p.66 抽出テキスト
May 3, 2022 Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 e960 CLINICAL STATEMENTS AND GUIDELINES use to allow patients to engage in decision-making for durable MCS or transplantation and for determination of recovery of neurologic status. 8.5 Cardiac Transplantation Recommendation for Cardiac Transplantation COR LOE Recommendation 1 C-LD 1. For selected patients with advanced HF despite GDMT, cardiac transplantation is indicated to improve survival and QOL.1–3 Value Statement: Intermediate Value (C-LD) 2. In patients with stage D (advanced) HF despite GDMT, cardiac transplantation provides intermediate economic value.4 Synopsis The evidence that cardiac transplantation provides a mortality and morbidity benefit to selected patients with stage D HF (refractory, advanced) is derived from observational cohorts. Datasets from the International Society for Heart and Lung Transplantation1 and United Network of Organ Sharing2 document the median survival of adult transplant recipients to be now >12 years; the median survival of patients with stage D HF without advanced therapies is <2 years. For comparison, the risk of death becomes greater than survival between 3 and 4 years on an LVAD, regardless of implant strategy (eg, bridge-to-transplant, bridge-to-decision, destination therapy).3 Improvements in pre- and posttransplant management have also increased more patients to be eligible for transplant, and treated rejection rates in the first year after transplantation are now <15%.1 Minimizing waitlist mortality while maximizing posttransplant outcomes continues to be a priority in heart transplantation and was addressed with the recent changes in donor allocation policy instituted in 2018.5 Several analyses6–11 have confirmed a decrease in waitlist mortality as well as an increase in the use of temporary circulatory support devices, graft ischemic times, and distances between donor and recipient hospitals. The impact on posttransplant survival remains uncertain. Multiorgan transplantation remains uncommon and reserved for highly selected candidates. In 2018, 7% of all heart transplants involved another organ, in addition to the heart.1 Recommendation-Specific Supportive Text 1. Cardiac transplantation is the established treatment for eligible patients with stage D HF refractory to GDMT, device, and surgical optimization. The survival of adult recipients who received a transplantation between 2011 and 2013 at 1, 3, and 5 years is 90.3%, 84.7%, and 79.6%, respectively.2 Conditional survival now approaches 15 years.1 Cardiac transplantation also improves functional status and health-related QOL.12–15 Good outcomes can be achieved in patients not only with HF that is primarily cardiovascular in origin, including reversible pulmonary hypertension,16 congenital heart disease,17 and hypertrophic cardiomyopathy,18 but also in patients with systemic conditions complicated by HF, such as muscular dystrophy,19 sarcoidosis,20 and amyloidosis.21 CPET can refine candidate prognosis and selection.22–28 Appropriate patient selection should include integration of comorbidity burden, caretaker status, and goals of care. The listing criteria, evaluation, and management of patients undergoing cardiac transplantation are described by the International Society for Heart and Lung Transplantation.29 The United Network of Organ Sharing Heart Transplant Allocation Policy was revised in 2018 with a broader geographic sharing policy and a 6-tiered system to better prioritize more unstable patients and minimize waitlist mortality.5–11 2. One study evaluated the cost-effectiveness of heart transplantation compared with medical therapy among patients with inotrope-dependent advanced HF.30 This analysis found transplantation was of intermediate value. The results were similar across a broad range of patient age, waitlist duration, and monthly mortality risk with medical therapy. 9 PATIENTS HOSPITALIZED WITH ACUTE DECOMPENSATED HF 9.1 Assessment of Patients Hospitalized With Decompensated HF Recommendations for Assessment of Patients Hospitalized With Decompensated HF COR LOE Recommendations 1 C-LD 1. In patients hospitalized with HF, severity of congestion and adequacy of perfusion should be assessed to guide triage and initial therapy.1–5 1 C-LD 2. In patients hospitalized with HF, the common precipitating factors and the overall patient trajectory should be assessed to guide appropriate therapy.5,6 Goals for Optimization and Continuation of GDMT 1 C-LD 3. For patients admitted with HF, treatment should address reversible factors, establish optimal volume status, and advance GDMT toward targets for outpatient therapy.6 Synopsis Initial triage includes clinical assessment of the hemodynamic profile for severity of congestion and adequa- Downloaded from http://ahajournals.org by on October 7, 2026