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Page 12 of 17 Singh et al. Vessel Plus 2018;2:33 I http://dx.doi.org/10.20517/2574-1209.2018.28

Figure 2. Timeline of events where modifications of “Standard criteria” toward more marginal donors were implemented

Some surgeons also opted to accept hearts with mild-to-moderate mitral or tricuspid insufficiency or
secundum-type atrial septal defects as these could be repaired immediately or post-operatively with
[115]
good results .
As the understanding of myocardial protection improved, the use of mildly hypertrophic left ventricles
[116]
with short ischaemic times were also proposed with the caveat that there were no ECG changes .
Patients with underlying malignancies were previously never considered donor candidates. However, the
risk of metastasis from a primary intracranial tumour is low. A German study in one of the earliest studies
evaluating the outcomes of recipients receiving organs from donors with intracranial malignancies showed
[117]
good follow up outcomes of more than 5 years .

Transplantation also requires commitment from the patients and health care providers as it involves a
long-term programme of treatment including pharmacological immunosuppression and regular surveil-
lance . Clinical decisions therefore should consider a patient’s ability to adhere to the demands of ongo-
[118]
ing treatment. Alternatives to transplantation include the use of Ventricular Assist Devices (VADs). These
are however limited in the National Health Service (NHS) due to the limited health care funding. In North
[119]
America, the Food and Drug Administration recently approved VADs as destination therapy . In its cur-
rent form, heart transplantation confers a significant survival advantage with a 1-year survival of 84.5%
and a 5-year survival of 72.5% which is significantly improved as compared to the 76.9% 1-year survival
and 62.7% 5-year survival in the 1980s [120,121] .

PRIMARY DIAGNOSTIC INDICATIONS FOR TRANSPLANT
The most frequent indications for heart transplantation in adults are chronic heart failure second-
ary to dilated cardiomyopathy or ischaemic heart disease [118] . There is also a significant number of
patients(approximately 3%) with adult congenital heart disease who present with advanced heart failure
[122]
in adulthood . These patients are slightly more complex to manage both surgically (due to the abnormal
anatomy, complex adhesions) and medically (due to human leucocyte antigen sensitisation, potentially
elevated pulmonary vascular resistance secondary to univentricular circulations and erythrocytosis sec-
ondary to cyanosis) [118,122] . Coronary artery disease is the most important contributor to heart failure with
[123]
a population-attributable risk of 65% in men and 48% in women . Most of the patients however can be
classified into ischaemic or non-ischaemic cardiomyopathies.