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In Switzerland 200’000 people suffer from congestive heart failure. Approximately 10’000 patients find themselves in an advanced state of the disease. When conservative treatment options are no longer available heart transplantation is the therapy of choice. Should this not be an option due to long waiting lists or medical issues assist device therapy becomes an option. Assist device therapy is separated in short-term and long-term support. Long-term support is nowadays performed with ventricular assist devices (VADs). The native heart is still in place and supported in parallel to the remaining function of the heart. The majority of patients are treated with a left ventricular assist device (LVAD). The right ventrical alone (RVAD) as well as bi-ventricular support (BiVAD) is rarely needed. The modern VADs are implantable and create a non-pulsative bloodflow. A percutaneous driveline enables energy supply and pump-control. Indication strategies for VAD implantations include bridge to transplant (short term support), bridge to candidacy and bridge to transplant. VADs become more and more a definite therapeutic option (destination therapy). VAD therapy might be a realistic alternative to organ transplantation in the near future.

Background: With the development of effective drug treatment in the last 2 decades, lung transplantation has become the final option in the management of pulmonary arterial hypertension (PAH). Its main advantage is the curative aspect with recovery of cardiopulmonary capacity. Scarcity of donor organs and chronic graft rejection, however, remain serious limitations to short- and long-term success, and emphasize the need for judicial patient selection. Timely presentation of the patient to the transplant center is of critical importance., Indication: Guidelines have been presented by the International Society for Heart and Lung Transplantation (ISHLT), the American Thoracic Society (ATS) and the American Society of Transplant Physicians (ASTP) in the year 1998. Selection criteria are clinical status (NYHA [New York Heart Association] > or = III and progressing, right heart insufficiency symptoms), hemodynamic data (mean pulmonary arterial pressure > 55 mmHg, systolic arterial pressure < 120 mmHg, cardiac index < 2 l/min/m2, central venous pressure > 15 mmHg, right heart function on echocardiography), and functional parameters (peak oxygen uptake < 10-12 ml/kg/min, 6-min walk test [MWT] < 332 m). Functional parameters have been shown to correlate with a 1-year mortality of 40% with a 6-MWT < 332 m, of 50% with a peak oxygen uptake < 10.4 ml/kg/min, and of 70% with a systolic arterial pressure < 120 mmHg. Combinations of the above lead to a 1-year survival of 23%. Mean survival of patients with primary pulmonary hypertension (PPH) is 2.8 years and is reduced to 6 months, when NYHA IV is reached (National Institutes of Health-PPH Registry 2002). These data underline the potential survival benefit from transplantation for patients with advanced lung failure due to PAH., Transplantation: Single lung, bilateral lung and heart-lung transplantation are the transplantation procedures available. Even though heart-lung transplantation was the first procedure to be performed in 1981, bilateral lung transplantation is the procedure most commonly performed at present. Choice of transplantation procedure should be made after thorough evaluation, taking the potential reversibility of right ventricular dysfunction after the operation into account (Figure 1). Hemodynamic instability from right and/or left ventricular failure, however, may complicate early postoperative management. Heart and lung transplantation should only be considered, if structural heart damage is present. Lung function improves immediately postoperatively and increases in the following 6 months. Most patients have normal function studies 1 year after transplantation., Statistics: The Registry of the ISHLT (01/1982-06/2003) reports PAH as primary diagnosis in 4.2% of all lung transplantations (457/10,959) and 24.3% (550/2,263) of all heart-lung transplantations. This corresponds to 1.1% of all single (66/5,793) and 7.6% of all bilateral lung transplantations (391/5,166). Single lung transplantation is associated with shorter ischemia, cardiopulmonary bypass and operation time. The procedure, however, is accompanied by ventilation/perfusion mismatch, a higher likelihood of reperfusion injury and less functional reserve in case of progressive chronic rejection. The advantages of bilateral lung transplantation are under discussion, particularly as 5-year survival seems to be higher in some centers. Heart and lung transplantation is reported to have similar results as bilateral lung transplantation (Table 1), showing survival advantages only in patients with Eisenmenger's syndrome or ventricular septal defect. Bilateral lung transplantation, therefore, is the procedure of choice at the Essen Transplant Center, provided donor organs are available., Conclusion: Thoracic transplantation has become a feasible therapeutic option in terminal PAH patients. Judicious patient selection, choice and timing of procedure are critical to a successful outcome.

After the first transplantation thirty-five years ago, heart transplantation has become an established and surgically widely standardized treatment modality for patients with end-stage heart failure. The improved medical therapy and alternative treatment options like revascularisation (CABAG), electrical resynchronization by a three-chamber pacemaker system or the implantation of mechanical assist device systems as well as the development of risk factor score systems to calculate the prognosis of patients with heart failure requires a new assessment of the indication for heart transplantation. The large number of heart transplanted patients and the results of randomized studies with new immunosuppressive drugs allow to calculate the risk, benefit and limitation of transplantation with relatively good reliability. These experiences and knowledge obtained and the German Transplantation Law, which passed the parliament in 1999, led to the establishment of a new heart allocation system. Additionally, by the central documentation of all transplantations in Germany, it becomes possible to compare the results of heart transplantations for better quality control.

In spite of pharmacological progress, end stage congestive heart failure is still associated with a decrease in quality and expectation of life. Heart transplantation remains the last therapeutic option for these patients. While the one year survival rate has increased over the last few years up to 84%, a major problem remains the significant lack of donors. Therefore, the criteria for the selection of candidates for cardiac transplantation have to be kept quite tight: Evidence of poor outcome without transplantation is associated with ejection fractions below 20 to 25%, cardiac indices less than 2.01/min/m2, left ventricular filling pressure above 20 mm Hg and a enddiastolic diameter of > 80 mm. There are, however, also quite important functional parameters indicating the need for heart transplantation, e.g. the maximal oxygene uptake being less than 10 ml/kg/min or below 50% of the age-appropriate value. Elevated pulmonary vascular resistance above 4 to 5 Wood units without a significant decrease during application of prostaglandin derivatives or inhalation of NO represents a contraindication for orthotopic heart transplantation; alternatively, a heterotopic transplantation can be considered. Since there is a significant shortage of suitable donor organs, the donor criteria have been broadened, e. g. the accepted donor age was increased to 60 years. Based on these extended criteria, a careful donor evaluation including cardiac history, cardiac examination, ECG and echocardiogram has to be performed. Coronary angiography in older donors is suggested, but in many cases not possible due to circumstances. Further precondition for a good graft function is a sophisticated donor management until the time of explantation. Hypovolemia and hypocalemia, hypothermia, hypoxia and rapid lost of circulating triiodothyronine (T3) have to be detected and balanced. The cardioplegic solution used might not only have an impact on the immediate postoperative performance of the graft, but also on the long term outcome, particularly with regard to graft vessel disease. There are generally two types of solutions: Those with intracellular and those with extracellular electrolyte concentrations. In addition, the potassium concentration might be of some importance. Potassium seems to damage endothelial cells and trigger subsequent immunological reactions. Therefore, high potassium concentrations in the cardioplegic solution might correlate with the incidence of graft vessel disease during the long term follow-up. The surgical technique for orthotopic heart transplantation developed at the beginning of the sixties by Lower and Shumway has been used unchanged for the last 30 years. The only alteration recently introduced is the separate direct anastomosis of the pulmonary and systemic veins in order to improve the atrial function. Until recently the commonly employed immunosuppressive strategy after heart transplantation consisted of the standard drugs cyclosporin, azathioprin and prednisolon. Some transplant-units use additionally induction therapy with antibody preparations. Many centers, however, abolished this regimen due to significant short and long term side effects. Promising new, more specific antibodies (which are chimerized or humanised) could revive the induction concept. The most thoroughly tested novel immunosuppressive agent is tacrolimus (FK506). It has been demonstrated to be 10 to 100 times more potent than cyclosporin A in in vitro and in vivo models. It binds to a different binding protein (FK-binding-protein) than cyclosporin (cyclophilin), but has a similar mechanism of action inhibiting the expression of T-cell-activator genes for certain cytokines. First non-randomised studies after heart transplantation performed at the University of Pittsburgh revealed that significantly more tacrolimus than cyclosporin patients were free of rejection. In order to confirm these observations, we performed a prospective randomised controlled clin

In conjunction with the report on "Posttransplant care and rehabilitation", the consensus paper on "Indications, contraindications, and therapeutic alternatives to cardiac transplantation" reflects the current practice in German cardiac transplant centers. This paper is based on a survey organized in 1994 by the Working Group on Thoracic Organ Transplantation of the German Society of Cardiology in which all German transplant centers participated.

A review is given concerning the development of surgery for the congenital heart in recent years, or decades, respectively. Longterm results of operative and conservative treatment should be critically considered to avoid unsuccessful operations. Data from West Germany show that this type of surgery should not be done in all places where cardiac surgery is performed.