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Fig. 11.1. Indications for heart transplantation. From: ISHLT website—www.ishlt.org, 2/03.

Fig. 11.1. Indications for heart transplantation. From: ISHLT website—www.ishlt.org, 2/03.

Once a patient is recognized to have those characteristics, a rigid evaluation process must be undertaken to determine if the individual patient is a suitable candidate for transplantation. The following must be considered in the evaluation process.

Patient Age

Establishing an upper age limit for recipients within a given program is highly controversial. During the decade of the 1980s, most programs limited transplantation to patients under age 55. By the late 1980s and early 1990s, successful outcomes with heart transplantation, coupled with many more patients above age 60 and 65 with end-stage heart disease, prompted many programs to offer heart transplantation to older patients. It is now apparent that patient selection by strictly age limit alone is inappropriate. Selection must instead be based on the patient's physiological rather than chronological state.

Nonetheless, it must be noted that one-year survival following heart transplantation decreases with age. According to the ISHLT Registry data, patient age 50-59 years is a significant risk factor for mortality within the first year following transplant (odds ratio 1.23). Recipient age > 60 years has an odds ratio of 1.73. Age seems to have its greatest impact by creating a significantly higher operative mortality associated with transplant procedure: by three months posttransplant the survival curves for patient

< 65 years and > 65 years are parallel (Fig. 11.2). Older patients in otherwise good physiological condition may benefit greatly from heart transplantation, with improved survival and quality of life. But because the risk of heart transplantation increases with age, patients above age 60 must be very carefully evaluated to exclude any other important risk factors.

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