Costanzo M R, Augustine S, Bourge R, Bristow M, O'Connell J B, Driscoll D, Rose E
Office of Scientific Affairs, American Heart Association, Dallas, TX 75231-4596, USA.
Circulation. 1995 Dec 15;92(12):3593-612. doi: 10.1161/01.cir.92.12.3593.
Improved outcome of heart failure in response to medical therapy, coupled with a critical shortage of donor organs, makes it imperative to restrict heart transplantation to patients who are most disabled by heart failure and who are likely to derive the maximum benefit from transplantation. Hemodynamic and functional indexes of prognosis are helpful in identifying these patients. Stratification of ambulatory heart failure patients by objective criteria, such as peak exercise oxygen consumption, has improved ability to select appropriate adult patients for heart transplantation. Such patients will have a poor prognosis despite optimal medical therapy. When determining the impact of individual comorbid conditions on a patient's candidacy for heart transplantation, the detrimental effects of each condition on posttransplantation outcome should be weighed. Evaluation of patients with severe heart failure should be done by a multidisciplinary team that is expert in management of heart failure, performance of cardiac surgery in patients with low left ventricular ejection fraction, and transplantation. Potential heart transplant candidates should be reevaluated on a regular basis to assess continued need for transplantation. Long-term management of heart failure should include continuity of care by an experienced physician, optimal dosing in conventional therapy, and periodic reevaluation of left ventricular function and exercise capacity. The outcome of high-risk conventional cardiovascular surgery should be weighed against that of transplantation in patients with ischemic and valvular heart disease. Establishment of regional specialized heart failure centers may improve access to optimal medical therapy and new promising medical and surgical treatments for these patients as well as stimulate investigative efforts to accelerate progress in this critical area.
心力衰竭患者经药物治疗后预后改善，加之供体器官严重短缺，因此必须将心脏移植限制于心力衰竭导致最严重功能障碍且可能从移植中获益最大的患者。预后的血流动力学和功能指标有助于识别这些患者。通过客观标准（如运动峰值耗氧量）对门诊心力衰竭患者进行分层，提高了选择合适成年心脏移植患者的能力。尽管接受了最佳药物治疗，这类患者的预后仍较差。在确定个体合并症对患者心脏移植候选资格的影响时，应权衡每种疾病对移植后结局的不利影响。对重度心力衰竭患者的评估应由一个多学科团队进行，该团队在心力衰竭管理、左心室射血分数低的患者的心脏手术操作及移植方面具有专业知识。潜在的心脏移植候选者应定期重新评估，以评估是否仍有移植需求。心力衰竭的长期管理应包括由经验丰富的医生提供持续护理、常规治疗中优化用药剂量以及定期重新评估左心室功能和运动能力。对于患有缺血性和瓣膜性心脏病的患者，应权衡高风险常规心血管手术与移植的结局。建立区域性专业心力衰竭中心可能会改善这些患者获得最佳药物治疗以及新的有前景的药物和手术治疗的机会，并促进研究工作，以加速这一关键领域的进展。
