Management of the posttransplant cardiac patient

More than 2000 Americans undergo a heart transplant each year, the only curative therapy for end-stage heart failure. Many factors are critical to a successful outcome, starting with skilled preoperative to postoperative care from a team of experienced clinicians and ancillary health-care professionals. This chapter describes the multiple factors critical to limiting posttransplant complications and preserving early graft function, including periprocedural immunosuppression, infection prophylaxis, and early recognition and treatment of any allograft-related right ventricular dysfunction. Successful outcomes also depend on efforts related to careful matching of heart donors and recipients, which helps limit posttransplant complications. The most basic factor for transplant success is the availability of donor organs, whose numbers have remained unchanged despite efforts to increase awareness and volume. New technologies show promise in boosting the number of viable donor hearts for transplant. One example is the "heart-in-a-box" organ preservation technology from TransMedics, Inc., which restores optimal ex vivo human heart perfusion, reduces ischemic time, and may help preserve function. Future developments to impact survival and graft function are expected to include personalized immunosuppression modifications, development of donor risk scores, and new immunosuppressive agents.