Medical care of heart transplant recipients has varied from center to center and been guided by the experience of individual clinicians ever since the dawn of heart transplantation in the 1960s.
The International Society for Heart and Lung Transplantation (ISHLT) has made an unprecedented commitment by convening experts in all areas of heart transplantation to develop practice guidelines for the care of heart transplant recipients. The Executive Summary of those guidelines is being published as a special featured article in the August issue of The Journal of Heart and Lung Transplantation (www.jhltonline.org).
"These comprehensive guidelines bring consensus and critical analysis of four decades of scientific evidence to a unified platform that will assuredly improve long-term outcomes of the patient undergoing heart transplantation," said Mandeep R. Mehra, MBBS, editor of The Journal of Heart and Lung Transplantation and past president of the ISHLT. "The development of these guidelines began during my tenure as ISHLT President in 2008, and we now see the painstaking culmination of three years of hard work from this group. We are proud of this final outcome which we believe will set the standard worldwide for care of these patients."
John Dark, President of the ISHLT, commented, "All of us working with Cardiac Transplant Recipients will welcome this new and definitive document. Dr Maria Rosa Constanza and her large and distinguished team are to be congratulated on combining science, art, and very considerable clinical experience. They have produced something with the truly international flavor of the ISHLT, which will be of benefit to our patients around the globe."
Because of the limited number of heart transplant recipients worldwide, most of the recommendations are based on expert consensus rather than evidence-based randomized controlled clinical trials. A concerted effort was made to highlight numerous gaps in evidence pertaining to many aspects of the care of heart transplant recipients in order to increase awareness of these issues and spur further research in many important areas of heart transplantation.
"As a longstanding member of ISHLT and former Editor of The Journal of Heart and Lung Transplantation, it has been a great honor for me to lead this challenging and critically important effort," stated Dr. Costanzo. "I owe a great debt of gratitude to Dr. Mandeep Mehra for entrusting me with the leadership of the Guidelines preparation, to my enormously talented Co-Chairs, Drs. Sharon Hunt and David Taylor, and to all the writers who have generously donated their time and expertise to bring the Guidelines to a successful completion. My greatest hopes are that the Guidelines will provide a common ground for the optimal care of heart transplant recipients worldwide and they will be an inspiration for young investigators to further our basic and clinical science knowledge of organ transplantation."
The work was divided into three Task Forces, each of which was co-chaired by a pediatric heart transplant physician who was specially mandated to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation.
Task Force 1 addressed the peri-operative care of heart transplant recipients, including the surgical issues affecting early post-operative care; monitoring and treatment of early hemodynamic, metabolic, and infectious issues; evaluation and treatment of allosensitization; evaluation and treatment of early coagulopathies; the organization of a multidisciplinary care team; management of ABO "incompatible" pediatric heart transplantation; and the use of extracorporeal membrane oxygenation (ECMO) for the hemodynamic support of pediatric recipients.
Task Force 2 discussed the mechanisms, diagnosis, and treatment of heart transplant rejection; the mechanisms of action, dosing, and drug level monitoring of immunosuppressive drugs as well as their adverse effects and interactions with concomitantly used medications; and reviews the major clinical trials and the immunosuppressive strategies to be used in special clinical situations.
Task Force 3 covered the myriad of clinical issues occurring long-term after heart transplantation, including cardiac allograft vasculopathy, the chronic adverse effects of immunosuppression (neurotoxicity, renal insufficiency, hypertension, bone disease, diabetes and malignancy), as well as reproductive health, exercise, psychologic problems, return to work, and operation of motor vehicles after heart transplantation.