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• W2224893286 abstract "In 2005, the International Society for Heart and Lung Transplantation (ISHLT) Board of Directors commissioned the development of the first International Listing Criteria for Heart Transplantation, published in 2006.1Mehra M.R. Kobashigawa J. Starling R. et al.Listing criteria for heart transplantation: International Society for Heart and Lung Transplantation guidelines for the care of cardiac transplant candidates—2006.J Heart Lung Transplant. 2006; 25: 1024-1042Abstract Full Text Full Text PDF PubMed Scopus (648) Google Scholar Subsequently, the ISHLT commissioned a focused update to concentrate on evolving areas of importance, not fully addressed previously. These include congenital heart disease (CHD), restrictive cardiomyopathy, and infectious diseases. In addition, we undertook a review of all 2006 guidelines to update those where new information was evident or evolution in practice demanded significant changes. All recommendations from the prior guideline were reviewed and the details of the older and newer versions are comprehensively summarized in Table 1. Specific areas of changes are discussed with the supporting evidence.Table 1A Comparison of the 2006 vs 2016 Guidelines for Section I (General Considerations)2006 Guideline recommendation2016 Guideline recommendation1.1. Cardiopulmonary stress testing to guide transplant listing1.1. Cardiopulmonary stress testing to guide transplant listingA maximal cardiopulmonary exercise test is defined as one with a respiratory exchange ratio (RER) > 1.05 and achievement of an anaerobic threshold on optimal pharmacologic therapy (Class I, Level of Evidence: B).Continuing approval without change.The presence of a CRT device does not alter the current peak Vo2 cutoff recommendations (Class I, Level of Evidence: B).In patients intolerant of a β-blocker, a cutoff for peak oxygen consumption (Vo2) of ≤ 14 ml/kg/min should be used to guide listing (Class I, Level of Evidence: B).Continuing approval without change.In the presence of a β-blocker, a cutoff for peak Vo2 of ≤ 12 ml/kg/min should be used to guide listing (Class I, Level of Evidence: B).Continuing approval without change.In young patients (< 50 years) and women, it is reasonable to consider using alternate standards in conjunction with peak Vo2 to guide listing, including percent of predicted (≤ 50%) peak Vo2 (Class IIa, Level of Evidence: B).Continuing approval without change.In the presence of a sub-maximal cardiopulmonary exercise test (RER < 1.05), use of ventilation equivalent of carbon dioxide (Ve/Vco2) slope of > 35 as a determinant in listing for transplantation may be considered (Class IIb, Level of Evidence: C).Continuing approval without change.In obese (body mass index [BMI] > 30 kg/m2) patients, adjusting peak Vo2 to lean body mass may be considered. A lean body mass–adjusted peak Vo2 of < 19 ml/kg/min can serve as an optimal threshold to guide prognosis (Class IIb, Level of Evidence: B).Continuing approval without change.Listing patients based solely on the criterion of a peak Vo2 measurement should not be performed (Class III, Level of Evidence: C).Continuing approval without change.1.2. Use of heart failure prognosis scores1.2. Use of heart failure prognosis scoresIn circumstances of ambiguity (e.g., peak Vo2> 12 and <14 ml/kg/ml) a Heart Failure Survival Score (HFSS) may be considered, and it may add discriminatory value to determining prognosis and guide listing for transplantation for ambulatory patients (Class IIb, Level of Evidence: C).Heart failure prognosis scores should be performed along with cardiopulmonary exercise test to determine prognosis and guide listing for transplantation for ambulatory patients. An estimated 1-year survival as calculated by the Seattle Heart Failure Model (SHFM) of < 80% or a Heart Failure Survival Score (HFSS) in the high/medium risk range should be considered as reasonable cut points for listing (Class IIb, Level of Evidence: C).Listing patients solely on the criteria of heart failure survival prognostic scores should not be performed (Class III, Level of Evidence: C).1.3. Role of diagnostic right-heart catheterization1.3. Role of diagnostic right-heart catheterizationRight heart catheterization (RHC) should be performed on all candidates in preparation for listing for cardiac transplantation and annually until transplantation (Class 1, Level of Evidence: C).Right heart catheterization (RHC) should be performed on all adult candidates in preparation for listing for cardiac transplantation and periodically until transplantation (Class 1, Level of Evidence: C). Periodic RHC is not advocated for routine surveillance in children (Class III, Level of Evidence: C).RHC should be performed at 3- to 6-month intervals in listed patients, especially in the presence of reversible pulmonary hypertension or worsening of heart failure symptoms (Class I, Level of Evidence: C).Continuing approval without change.A vasodilator challenge should be administered when the pulmonary artery systolic pressure is ≥ 50 mm Hg and either the transpulmonary gradient is ≥ 15 or the pulmonary vascular resistance (PVR) is > 3Wood units while maintaining a systolic arterial blood pressure > 85 mm Hg (Class I, Level of Evidence: C).Continuing approval without change.When an acute vasodilator challenge is unsuccessful, hospitalization with continuous hemodynamic monitoring should be performed, as often the PVR will decline after 24 to 48 hours of treatment consisting of diuretics, inotropes and vasoactive agents such as inhaled nitric oxide (Class I, Level of Evidence: C).Continuing approval without change.If medical therapy fails to achieve acceptable hemodynamics, and if the left ventricle cannot be effectively unloaded with mechanical adjuncts, including an intra-aortic balloon pump (IABP) and/or left ventricular assist device (LVAD), it is reasonable to conclude that the pulmonary hypertension is irreversible (Class IIb, Level of Evidence: C).If medical therapy fails to achieve acceptable hemodynamics and if the left ventricle cannot be effectively unloaded with mechanical adjuncts, including an intra-aortic balloon pump (IABP) and/or left ventricular assist device (LVAD), it is reasonable to conclude that the pulmonary hypertension is irreversible. After LVAD, reevaluation of hemodynamics should be done after 3 to 6 months to ascertain reversibility of pulmonary hypertension (Class IIA, Level of Evidence: C).1.4. Comorbidities and their implications for heart transplantation listing1.4. Comorbidities and their implications for heart transplantation listing1.4.1. Age, obesity, and cancer1.4.1. Age, obesity, and cancerPatients should be considered for cardiac transplantation if they are ≤ 70 years of age (Class I, Level of Evidence: C).Continuing approval without change.Carefully selected patients > 70 years of age may be considered for cardiac transplantation. For centers considering these patients, the use of an alternate-type program (i.e., use of older donors) may be pursued (Class IIb, Level of Evidence: C).Carefully selected patients > 70 years of age may be considered for cardiac transplantation (Class IIb, Level of Evidence: C).Overall, pre-transplant BMI > 30 kg/m2 or percent ideal body weight (PIBW) > 140% are associated with poor outcome after cardiac transplantation. For obese patients, it is reasonable to recommend weight loss to achieve a BMI of < 30 kg/m2 or percent BMI of < 140% of target before listing for cardiac transplantation (Class IIa, Level of Evidence: C).Pre-transplant body mass index (BMI) > 35 kg/m2 is associated with a worse outcome after cardiac transplantation. For such obese patients, it is reasonable to recommend weight loss to achieve a BMI of ≤ 35 kg/m2 before listing for cardiac transplantation (Class IIa, Level of Evidence: C).Pre-existing neoplasms are diverse, and many are treatable with excision, radiotherapy, or chemotherapy to induce cure or remission. In these patients needing cardiac transplantation, collaboration with oncology specialists should occur to stratify each patient as to their risk of tumor recurrence. Cardiac transplantation should be considered when tumor recurrence is low based on tumor type, response to therapy, and negative metastatic work-up. The specific amount of time to wait to transplant after neoplasm remission will depend on the aforementioned factors and no arbitrary time period for observation should be used (Class I, Level of Evidence: C).Continuing approval without change.1.4.2. Diabetes, renal dysfunction, and peripheral vascular disease1.4.2. Diabetes, renal dysfunction, and peripheral vascular diseaseDiabetes with end-organ damage other than non-proliferative retinopathy or poor glycemic control (glycosylated hemoglobin [HbA1c] > 7.5%) despite optimal effort is a relative contraindication for transplant (Class IIa, Level of Evidence: C).Diabetes with end-organ damage (other than non-proliferative retinopathy) or persistent poor glycemic control (glycosylated hemoglobin [HbA1c] > 7.5% or 58 mmol/mol) despite optimal effort is a relative contraindication for transplant (Class IIa, Level of Evidence: C).Renal function should be assessed using estimated glomerular filtration rate (eGFR) or creatinine clearance under optimal medical therapy. Evidence of abnormal renal function should prompt further investigation, including renal ultrasonography, estimation for proteinuria, and evaluation for renal arterial disease, to exclude intrinsic renal disease. It is reasonable to consider the presence of irreversible renal dysfunction (eGFR < 40 ml/min/1.73 m2) as a relative contraindication for heart transplantation alone (Class IIa, Level of Evidence: C).Renal function should be assessed using estimated glomerular filtration rate (eGFR) or creatinine clearance under optimal medical therapy. Evidence of abnormal renal function should prompt further investigation, including renal ultrasonography, estimation of proteinuria, and evaluation for renal arterial disease, to exclude intrinsic renal disease. It is reasonable to consider the presence of irreversible renal dysfunction (eGFR < 30 ml/min/1.73 m2) as a relative contraindication for heart transplantation alone (Class IIa, Level of Evidence: C).Clinically severe symptomatic cerebrovascular disease, which is not amenable to revascularization, may be considered a contraindication to transplantation. Peripheral vascular disease may be considered as a relative contraindication for transplantation when its presence limits rehabilitation and revascularization is not a viable option (Class IIb, Level of Evidence: C).Clinically severe symptomatic cerebrovascular disease may be considered a contraindication to transplantation. Peripheral vascular disease may be considered a relative contraindication for transplantation when its presence limits rehabilitation and revascularization is not a viable option (Class IIb, Level of Evidence: C).1.4.3. Assessment of frailtyAssessment of frailty (3 of 5 possible symptoms, including unintentional weight loss of ≥10 pounds within the past year, muscle loss, fatigue, slow walking speed, and low levels of physical activity) could be considered when assessing candidacy (Class IIb, Level of Evidence: C).1.4.4. Mechanical circulatory support for bridge to candidacyUse of mechanical circulatory support should be considered for patients with potentially reversible or treatable comorbidities, such as cancer, obesity, renal failure, tobacco use, and pharmacologically irreversible pulmonary hypertension, with subsequent reevaluation to establish candidacy (Class IIb, Level of Evidence: C).1.5. Tobacco use, substance abuse, and psychosocial evaluation in candidates1.5. Tobacco use, substance abuse, and psychosocial evaluation in candidates1.5.1. Tobacco use1.5.1. Tobacco useEducation on the importance of tobacco cessation and reduction in environmental or second-hand exposure should be performed before the transplant and continue throughout the pre- and post-transplant periods (Class I, Level of Evidence: C).Continuing approval without change.It is reasonable to consider active tobacco smoking as a relative contraindication to transplantation. Active tobacco smoking during the previous 6 months is a risk factor for poor outcomes after transplantation (Class IIa, Level of Evidence: C).Continuing approval without change.1.5.2. Substance abuse1.5.2. Substance abuseA structured rehabilitative program may be considered for patients with a recent (24-month) history of alcohol abuse if transplantation is being considered (Class IIb, Level of Evidence: C).Continuing approval without change.Patients who remain active substance abusers (including alcohol) should not receive heart transplantation (Class III, Level of Evidence: C).Continuing approval without change1.5.3. Psychosocial evaluation1.5.3. Psychosocial evaluationPsychosocial assessment should be performed before listing for transplantation. Evaluation should include an assessment of the patient’s ability to give informed consent and comply with instruction, including drug therapy, as well as assessment of the support systems in place at home or in the community (Class I, Level of Evidence: C).Continuing approval without change.Mental retardation or dementia may be regarded as a relative contraindication to transplantation (Class IIa, Level of Evidence: C).Any patient for whom social supports are deemed insufficient to achieve compliant care in the outpatient setting may be regarded as having a relative contraindication to transplant. The benefit of heart transplantation in patients with severe cognitive-behavioral disabilities or dementia (e.g., self-injurious behavior, inability to ever understand and cooperate with medical care) has not been established, has the potential for harm, and therefore, heart transplantation cannot be recommended for this sub-group of patients (Class IIa, Level of Evidence: C).Poor compliance with drug regimens is a risk factor for graft rejection and mortality. Patients who have demonstrated an inability to comply with drug therapy on multiple occasions should not receive transplantation (Class III, Level of Evidence: C).Continuing approval without change.1.6. Guidance for screening grids and serial pre-transplant evaluation1.6. Guidance for screening grids and serial pre-transplant evaluationSee grid in paper.Continuing approval without change.1.7. Dynamic listing and new donor allocation algorithms1.7. Dynamic listing and new donor allocation algorithmsListed patients who are in an outpatient ambulatory non–inotropic-therapy-dependent state should be continually evaluated for maximal pharmacologic and device therapy, including implantable cardioverter defibrillator (ICD) or biventricular pacing, when appropriate. Such patients must be re-evaluated at 3- to 6-month intervals with cardiopulmonary exercise testing to assess their response to therapy and, if they have improved significantly, they may be candidates for delisting (Class I, Level of Evidence: C).Listed patients in an outpatient, ambulatory, non–inotropic therapy–dependent state should be continually evaluated for maximal pharmacologic and device therapy, including implantable cardioverter defibrillator (ICD) or biventricular pacing, when appropriate. Such patients must be re-evaluated at 3- to 6-month intervals with cardiopulmonary exercise testing and heart failure survival prognostic scores to assess their response to therapy and, if they have improved significantly, should be considered for delisting (Class I, Level of Evidence: C).Redesigned allocation algorithms should be considered that allow for the prioritization of higher-status patients within larger geographic areas (within accepted safe ischemic time limitations). This practice may reduce deaths on the waiting list by both providing more hearts in a timely fashion to the higher-acuity population (Class I, Level of Evidence: C).DeleteHigher prioritization for highly sensitized patients may be considered due to difficulty obtaining a donor, causing excessive waiting times and an increase in waiting list mortality (Class IIb, Level of Evidence: C).1.8 RetransplantationRetransplantation is indicated for those patients who develop significant CAV with refractory cardiac allograft dysfunction, without evidence of ongoing rejection (Class IIa, Level of Evidence: C). Open table in a new tab Please note that the numeric categorization has been adjusted to coincide with the 2006 guidelines as closely as possible. The 2006 recommendations for cardiopulmonary stress testing remain unchanged in the 2016 version, with the exception of an additional comment on cardiac resynchronization therapy (CRT) devices. Recommendation: The presence of a CRT device does not alter the current peak volume of oxygen consumption (Vo2) cutoff recommendations (Class I, Level of Evidence: B). Evidence from the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) trial has shown that despite improvements in New York Heart Association Functional Classification or 6-minute walk test distance, CRT did not have an effect on the predictability of peak Vo2 on adverse cardiac events.2De Marco T. Wolfel E. Feldman A.M. et al.Impact of cardiac resynchronization therapy on exercise performance, functional capacity, and quality of life in systolic heart failure with QRS prolongation: COMPANION trial sub-study.J Card Fail. 2008; 14: 9-18Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar A more recent retrospective study evaluated the predictability of peak Vo2 in patients undergoing evaluation for heart transplantation (HT) with an implantable cardioverter defibrillator (ICD), CRT, or both (CRT-D) devices. This study suggested that a peak Vo2 ≤ 10 ml/kg/min rather than the traditional cutoff value of ≤ 14 ml/kg/min may be more useful for risk stratification in the device era.3Goda A. Lund L.H. Mancini D. The Heart Failure Survival Score outperforms the peak oxygen consumption for heart transplantation selection in the era of device therapy.J Heart Lung Transplant. 2011; 30: 315-325Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar At this time, we feel that using currently accepted peak Vo2 values are appropriate when taken into context with the rest of the data collected during the evaluation process. Heart failure survival scores (HFSSs) have been used to predict morbidity and mortality in ambulatory heart failure patients. Their usefulness in guiding HT listing in ambulatory patients has been evaluated. Recommendation: Heart failure survival prognosis scores may be assessed along with the cardiopulmonary exercise testing to determine prognosis and guide listing for transplantation for ambulatory patients. An estimated 1-year survival, as calculated by the Seattle Heart Failure Model (SHFM) of < 80%, or an HFSS in the high-risk to medium-risk range should be considered as reasonable cut points for listing (Class IIb, Level of Evidence: C). The use of risk scores to assist clinicians with therapeutic decisions has increased, especially with the introduction of various risk models for mechanical circulatory support (MCS). The SHFM and HFSS have been evaluated as tools to guide listing for HT. Notably, the SHFM was found to potentially underestimate 1-year risk of needing urgent transplantation, ventricular assist device (VAD), or mortality in patients with advanced heart failure being considered for transplantation and in some special populations.4Gorodeski E.Z. Chu E.C. Chow C.H. et al.Application of the Seattle Heart Failure Model in ambulatory patients presented to an advanced heart failure therapeutics committee.Circ Heart Fail. 2010; 3: 706-714Crossref PubMed Scopus (64) Google Scholar, 5Kalogeropoulos A.P. Georgiopoulou V.V. Giamouzis G. et al.Utility of the Seattle Heart Failure Model in patients with advanced heart failure.J Am Coll Cardiol. 2009; 53: 334-342Crossref PubMed Scopus (108) Google Scholar For those patients with intermediate risk of needing urgent transplantation, VAD, or mortality as assessed by the SHFM, the addition of peak Vo2 may assist in improved risk stratification and aid listing decisions.6Levy W.C. Aaronson K.D. Dardas T.F. et al.Prognostic impact of the addition of peak oxygen consumption to the Seattle Heart Failure Model in a transplant referral population.J Heart Lung Transplant. 2012; 31: 817-824Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar The HFSS was compared with peak Vo2 in a retrospective study of heart failure patients with CRT, CRT-D, or ICD alone.3Goda A. Lund L.H. Mancini D. The Heart Failure Survival Score outperforms the peak oxygen consumption for heart transplantation selection in the era of device therapy.J Heart Lung Transplant. 2011; 30: 315-325Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar The HFSS outperformed peak VO2 in its ability to discriminate between patients at low or medium risk of death at 1 year. Goda et al7Goda A. Williams P. Mancini D. Lund L.H. Selecting patients for heart transplantation: comparison of the Heart Failure Survival Score (HFSS) and the Seattle heart failure model (SHFM).J Heart Lung Transplant. 2011; 30: 1236-1243Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar went on to determine that combining both risk scores in patients undergoing transplant evaluation outperformed either risk score alone in predicting event-free survival. These risk scores may assist the clinician in discriminating patients who should be listed for transplantation; however, the inherent limitations of each risk score need to be kept in mind. Recommendation: Listing patients solely on the criteria of heart failure survival prognostic scores should not be performed (Class III, Level of Evidence: C). Right-heart catheterization (RHC) remains an important test for assessing and maintaining HT candidacy. The following changes are regarding timing for repeat measurements. Recommendation: RHC should be performed on all adult candidates in preparation for listing for cardiac transplantation and periodically until transplantation (Class I, Level of Evidence: C). Periodic RHC is not advocated for routine surveillance in children (Class III, Level of Evidence: C). There was consensus that RHC should be performed periodically as the medical team feels it is indicated and that annual evaluation may be too long of a time period in some patients. In the previous guideline, a time period frequency of 3 to 6 months was suggested; however, at this time, we believe that programs should individualize the frequency depending on the situation (presence of pulmonary hypertension on the initial RHC, ongoing stability of heart failure, current left ventricular assist device [LVAD] support). RHC will need to be considered case-by-case in children, and routine periodic surveillance is not generally advocated, unless evidence for clinical change is noted. Recommendation: If medical therapy fails to achieve acceptable hemodynamics and if the LV cannot be effectively unloaded with mechanical adjuncts, including an intra-aortic balloon pump (IABP) and/or LVAD, it is reasonable to conclude that the pulmonary hypertension is irreversible. After LVAD implantation, re-evaluation of hemodynamics should be done after 3 to 6 months to ascertain reversibility of pulmonary hypertension (Class IIA, Level of Evidence: C). Elevated pulmonary vascular resistance (PVR) that is refractory to medical therapy may be a contraindication to HT, depending on severity. VADs have been used in patients with refractory elevations in PVR. Investigators in 2 separate studies have shown that this strategy can be successful at reducing PVR into a range that is safe for cardiac transplantation.8Mikus E. Stepanenko A. Krabatsch T. et al.Reversibility of fixed pulmonary hypertension in left ventricular assist device support recipients.Eur J Cardiothorac Surg. 2011; 40: 971-977Crossref PubMed Scopus (94) Google Scholar, 9Kutty R.S. Parameshwar J. Lewis C. et al.Use of centrifugal left ventricular assist device as a bridge to candidacy in severe heart failure with secondary pulmonary hypertension.Eur J Cardiothorac Surg. 2013; 43: 1237-1242Crossref PubMed Scopus (41) Google Scholar More importantly, both groups of authors reported some benefit as early as 1 month, but it may take as long as 3 to 6 months to achieve maximum reversibility. Therefore, in order to make full determination of reversibility after VAD implantation, it is important to allow enough time for this therapy to have an effect. Evaluation and handling of comorbidities is imperative in order to improve post-transplant outcomes. In this section, the issues of age, obesity, and renal function were modified according to contemporary practice. The use of MCS systems in patients with comorbidities and their implications were also discussed in this guideline. Recommendation: Carefully selected patients >70 years of age may be considered for cardiac transplantation (Class IIb, Level of Evidence: C). Goldstein et al10Goldstein D.J. Bello R. Shin J.J. et al.Outcomes of cardiac transplantation in septuagenarians.J Heart Lung Transplant. 2012; 31: 679-685Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar reported the outcomes of cardiac transplantation in septuagenarians who were carefully evaluated and underwent HT in the United States. These patients derived benefit from this therapy, suffering less rejection but a higher mortality than those slightly younger. Most programs that are performing transplantation in patients aged >70 years are doing so with both specific donor and recipient criteria in place. Therefore, the need to state use of an “alternative allocation” program was felt to be unnecessary and adds to confusion. Nevertheless, local policies to define the upper age limit for eligibility to transplant should be placed into the context of local organ availability and quality in order to maintain acceptable transplant outcomes and a reasonable chance to transplant all listed patients. Recommendation: A pre-transplant body mass index (BMI) >35 kg/m2 is associated with a worse outcome after cardiac transplantation. For such obese patients, it is reasonable to recommend weight loss to achieve a BMI of ≤35 kg/m2 before listing for cardiac transplantation (Class IIa, Level of Evidence: C). Several reports have been published since the 2006 guidelines regarding the effect of BMI on outcomes after HT.11Weiss E.S. Allen J.G. Russell S.D. Shah A.S. Conte J.V. Impact of recipient body mass index on organ allocation and mortality in orthotopic heart transplantation.J Heart Lung Transplant. 2009; 28: 1150-1157Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 12Russo M.J. Hong K.N. Davies R.R. et al.The effect of body mass index on survival following heart transplantation: do outcomes support consensus guidelines?.Ann Surg. 2010; 251: 144-152Crossref PubMed Scopus (66) Google Scholar, 13Macha M. Molina E.J. Franco M. et al.Pre-transplant obesity in heart transplantation: are there predictors of worse outcomes?.Scand Cardiovasc J. 2009; 43: 304-310Crossref PubMed Scopus (12) Google Scholar BMI in the obese range but < 35 kg/m2 has not been convincingly associated with an increase in mortality after transplantation. However, those patients with a BMI >35 kg/m2 had longer waiting times, were less likely to find a suitable donor, and in some reports had an increase in post-transplant morbidity and mortality. On the basis of these data, the guideline has been amended to recommend that patients achieve a BMI ≤ 35 kg/m2 for listing. Because BMI is the parameter used most often, we opted to remove percentage ideal body weight < 140% from the guideline. Recommendation: Diabetes with end-organ damage (other than non-proliferative retinopathy) or persistent poor glycemic control (glycosylated hemoglobin [HbA1c] > 7.5% or 58 mmol/mol), despite optimal effort, is a relative contraindication for transplant (Class IIa, Level of Evidence: C). The addition of a HbA1c value of 58 mmol/mol was added to be comprehensive and internationally relevant. Recommendation: Renal function should be assessed using the estimated glomerular filtration rate (eGFR) or creatinine clearance under optimal medical therapy. Evidence of abnormal renal function should prompt further investigation, including renal ultrasonography, estimation of proteinuria, and evaluation for renal arterial disease, to exclude intrinsic renal disease. It is reasonable to consider the presence of irreversible renal dysfunction (eGFR < 30 ml/min/1.73 m2) as a relative contraindication for HT alone (Class IIa, Level of Evidence: C). Renal dysfunction continues to play an important role in outcomes after HT. More often than not, committees are forced to make decisions regarding HT alone, heart-kidney transplant, or deferring transplantation altogether. Unfortunately, which test or formula required to determine irreversible renal dysfunction has not been fully elucidated, with several prevalent formulas to measure eGFR. In the current guidelines, the eGFR, a measure of renal function, was reduced to < 30 ml/min/1.73 m2 to be considered as a relative contraindication for HT. Recommendation: Clinically severe symptomatic cerebrovascular disease (CVD) may be considered a contraindication to transplantation. Peripheral vascular disease may be considered a relative contraindication for transplantation when its presence limits rehabilitation and revascularization is not a viable option (Class IIb, Level of Evidence: C). Cerebrovascular accidents are a devastating complication after transplant surgery and can greatly alter quality of life and survival. The prior guideline included “not amenable to revascularization” in its" @default.
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• W2224893286 date "2016-01-01" @default.
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• W2224893286 title "The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update" @default.
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