Summary of Significant Changes. Policy

Transcription

1 This Plicy replaces POL229/3 Cpy Number Effective 17/05/17 Summary f Significant Changes Updated survival rates fllwing heart transplantatin. Edited Sectin 6.2 in light f new prcess fr urgent heart-lung blck allcatin Plicy This plicy has been created by the Cardithracic Advisry Grup (CTAG) n behalf f NHSBT. The plicy has been cnsidered and apprved by the Transplant Plicy Review Cmmittee (TPRC), which acts n behalf f the NHSBT Bard, and which will be respnsible fr annual review f the guidance herein. Last updated: April 2017 Apprved by TPRC: April 2017 The aim f this dcument is t prvide a plicy fr the selectin f adult and paediatric patients n t the UK natinal transplant list and, where necessary, criteria fr their de-selectin. These criteria apply t all prpsed recipients f rgans frm deceased dnrs. In the interests f equity and justice all centres shuld wrk t the same selectin criteria. Nncmpliance t these guidelines will be handled directly by NHSBT, in accrdance with POL198 NHS Bld and Transplant Organ Dnatin and Transplantatin: Plicy n Nn-cmpliance with Selectin and Allcatin plicies plicies-and-guidance/#nncmpliance It is acknwledged that these guidelines will require regular review and refreshment. Where they d nt cver specific individual cases, an Adjudicatin Panel will cnsider whether transplantatin is apprpriate. Heart transplantatin is an established treatment in patients wh have a likelihd f pr survival r impaired quality f life secndary t acute r chrnic heart disease. Selectin criteria fr adult transplantatin are largely based n utcme measures pst-transplant. While the same general principles apply t children, in sme circumstances, even a smaller prbability f lng-term success may be a wrthwhile utcme fr sme children and their families. In selected patients, heart transplantatin imprves survival and quality f life. Data n ver 78,000 transplants frm the Registry f the Internatinal Sciety fr Heart and Lung Transplantatin shw that half f the patients survive fr mre than 10 years and the median survival fr thse wh survived the first year after transplantatin is currently 13 years. 1 Current UK data (UK Transplant Registry) shw that current 1- and 5- year survival rates are 84% and 71% fr adults and 93% and Authr(s): Kathy Zalewska Page 1 f 10

2 85% fr paediatric patients, respectively ( The decisin t recmmend heart transplantatin depends n a balance f the benefits, risks and alternatives. Hwever, the scarcity f suitable dnr hearts makes it necessary t als cnsider the ppulatin f ptential heart transplant candidates; selectin is based bth n the patient s clinical need and n their capacity t benefit. Decisin-making shuld be fair and transparent. Transplant centres make decisins abut whether t list patients in a multi-disciplinary team (MDT) meeting and in the light f relevant guidelines. Nevertheless, selectin cannt be an exact science, and any patient wh is dissatisfied with the decisin made in his/her case is entitled t an pinin frm a secnd transplant centre. 1. Cnditins That Are Cnsidered fr Transplantatin a) Advanced heart failure usually secndary t ischaemic heart disease r idipathic dilated cardimypathy with severe systlic ventricular dysfunctin b) Severe ventricular dysfunctin secndary t valve disease. c) Diastlic dysfunctin usually secndary t idipathic restrictive r hypertrphic cardimypathy d) Heart failure secndary t cngenital heart disease Patients with ther cnditins including specific heart muscle diseases may be candidates fr transplantatin and need t be cnsidered n a case-by-case basis. 2. Referral Clinicians lking after ptential transplant candidates shuld discuss referral with ne f the heart transplant centres in the UK and, when apprpriate, arrange fr frmal referral. Paediatric patients will be referred t ne f the tw paediatric heart transplant centres. It is advisable t discuss patients with transplant centres at an early stage s a cmbined apprach can be frmulated. Guidance is available in the published natinal guidelines Assessment f Candidates fr Transplantatin Patients shuld be fully assessed in ne f the heart transplant centres. Patients shuld be discussed at the MDT meeting and, if apprpriate fr transplantatin, shuld be ffered listing. 4. Heart Allcatin Overview There are three tiers f allcatin: the super-urgent heart allcatin scheme (SUHAS), the urgent heart allcatin scheme (UHAS) and the nn-urgent allcatin scheme (NUHAS). A patient may be registered n t ne f these three schemes accrding t the selectin criteria utlined in this dcument. The rder in which patients are ffered dnr rgans is utlined in NHS Bld and Transplant Heart Allcatin Plicy There are seven licensed heart transplant centres in the UK: Birmingham, Great Ormnd Street, Glasgw, Harefield, Manchester, Newcastle, and Papwrth. Newcastle transplant adult and paediatric patients; Great Ormnd Street transplant paediatric patients nly. Authr(s): Kathy Zalewska Page 2 f 10

3 4.1 Adult Patients An adult patient is defined as being a patient aged 16 years r abve at the time f registratin. 4.2 Paediatric Patients A paediatric patient is defined as being a patient aged less than 16 years at the time f registratin. A paediatric patient wh reaches their 16 th birthday while n the waiting list will retain their paediatric status. 4.3 Small Adult Patients A small Adult is defined as being a patient with a bdy weight f 30 kg r less at the time f listing. Paediatric patients and Small Adults will receive ffers fr hearts available frm a paediatric dnr befre adult patients. A centre may request, thrugh the Cardithracic Advisry Grup (CTAG) Adjudicatin Panel (Sectin 7), registratin f a Small Adult, weighing between 30 kg and 40 kg, when there are specific reasns t justify inclusin in this pririty grup (such as excess fluid retentin which may nt reflect lean bdy mass). In such cases, indicatin fr Small Adult listing shuld be marked n the registratin frm. 4.4 Patient Categries There are three patient categries fr which a patient can be registered. Table 1 indicates which patient categry (Paediatric, Small Adult r Adult) a patient is classed in depending upn the registered status f the patient (i.e. by age and whether they are registered as a Small Adult) and which type f centre they are registered at. The type f centre is imprtant because generally a 15 year ld patient, fr example, registered at an adult centre will, by definitin, be f adult size and hence require adult sized rgans, whereas generally a 15 year ld patient at a paediatric centre will require specialist paediatric treatment and hence paediatric sized rgans. A patient will nly have ne classificatin and cannt be dual listed t receive ffers as part f mre than ne scheme. Table 1: Patient categry fr allcatin (Paediatric/Small Adult/Adult) by patient status and centre type Status f patient Adult Centre (Harefield, Papwrth, Birmingham, Manchester, Glasgw) Adult & Paediatric Centre (Newcastle*) Paediatric Centre (GOSH) Aged under 16 Adult Paediatric Paediatric Aged 16 r abve (nt Small Adult Adult Paediatric Adult) Small Adult Aged 16 r abve and weight 30kg r Aged 16 r abve, weight between 30-40kg and agreed by Adjudicatin Panel Small Adult Small Adult Paediatric * Newcastle is cunted as bth an adult centre and a paediatric centre in this dcument. 5. Listing f Patients Authr(s): Kathy Zalewska Page 3 f 10

4 Transplant centres shuld request NHSBT t place eligible patients n the UK natinal heart transplant list. Patients wh have nt been registered shuld nt be ffered an rgan. Patients are required t cnsent t transfer f their data nt the UK Transplant Registry, which is maintained by NHSBT in rder t ensure equitable allcatin and fllw-up data are used t mnitr utcmes. Patients will be placed n the natinal transplant list when a registratin frm has been received and key infrmatin is validated by NHSBT. Discrepancies r missing infrmatin will be fllwed up with the lcal centre and might cause a delay in registratin. Determinatin f eligibility fr NHS treatment shuld be determined by the hspital and advice may be given by the natinal Department f Health. Accepted patients are classified as Grup 1 r Grup 2 (as defined by The NHS Bld and Transplant, England, Directins 2005 Guidance: Nevertheless it shuld be nted that natinals f a nn-uk cuntry may nly be registered n a transplant list after they have been accepted by a cnsultant as suitable fr treatment. 5.1 Nn-Urgent Heart Allcatin Scheme (NUHAS) Listing criteria fr NUHAS heart transplantatin Table 2 utlines guideline criteria fr nn-urgent heart registratin. These criteria are applicable fr all patient categries. Generally speaking, tw r mre criteria need t be met fr listing. Table 2: Guideline listing criteria fr Nn-Urgent Heart Allcatin Scheme registratin: tw r mre criteria need t be met Persistent NYHA Class III/IV symptms despite ptimum medical therapy (inc CRT if indicated) Peak VO 2 <14 ml/kg/min r <50% predicted in diagnstic CPEX test Unable t cmplete satisfactry CPEX because f cardiac status BNP persistently >400 pg/ml r NT-prBNP >1600 pg/ml, r increasing despite treatment Lw cardiac index (<2 L/min/m 2 ) Tw r mre admissins with decmpensated heart failure in last 12 mnths despite adequate medical therapy and adherence Deterirating WHO Grup II pulmnary hypertensin Deterirating renal functin due t cardirenal syndrme Persisting hypnatraemia (<130 mml/l) despite ptimum medical treatment Recurrent ventricular arrhythmia despite drug, EP and device treatment Deterirating liver functin due t right heart failure despite ptimum medical treatment Persistent/recurrent symptmatic pulmnary edema r serius systemic cngestin despite ptimum medical treatment NUHAS Registratin Prcess In rder t register a patient n the NUHAS, the transplant centre must cmplete the Heart/Lung Recipient Registratin Frm (FRM4847) via ODT Online and select the ptin fr Heart. Authr(s): Kathy Zalewska Page 4 f 10

5 5.2 Urgent Heart Allcatin Scheme (UHAS) Patients wh have advanced heart failure and a very pr shrt-term prgnsis are priritised by placing them n the Urgent Heart Allcatin Scheme (UHAS) Listing Criteria fr UHAS Heart Transplantatin Table 3 utlines the criteria fr adult urgent heart registratin. These criteria are applicable fr patients registering under the Adult r Small Adult patient categries. Table 3: Listing criteria fr adult Urgent Heart Allcatin Scheme registratin Categry 21 - Adult inpatient dependent n intravenus intrpes which cannt be weaned Categry 22 - Adult lng-term VAD r TAH patient with ne f the fllwing cmplicatins: Right ventricular failure dependent n intrpes Recurrent systemic infectin related t VAD/TAH Other VAD/TAH issues including recurrent r refractry VAD/TAH thrmbsis. Patient registratin must be agreed by CTAG Adjudicatin Panel and evidence f agreement ed t NHSBT (Sectin 7) Categry 23 - Exceptinally sick adult patient - high risk f dying r having an irreversible cmplicatin but des nt meet urgent listing criteria. Patient registratin must be agreed by CTAG Adjudicatin Panel and evidence f agreement ed t NHSBT (Sectin 7). Categry 31 - ACHD arrhythmia patients. Refractry arrhythmia (> 1 hspital admissin ver last 3 mnths with haemdynamic instability r assciated with kidney r liver dysfunctin). Categry 32 - ACHD patients with n ptin fr cnventinal escalatin f therapy. Inpatients unsuitable fr intrpes and/r VAD with ne f the fllwing: Bilirubin and transaminases > 2x nrmal Deterirating renal functin (egfr <50ml/min/1.73m, r 20% reductin frm baseline); Requirement fr dialysis/cvvh fr fluid r electrlyte management; recurrent admissins (> 3 in preceding 3 mnths) with episdes f right heart failure r prtein lsing enterpathy requiring ascites drainage. Fr any paediatric urgent listing there must be agreement between the tw paediatric centres. This shuld invlve the clinical leads r in their absence an appinted deputy. If there is disagreement this shuld be nted at the time f discussin with the chair f CTAG. Table 4 utlines the criteria fr paediatric urgent heart registratin. These criteria are applicable fr patients registering under the paediatric patient categry nly. Table 4: Listing criteria fr paediatric Urgent Heart Allcatin Scheme registratin Categry 51 - Paediatric with shrt-term MCSD: Mechanical circulatry supprt fr acute haemdynamic decmpensatin using a shrt-term right, left r bi-ventricular device (including Berlin Heart), implanted as a specific bridge-t-transplantatin Authr(s): Kathy Zalewska Page 5 f 10

6 Categry 52 - Paediatric with MCSD with device-related cmplicatins: Mechanical circulatry supprt with bjective medical evidence f significant device-related cmplicatins such as thrmb-emblism, device infectin, mechanical failure and/r lifethreatening ventricular arrhythmias. Panel reactive antibdy sensitisatin des nt qualify fr urgent registratin in this criterin Categry 54 - Paediatric with VA ECMO: Mechanical circulatry supprt using extracrpreal membrane xygenatin as a specific bridge-t-transplantatin Categry 55 - Paediatric >15kg n high-dse intrpes: Patients >15kg n cntinuus central infusin f a high dse intravenus intrpe Categry 56 - Paediatric 15kg n ventilatin and intrpes: Patients 15kg wh are ventilated and n intrpes. Categry 59 - Paediatric patients utside the criteria listed abve, but fr whm the patient's transplant physicians believe urgent listing is justified using acceptable medical criteria nt included abve. Fr paediatric patients whereby a maximum acceptable dnr size has been specified t be 160 cm in height and/r 60kg in weight, their eligibility fr registering under this categry must be discussed and agreed by a panel f representatives frm each paediatric transplant centre and the CTAG Chair r his deputy. Evidence f this agreement must be ed t NHSBT UHAS Registratin Prcess Request fr registratin n the UHAS must be made by submitting a Super-Urgent/Urgent Heart Recipient Registratin Frm (FRM4351) t the ODT Duty Office by fax r . The centre must specify the UHAS as the scheme they wish t register n t as well as the UHAS listing categry. Indicatin can be made n the frm t request dnr heart ffers frm 1) bld grup identical dnrs nly, 2) identical and cmpatible dnrs r 3) dnrs f any bld grup (ptin available t paediatric patients nly). Patients n the UHAS can als be registered with a maximum and minimum dnr height and weight they are willing t accept, at the time f registratin. These patients will subsequently nt receive ffers f dnr hearts frm dnrs that fall utside f these specified criteria. If there are any bvius errrs r missing data, the ODT Duty Office will call the centre immediately fr clarificatin. When key infrmatin has been validated and it is cnfirmed that the patient is eligible, the ODT Duty Office will place the patient n the UHAS and ntify all heart transplant centres in the UK by facsimile f an annymised cpy f the frm t all designated heart transplant centres. A summary f patients n the SU/UHAS will be sent by facsimile r t all designated centres by the ODT Duty Office each day. Centres wishing t seek clarificatin f the details f a patient n the UHAS must ntify the ODT Duty Office by telephne. The clinician frm the centre seeking clarificatin will make direct cntact with the registering centre and discuss the case clinician t clinician. In cases where clarificatin has been sught, the ODT Duty Office will seek cnfirmatin f the patient s status frm the registering centre 24 hurs after a registratin. Where there remains a dispute this shuld be discussed with the Chairman f CTAG wh may refer the case t the Adjudicatin Panel (Sectin 7). After a mnth waiting n the urgent list has elapsed, the centre must submit a Super-Urgent/Urgent Heart Recipient Mnthly Update Frm (FRM4352) t the ODT Duty Office by fax r . This shuld ccur fr every mnth a patient waits n the list. Authr(s): Kathy Zalewska Page 6 f 10

7 If a patient has been suspended frm the UHAS waiting list fr mre than 14 days, the patient shuld be remved frm the list. If the patient is t re-jin the UHAS waiting list, a new registratin frm must be submitted and they will nt retain any waiting time frm their previus urgent registratin. 5.3 Super-Urgent Heart Allcatin Scheme (SUHAS) Patients wh have advanced heart failure and are placed n temprary mechanical circulatry supprt device (tmcsd) r are nt suitable fr tmcsd are priritised by placing them n the Super- Urgent Heart Allcatin Scheme (SUHAS) Listing Criteria fr SUHAS Heart Transplantatin The Super-Urgent Heart Allcatin Scheme (SUHAS) is available fr patients in the adult patient categry nly. Table 5 utlines the criteria fr adult Super-Urgent heart registratin. Table 5: Listing criteria fr adult Super-Urgent Heart Allcatin Scheme registratin Categry 11 - Adult patient n shrt-term mechanical circulatry supprt (MCSD) Categry 12 - Adult patient at imminent risk f dying r irreversible cmplicatins. Meets criteria fr urgent listing but is nt suitable fr lng-term VAD and/r ther exceptinal circumstances. Agreed by CTAG Adjudicatin Panel (Sectin 7) and evidence f agreement ed t NHSBT SUHAS Registratin Prcess Request fr registratin n the SUHAS must be made by submitting a Super-Urgent/Urgent Heart Recipient Registratin Frm (FRM4351) t the ODT Duty Office by fax r . The centre must specify the SUHAS as the scheme they wish t register n t as well as the SUHAS listing categry. Indicatin can be made n the frm t request dnr heart ffers frm 1) bld grup identical dnrs nly, 2) identical and cmpatible dnrs r 3) dnrs f any bld grup (ptin available t paediatric patients nly). Patients n the SUHAS can als be registered with a maximum and minimum dnr height and weight they are willing t accept, at the time f registratin. These patients will subsequently nt receive ffers f dnr hearts frm dnrs that fall utside f these specified criteria. If there are any bvius errrs r missing data, the ODT Duty Office will call the centre immediately fr clarificatin. When key infrmatin has been validated and it is cnfirmed that the patient is eligible, the ODT Duty Office will place the patient n the SUHAS and ntify all heart transplant centres in the UK by facsimile f an annymised cpy f the frm t all designated heart transplant centres. A summary f patient n the SU/UHAS will be sent by facsimile r t all designated centres by the ODT Duty Office each day. Fr cases where a centre wishes t seek clarificatin f the details f a patient n the SUHAS, the prcess is the same as fr the UHAS (see Sectin 5.2.2). After a mnth waiting n the super-urgent list has elapsed, the centre must submit a Super- Urgent/Urgent Heart Recipient Mnthly Update Frm (FRM4351) t the ODT Duty Office by fax r . This shuld ccur fr every mnth a patient waits n the list. If a patient has been suspended frm the SUHAS waiting list fr mre than 14 days, the patient shuld be remved frm the list. If the patient is t re-jin the SUHAS waiting list, a new registratin frm must be submitted and they will nt retain any waiting time frm their previus super-urgent registratin. Authr(s): Kathy Zalewska Page 7 f 10

8 6. Heart-Lung Transplantatin A patient wh requires a heart-lung blck can register n t the nn-urgent heart-lung allcatin scheme (NUHLAS). Any patient (Paediatric, Small Adult and Adult patient categries) has access t this scheme. 6.1 Nn-Urgent Heart-Lung Allcatin Scheme In rder t register a patient n the NUHLAS, the transplant centre must cmplete the Heart/Lung Recipient Registratin Frm (FRM4847) via ODT Online and select the ptin fr Heart and Lung. 6.2 Urgent Heart-Lung Allcatin Scheme If an urgent heart patient als requires lungs, the patient can be registered n t the Urgent Heart- Lung Allcatin Scheme (UHLAS). The centre must write t the CTAG Adjudicatin Panel (Sectin 7) fr apprval. If apprved, the centre must infrm the Duty Office at the time f registratin and again at time f ffering. Fr full details f allcatin see: 7. Adjudicatin Panel It is recgnised that n system can describe every clinical situatin and an equitable system must allw fr cnsideratin fr individual cases in a transparent way. There are hence aspects f the UHAS, SUHAS and the UHLAS whereby the individual case is referred t the CTAG Adjudicatin Panel fr apprval. 7.1 Adult Cases The CTAG Adjudicatin Panel is made up f the CTAG Chairman plus ne representative frm each f the 7 designated heart transplant centres. The registering centre must prvide the panel with relevant details by . The patient may be registered if the majrity agree n the case fr listing but if the panel cannt reach a cnsensus, the CTAG Chairman has the casting vte. In cases where the patient is frm the same centre as the CTAG Chair, the prcess will be administrated by the Deputy CTAG Chair. A decisin will be made within 24 hurs f receiving the request. The decisins f the Adjudicatin Panel will be presented annually at meetings f the CTAG. Fr cases where apprval is granted, cnfirmatin f apprval by the Adjudicatin Panel must be sent t the ODT Duty Office via r fax at the same time as the Super-Urgent/Urgent Heart Recipient Registratin Frm. Such patients will nt be registered until the cnfirmatin dcumentatin is received and the registering centre must immediately call the ODT Duty Office t clarify that the infrmatin has been sent. Cnfirmatin dcumentatin shuld be sent either by fax r by t: duty.ffice@nhsbt.nhs.uk and ODTOperatinsDutyOfficeManagers@nhsbt.nhs.uk. 7.2 Paediatric Cases Fr paediatric patients, the case must be referred nt t the CTAG Adjudicatin Panel but t the CTAG Chairman and a representative frm each f the tw paediatric centres fr apprval. A decisin will be made within 24 hurs f case referral. Again, fr cases where apprval is granted, cnfirmatin f apprval by the CTAG Chair must be sent t the ODT Duty Office via at the same time as the Super-Urgent/Urgent Heart Recipient Registratin Frm. Such patients will nt be registered until the cnfirmatin dcumentatin is received and the registering centre must Authr(s): Kathy Zalewska Page 8 f 10

9 immediately call the ODT Duty Office t clarify that the infrmatin has been sent. Cnfirmatin dcumentatin shuld be sent either by fax r by t: duty.ffice@nhsbt.nhs.uk and ODTOperatinsDutyOfficeManagers@nhsbt.nhs.uk. 7.3 Types f Referral The fllwing cases can be referred t the relevant panel t btain a decisin ver patient registratin Super-Urgent Heart Registratin Fr an adult t be registered n t the SUHAS under Categry 12, the case must be accmpanied by prf f apprval frm the CTAG Adjudicatin Panel Urgent Heart Registratin The fllwing cases must be accmpanied by prf f apprval frm the relevant panel: an Adult r Small Adult t be registered n t the UHAS under Categry 22 r 23 a Paediatric patient t be registered n t the UHAS under Categry Urgent Heart Patients Wh Als Require Lungs An urgent heart patient wh als requires lungs must be discussed and apprved by the CTAG Adjudicatin Panel befre the centre is able t request dnr lungs (Sectin 6.2) Small Adult Registratins The CTAG Adjudicatin Panel is als used t make decisins ver whether a patient between 30 kg and 40 kg in weight shuld be registered as a Small Adult (Sectin 4.3). In such cases, the registering centre must prvide the panel with relevant details and the Panel will respnd with their decisin within 24 hurs. Small Adult patients have access t the NUHAS and the UHAS Disputes Over Existing Patient Registratins Fr cases where a centre has sught clarificatin ver the details f a patient n either the SUHAS r the UHAS and disputed the registratin f such patient with the registering centre, the case may be referred t the CTAG Adjudicatin Panel. 8. Cntraindicatins, Risk-factrs and Cmrbidities Nt all patients wh meet criteria fr transplantatin are suitable fr a variety f reasns. Patients need full evaluatin by a discussin at an MDT meeting. Sme cntraindicatins are abslute and thers are relative. The team needs t take a balanced decisin based n need and aviding futility. A full discussin f the cntraindicatins, risk factrs and cmrbidity is available in Reference 2. The factrs belw need t be cnsidered, althugh the list is nt exhaustive Cardirenal syndrme and ther causes f renal dysfunctin Liver dysfunctin Pulmnary hypertensin caused by heart failure and ther factrs Age (since lder age is assciated with c-mrbidities) Previus cardiac surgery Diabetes mellitus Obesity Vascular disease Infectin that is resistant t treatment Authr(s): Kathy Zalewska Page 9 f 10

10 Pulmnary emblism Immunsuppressin Current and previus malignancy Autimmune disease Scial factrs that, despite full supprt, will result in pr utcmes Substance use and alchl abuse Smking Nn-adherence t treatment, despite supprt, that is likely t result in graft failure Mental capacity that, despite supprt, will result in pr utcmes Mental illness that, despite full assessment and treatment, will result in pr utcmes Other cmrbidity 9. Selectin fr Re-transplant A small number f patients may require and be suitable fr a secnd heart transplant. They will need t be assessed in a similar way t ther ptential recipients and a decisin made based n the risks and benefit fr that individual, relative t ther ptential recipients. Patients that have had a previus transplant may nt be registered n t the SUHAS r the UHAS until three mnths have elapsed. 10. Fllw-up n List and De-listing Patients wh are listed fr transplantatin shuld be mnitred at apprpriate intervals t ensure their suitability fr transplantatin; maintain current clinical and ther data; address any cncerns f the patient and their carers; and ensure cnsent cntinues t be current. Sme patients waiting n the list may deterirate t the pint where they need urgent r super-urgent listing, r mechanical circulatry supprt. Occasinally it may be apprpriate t de-list patients and palliate apprpriately. This must be dne with tact and sensitivity. In these circumstances, patients are entitled t a secnd pinin. References 1. Taylr DO, Stehlik J, Edwards LB, et al. Registry f the Internatinal Sciety fr Heart and Lung Transplantatin: twenty-sixth fficial adult heart transplant reprt J Heart Lung Transplant 2009;28:1007e Banner NR, Bnser RS, Clark AL et al. UK guidelines fr referral and assessment f adults fr heart transplantatin. Heart 2011;97: Authr(s): Kathy Zalewska Page 10 f 10