Pretransplant Management Of The Recipient

Most patients are evaluated for cardiac transplantation due to symptoms of heart failure. Some patients, however, are considered primarily because of low left ventricular ejection fractions with or without ventricular arrhythmias, severe angina refractory to medical therapy or end-stage coronary artery disease. Despite ejection fractions that may be considered low enough to be an indication for transplantation, many patients can be managed medically. Their arrhythmias may be treated with amiodarone, radio frequency ablation or an implantable defibrilla-tor. Intractable angina due to severe coronary artery disease may be amenable to less conventional methods like transmyocardial laser revascularization. Unfortunately the number of patients who can be treated by these methods is small, and the majority are referred with severe symptoms of heart failure.

The initial medical therapy for these patients is exercise within their level of tolerance, restrictions on fluid (2 L/day), and sodium (2 gm/day). First line medications typically include digoxin, loop diuretics, and ACE inhibitors. When this medical regimen fails it is most commonly due to a direct failure to recognize fluid overload. This may lead to recurrent hospitalizations. During these hospitalizations optimization is usually possible with fluid balance and vasodilatation with hemodynamic monitoring. For example, intravenous nitroprusside and diuretics

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