For which of the following clinical scenarios would cardiac transplantation be an appropriate therapeutic modality?

C. A 25-year-old male athlete with insidious onset of heart failure secondary to idiopathic dilated cardiomyopathy.

D. A 55-year-old woman who is status post two previous surgeries for coronary artery revascularization, now presenting with heart failure in the absence of angina, left ventricular ejection fraction of 15%, and insufficient target coronary arteries for a third bypass procedure.

E. A newborn infant with hypoplastic left heart syndrome and no other congenital anomalies.

F. A 30-year-old woman who develops irremediable heart failure due to postpartum cardiomyopathy after giving birth.

DISCUSSION: Scenarios A and B are not appropriate for cardiac transplantation. The patient in example A would be far better served by a conventional revascularization procedure such as coronary artery bypass grafting. The risk might be somewhat greater than normal because of his depressed left ventricular ejection fraction; however, cardiac transplantation is a therapy that is necessarily reserved for persons for whom no other procedure is available. That clearly is not the case in this example. In example B, despite the fact that this patient's disease might be benefited by cardiac transplantation, she is too old to withstand the rigors of this procedure and its attendant therapies. Examples, C, D, E, and F, all represent situations in which cardiac transplantation would be appropriate. In all these cases there is end-stage heart disease, and no other therapies are available that are likely to have any substantial benefit. Therefore, it is appropriate to consider cardiac transplantation for these patients, as a last resort.