In addition to these objective measures, candidates must also undergo a thorough evaluation of comorbid conditions and psychosocial health in order to be considered for transplantation. Absolute contraindications are becoming fewer and fewer in the advancing world of cardiac transplantation, although assessing the burden of multiple relative contraindications remains critical to achieving good outcomes. Many patients with concomitant conditions or issues that were once thought too high risk for transplant are now being transplanted successfully in experienced centers. A recent analysis from the Cardiac Transplant Research Database shows that modest improvements in overall transplant survival over the past two decades have occurred despite increased transplant recipient comorbidity and less than ideal organ donors. While physicians will frequently wish to offer transplantation to his or her patient despite substantial comorbidities, the transplant community’s societal responsibility to shepherd a limited resource must take precedence as this offers the greatest opportunity to do the most good. For this reason, many centers limit candidacy to patients <70 years of age and BMI <35. Other relative contraindications to transplantation are recognized in a thorough history and physical, and standardized imaging and laboratory testing with subspecialty consultation always required (Table 16.2).

16.1.2 Post-Transplantation Care and Complications

Immunosuppression is required in the transplant recipient to prevent allograft destruction, and is responsible for the longevity that many recipients experience. However, despite their necessity for preventing organ rejection, immunosuppressant medications also lead to significant morbidity and mortality. An extensive description of specific anti-rejection therapy is beyond the scope of this chapter, and questions should be directed to individual transplant centers as protocols vary and treatment is tailored to each patient’s risk profile, comorbidities, and subsequent side effects. On average, 50% of patients are treated with induction immunosuppressive therapy during the initial post-transplant period. This is followed by lifelong maintenance immunosuppression using a combination of agents. Often this includes “triple therapy” with a combination of a calcineurin inhibitor (i.e. cyclosporine or tacrolimus), a corticosteroid, and an antiproliferative agent (mycophenolate mofetil, sirolimus, everolimus or azathioprine).

Table 16.2 Contraindications to Cardiac Transplant.

Routine cardiac biopsy is an important part of post-transplantation care to detect allograft rejection. If clinically evident, rejection is most commonly heralded by signs and symptoms of congestive heart failure or, less commonly, supraventricular arrhythmias; however, most episodes of cellular rejection are asymptomatic. The presentation of a transplant patient in congestive heart failure is an emergency and should be treated as such with rapid assessment of cardiac function and specialty consultation. The incidence of rejection is highest early after transplantation and decreases substantially over time. In the absence of rejection, the intensity of the immunosuppressive regimen is decreased over time. The schedule of routine surveillance biopsies is correspondingly most intensive in the initial weeks and months following transplantation. Gene expression profiling from peripheral blood mononuclear cells may be used in lieu of biopsies in patients at low risk for cellular rejection.

As in any immunocompromised host, opportunistic infections pose a significant challenge to the post-transplant patient (Table 16.3

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