Transplantation.
Recognise the window.
Plan beyond the operation.
Transplantation can offer selected patients with advanced heart failure longer survival and better quality of life. Referral begins a conversation about options; it does not commit someone to a waiting list.
Refer before the options narrow.
Advanced heart failure is a clinical trajectory, not simply a very low ejection fraction. Persistent severe symptoms, recurrent admissions and progressive organ dysfunction despite appropriate treatment should prompt an advanced-HF discussion. Patients with restrictive, hypertrophic or congenital disease may need assessment even when EF is preserved.
Recognise the pattern
- Repeated admissions or urgent visits for congestion or low output.
- Increasing diuretic requirements, refractory fluid retention or dependence on intravenous therapy.
- Persistent marked exercise limitation, fatigue or symptoms at rest.
- Low blood pressure or renal dysfunction limiting prognostic medicines.
- Inotrope dependence, recurrent ventricular arrhythmias or repeated ICD therapies.
- Worsening renal or hepatic function, weight loss, malnutrition or progressive frailty.
Assess what can still change
Review treatment, adherence, rhythm, ischaemia, valve disease and other reversible contributors. Confirm whether medical therapy and appropriate devices have been optimised, but do not postpone referral while deterioration continues.
Referral is especially time-sensitive when end-organ injury is progressing. Cardiogenic shock or escalating support needs require urgent specialist discussion rather than a routine outpatient pathway.
Referral, assessment and listing are different decisions
The advanced-HF team may recommend further optimisation, transplantation assessment, mechanical support, or a care plan focused on symptom control. Supportive and palliative care can run alongside active treatment at every stage.
Assess the person.
Estimate the benefit.
Selection balances the risk of continuing with the native heart against the risks of transplantation and lifelong treatment. A multidisciplinary assessment considers expected benefit, operative risk, other disease, rehabilitation potential and the person's priorities.
How severe is the cardiac limitation?
Review symptoms, admissions, treatment tolerance, rhythm and imaging. CPET measures integrated exercise capacity: peak oxygen uptake, ventilatory efficiency and whether effort was adequate all matter. Results require context, including age, body composition, medication and non-cardiac limitation; no single CPET value should decide listing.
Right-heart catheterisation measures filling pressures and cardiac output and helps distinguish passive pulmonary venous hypertension from an additional pulmonary vascular component.
Revisit the investigations chapter ↗Why does pulmonary vascular resistance matter?
The donor right ventricle must pump into the recipient's pulmonary circulation. Markedly elevated, poorly reversible resistance can cause acute donor RV failure even if the donor heart was previously healthy.
Interpret pulmonary pressures with wedge pressure and flow. The team may assess reversibility after decongestion, vasodilator testing or a period of LV unloading. A high pulmonary artery pressure alone does not establish irreversible pulmonary vascular disease.
Can the rest of the body recover?
Renal and hepatic assessment asks how much dysfunction reflects low output or congestion and how much is intrinsic, irreversible disease. Review lung disease, vascular disease, diabetes and its complications, infection, malignancy risk, nutrition and frailty. Some patients require consideration of combined-organ transplantation; that is a separate specialist assessment.
Compatibility, infection and practical preparation
Assessment includes blood group, body size, HLA sensitisation and donor-specific antibody risk, alongside infection screening and vaccination planning. Previous pregnancy, transfusion or mechanical support can contribute to sensitisation. Donor selection and crossmatching aim to reduce immune incompatibility; the exact pathway is centre-specific.
Dental health, cancer screening and rehabilitation needs are reviewed. Psychological assessment, medication-taking, substance use, health literacy, transport and social support matter because treatment continues long after surgery. Identify barriers and provide support rather than treating social circumstances as a simple pass/fail test.
What may prevent or postpone listing?
Examples include uncontrolled infection, active malignancy with unacceptable recurrence risk, severe irreversible non-cardiac disease, or pulmonary vascular disease that cannot be made compatible with safe transplantation. Some barriers are modifiable. Age, frailty and comorbidity are assessed together; a single birthday or EF is not an adequate selection rule.
The transplant centre makes the decision using current national policy and individual assessment. Assessment may lead to acceptance, further work before reconsideration, or a recommendation against transplantation.
A waiting list is an active care pathway.
Listing does not guarantee a transplant or a predictable date. UK allocation considers clinical urgency and donor–recipient suitability under NHS Blood and Transplant policy. Blood group, size, sensitisation and donor availability can all affect the wait; this is not simply a first-come, first-served queue.
Keep reassessing
Continue appropriate HF treatment, review congestion and perfusion, maintain nutrition and physical capacity where possible, and update the centre about admissions, infections or new diagnoses. Deterioration can alter urgency, support requirements or eligibility. Improvement can also change the balance of benefit.
Patients need a clear contact plan and preparation for an offer at short notice. An offer can still be cancelled if donor assessment or recipient circumstances make proceeding unsafe.
Support while a decision or donor is awaited
Selected patients need inotropes or temporary mechanical support for severe low output. A durable LVAD may be used as a bridge to transplant or to improve candidacy. Temporary VA-ECMO can support selected patients in shock while recovery, neurological status and longer-term options are assessed.
Every bridge needs a destination and repeated review. Neither an LVAD nor ECMO automatically makes someone a transplant candidate.
Explore LVAD and ECMO ↗Donation after brain death and circulatory death
Donor hearts may come from donation after brain death (DBD) or, in established programmes, donation after circulatory death (DCD). These describe the circumstances of donation, not the recipient's diagnosis. DCD heart transplantation requires specialised retrieval, preservation and assessment techniques.
The transplant team discusses donor-specific benefits and uncertainties, organ quality and transmission risks. Preservation and perfusion methods support assessment and transport; they do not remove all risk of graft dysfunction.
A new pump.
A different physiological context.
In an orthotopic transplant, the donor heart replaces the native heart in its usual position. During cardiopulmonary bypass, surgical connections restore venous return, pulmonary circulation and systemic outflow. A bicaval technique connects the venae cavae separately; a recipient left-atrial cuff around the pulmonary veins is retained.
The early postoperative priorities
Intensive-care monitoring focuses on graft function, haemodynamics, bleeding, rhythm, oxygenation, renal function and infection. Primary graft dysfunction is early pump failure without an identifiable secondary cause; it is not synonymous with rejection. Severe dysfunction may require temporary mechanical support.
The donor RV is particularly vulnerable to a high pulmonary vascular load. Secondary causes of graft dysfunction—including surgical problems, pulmonary hypertension and rejection—need specific investigation.
The transplanted heart is initially denervated
Surgical interruption of autonomic nerves removes much of the immediate neural control of heart rate. Resting heart rate is often higher, and the rise and recovery during exercise can be slower as circulating catecholamines assume a greater role. Warm-up and cool-down are useful in rehabilitation.
Denervation can blunt typical angina; absence of chest pain does not exclude graft coronary disease. Variable reinnervation may develop over time. Drug and rhythm responses can differ, so involve the transplant team in acute management.
Protect the graft.
Preserve immune defence.
The recipient's immune system can recognise donor antigens as foreign. Immunosuppression reduces that response, but increases infection and malignancy risk and carries drug-specific toxicity. Treatment aims for sufficient suppression with the lowest acceptable burden—not maximal suppression at all times.
Qualitative teaching pathways. These processes can coexist; symptoms and timing alone cannot classify rejection.
How do the medicines interrupt this response?
A common maintenance regimen combines a calcineurin inhibitor, an antimetabolite and a corticosteroid. The combination targets different parts of the response; doses and later steroid withdrawal are individualised by the transplant team.
Calcineurin inhibitor · commonly tacrolimus
Tacrolimus binds FKBP12 and inhibits calcineurin, reducing activation of transcription factors needed for interleukin-2 production and T-cell activation. Ciclosporin acts through a different binding protein, cyclophilin, on the same signalling pathway.
Monitor drug exposure and renal function, potassium, magnesium, blood pressure and glucose. Nephrotoxicity, tremor and other neurotoxicity are relevant; interactions can markedly change concentrations.
Antimetabolite · commonly mycophenolate
Mycophenolate inhibits inosine monophosphate dehydrogenase, limiting de novo guanine synthesis. Lymphocytes depend heavily on this pathway, so their proliferation is reduced.
Diarrhoea and other gastrointestinal effects, leucopenia and infection can limit treatment. It is teratogenic: pregnancy planning requires specialist advice and an advance medication plan.
Corticosteroid · commonly prednisolone
Glucocorticoid-receptor activation changes gene transcription and suppresses several inflammatory and immune pathways. Steroids are often used early, then reduced according to the programme and rejection risk; some patients remain on long-term treatment.
Consider hyperglycaemia, weight gain, osteoporosis, infection, mood changes and adrenal suppression. Patients must not abruptly stop prescribed steroids.
Other strategies · selected patients
Induction therapy around transplantation may use lymphocyte-depleting or interleukin-2 receptor-directed treatment. mTOR inhibitors such as sirolimus or everolimus inhibit growth signalling downstream of cytokine receptors and may form part of an alternative maintenance strategy.
Choice depends on rejection risk, renal function, malignancy or vasculopathy and tolerability. mTOR inhibitors can cause impaired wound healing, mouth ulcers, dyslipidaemia, proteinuria and pneumonitis. Regimens and drug targets belong to the transplant centre.
Surveillance: rejection can be clinically silent
Follow-up combines clinical assessment, ECG, echocardiography, blood tests and centre-specific rejection surveillance. Endomyocardial biopsy samples myocardial tissue to assess cellular rejection and antibody-mediated injury. Donor-specific antibody testing adds information; a positive antibody result alone does not establish clinically significant rejection.
Some programmes use non-invasive molecular tests in selected settings. These complement a defined surveillance pathway and do not make every biopsy unnecessary. New graft dysfunction or haemodynamic compromise needs urgent specialist assessment, even if recent surveillance was reassuring.
The operation begins lifelong care.
Many recipients regain substantial function and quality of life, but transplantation replaces one complex condition with a different long-term care pathway. Outcomes depend on recipient and donor factors, complications and follow-up; population survival figures should support an individual discussion, not be presented as a personal forecast.
Infection prevention and recognition
Early infection risk reflects surgery and intensive care; opportunistic infections become important with immunosuppression. CMV risk depends partly on donor and recipient status. CMV and Pneumocystis prophylaxis, vaccination and monitoring follow the centre's protocol.
Fever may be absent or muted. New breathlessness, cough, diarrhoea, urinary symptoms or unexplained malaise require a low threshold for advice. Vaccination should be planned with the transplant team; live vaccines are generally avoided after transplantation.
Protect vessels, kidneys and bones
Monitor hypertension, dyslipidaemia, diabetes, renal dysfunction and bone health. Coronary allograft vasculopathy requires dedicated surveillance because diffuse disease and denervation can make symptoms unreliable. Lipid-lowering therapy and risk-factor management form part of specialist follow-up.
Immunosuppression increases skin cancer and other malignancy risks, including post-transplant lymphoproliferative disease. Sun protection, skin review and age-appropriate screening remain important.
Medication safety is shared work
Patients need consistent access to medicines, clear instructions for blood sampling and a plan for missed doses or vomiting. Drug concentrations depend on sample timing: interpret a trough only in relation to the last dose and the centre's target. Never change or withhold immunosuppression casually.
Check every new prescription, over-the-counter medicine and supplement for interactions. Macrolides, azole antifungals, rifampicin and St John's wort are examples that can substantially alter calcineurin-inhibitor exposure. Avoid generic advice to “stop nephrotoxic drugs” without discussing the transplant regimen.
When a transplant recipient becomes unwell
New breathlessness, oedema, syncope, arrhythmia, hypotension, fever, reduced urine output or inability to retain medicines warrants prompt contact with the transplant centre. Severe instability needs emergency assessment and simultaneous specialist involvement. Consider infection, rejection, graft vascular disease, drug toxicity and ordinary non-transplant causes.
Recovery extends beyond the graft
Cardiac rehabilitation, nutrition, mental health, return to work, travel and sexual health are part of care. Discuss pregnancy before conception. Patients and families may need help with uncertainty, the meaning of donation and the practical burden of treatment.
The transplant centre coordinates specialist surveillance, while community nurses, pharmacists, primary care and local cardiology teams contribute substantially. Agree who orders tests, reviews results, supplies medicines and responds to abnormalities. Reliable shared care is active clinical work.
NHS Blood and Transplant · heart transplantation
NHSBT · assessment tests
NHSBT · UK donor allocation
NHSBT · transplant medicines
ISHLT · evaluation and care of cardiac transplant candidates (2024)
ISHLT · care of heart transplant recipients (2023)
Educational first draft, 30 October 2026. National allocation policy, eligibility decisions, drug targets and surveillance schedules should be checked with the transplant centre before clinical use.