosuppression, which provide early gains in rejection avoidance but are associated with infections and late-outcome challenges. In this article, we review contemporary advances and challenges in this field to focus on donor recovery strategies, left ventricular assist devices, and immunosuppressive monitoring therapies with the potential to enhance outcomes. We also describe opportunities for future discovery to include a renewed focus on long-term survival, which continues to be an area that is under-studied and poorly characterized, non-human sources of organs for transplantation including xenotransplantation as well as chimeric transplantation, and technology competitive to human heart transplantation, such as tissue engineering.

Heart failure: an update from the last years and a look at the near future

“…Advanced therapeutic strategies including HTx, mechanical circulatory support (MCS) implantation, intermittent inotropes, and also end-of-life cares are often required in these patients. 324 Age and shock severity predict mortality in cardiac intensive care unit. 325 Heart transplantation remains a limited therapeutic option due to the disproportion between donors and possible candidates needing the transplantation.…”

“…Advanced therapeutic strategies including HTx, mechanical circulatory support (MCS) implantation, intermittent inotropes, and also end‐of‐life cares are often required in these patients 324 . Age and shock severity predict mortality in cardiac intensive care unit 325 …”

Global challenges in left ventricular assist device therapy: a tale across two continents

“…Innovation and expansion in donor organ procurement and utilization (propelled by the use of substance abuse related and hepatitis C viremic donors, donation after circulatory death and ex-situ perfusion) has stimulated an increase in HT. 7,8 A US policy change in 2018 in the national heart allocation system precipitously reduced bridge use of LVADs in exchange for an increase in the use of temporary mechanical circulatory support in candidates awaiting HT. 9 The majority of LVAD implants are now designated as indicated for lifetime use in the US.…”

Breaking barriers in cardiac donation after circulatory death.

“…The shortage of donors and the long waiting list for heart transplantation (HT), have led to search alternatives to brain-dead donation, reviving interest in controlled donation after circulatory death (cDCD) programs (1). It is developed using thoracoabdominal normothermic regional perfusion (TANRP) with extracorporeal membrane oxygenation (ECMO) devices and preserved in cold storage, allowing to perform cardiac transplantation without ex-situ perfusion.…”