Heart Transplantation Adult and Pediatric

Section: Surgery
Effective Date: January 01, 2020
Revised Date: November 14, 2019

Description

Heart transplantation consists of replacing a diseased heart with a healthy donor heart. It is used for individuals with refractory end-stage cardiac disease.

Criteria

Adult Individuals –

Heart transplantation may be considered medically necessary for selected adults with end-stage heart failure when individual selection criteria are met:

  • Hemodynamic compromise due to heart failure demonstrated by ANY ONE of the following:
  • Maximal VO2 (oxygen consumption) less than 10 mL/kg/min with achievement of anaerobic metabolism; or
  • Refractory cardiogenic shock; or
  • Documented dependence on intravenous inotropic support to maintain adequate organ perfusion; or
  • Ischemia consistently limiting routine activity not amenable to bypass surgery or angioplasty; or
  • Ventricular arrhythmias refractory to ALL accepted therapeutic modalities.

 

Probable Indications for Heart Transplantation

  • Maximal VO2 less than 14 mL/kg/min and major limitation of the individual’s activities; or
  • Ischemia not amenable to bypass surgery or angioplasty; or
  • Renal function/fluid balance instability not due to individual non-compliance with regimen of weight monitoring, flexible use of diuretic drugs, and salt restriction.

Inadequate Indications for Heart Transplantation

Unless other factors as listed above are present, the following conditions are considered not medically necessary:

  • Ejection fraction less than 20%; or
  • Heart Failure, history of functional class III or IV symptoms; or
  • Maximal VO2 greater than 15 mL/kg/min; or
  • Ventricular arrhythmias, previous.

Heart transplantation for all other adult conditions is considered not medically necessary.

In addition to the above criteria and subject to the discretion of the transplant center, a Hepatitis C Virus (HCV) positive donor organ may be considered an acceptable organ option for an HCV negative adult recipient 18 years of age or older.

Procedure Codes

33940 33944 33945

Pediatric Individuals – Accepted Indications for Heart Transplantation

Heart transplantation may be considered medically necessary for selected children with end-stage heart failure when individual selection criteria are met:

  • Heart failure with persistent symptoms at rest who require at least ONE of the following:
    • Circulatory support, mechanical; or
    • Infusion of intravenous inotropic agents, continuous; or
    • Ventilator support, mechanical; or
  • Heart disease with symptoms of heart failure who do not meet the above criteria but who have at least ONE of the following:
    • Anatomical and physiological conditions that EITHER:
      • Are likely to worsen the natural history of congenital heart disease in infants with a functional single ventricle; or
      • May lead to consideration for heart transplantation without systemic ventricular dysfunction; or
    • Cardiomyopathies or previously repaired or palliated congenital heart disease and significant growth failure attributable to the heart disease; or
    • Cardiomyopathy, restrictive, with reactive pulmonary hypertension; or
    • Limitation of exercise and activity, severe (if measurable, such individuals would have a peak maximum oxygen consumption less than 50% predicted for age and sex); or
    • Near sudden death and/or life-threatening arrhythmias, untreatable with medications or an implantable defibrillator; or
    • Pulmonary hypertension, reactive, and potential risk of developing fixed, irreversible elevation of pulmonary vascular resistance that could preclude orthotopic heart transplantation in the future.

Heart transplantation for all other pediatric conditions is considered not medically necessary.

Procedure Codes

33940 33944 33945

Potential Contraindications

The following conditions represent potential contraindications to heart transplantation subject to the judgement of the transplant center:

  • End-stage disease not attributed to heart or lung disease; or
  • Infection, active, making immunosuppression unsafe; or
  • Malignancy, current or history of, with moderate to high risk of recurrence; or
  • Pulmonary disease, severe, despite optimal medical therapy, not expected to improve with heart transplantation; or
  • Pulmonary hypertension, fixed, as evidenced by:
    • Pulmonary vascular resistance (PVR) greater than 5 Wood units; or
    • Transpulmonary gradient (TPG) greater than or equal to 16 mm/Hg despite treatment; or
  • Psychosocial conditions or chemical dependency affecting ability to adhere to therapy; or
  • Systemic disease that could be exacerbated by immunosuppression.

 

Conditions determined to be a contraindication to heart transplantation are considered not medically necessary.

Re-transplantation

Heart re-transplantation after a failed primary heart transplant may be considered medically necessary in individuals who meet criteria for heart transplantation.

Heart re-transplantation after a failed primary heart transplant is considered not medically necessary in individuals who do not meet criteria for heart transplantation.

Procedure Codes

33940 33944 33945

Diagnosis Codes

I25.110 I25.111 I25.118 I25.119 I25.2 I25.3 I25.41
I25.42 I25.5 I25.6 I25.700 I25.701 I25.708 I25.709
I25.710 I25.711 I25.718 I25.719 I25.720 I25.721 I25.728
I25.729 I25.730 I25.731 I25.738 I25.739 I25.750 I25.751
I25.758 I25.759 I25.760 I25.761 I25.768 I25.769 I25.790
I25.791 I25.798 I25.799 I25.810 I25.811 I25.812 I25.82
I25.83 I25.84 I25.89 I25.89 I25.9 I47.0 I47.1
I47.2 I47.9 I49.01 I49.02 I50.1 I50.20 I50.21
I50.22 I50.23 I50.30 I50.31 I50.32 I50.33 I50.40
I50.41 I50.42 I50.43 I50.9 R57.0 T86.22

Professional Statements and Societal Positions

American College of Cardiology Foundation and American Heart Association-2017

Guidelines from the American College of Cardiology Foundation and American Heart Association were updated in 2017.Evaluation for heart transplantation was recommended for [individuals] in whom heart failure is assessed as refractory based on New York Heart Association functional class III or IV (stage D) for heart failure after previous guideline-directed medical therapy, use of devices such as an implantable cardioverter defibrillator or a cardiac resynchronization therapy device, or surgical management.

 

American Heart Association-2007

TheAmerican Heart Association(2007) indicated that, based on level B (nonrandomized studies) or level C (consensus opinion of experts) evidence, heart transplantation is indicated for pediatric [individuals] as therapy for the following indications:

  • Stage D heart failure (interpreted asabnormalcardiac structureand/orfunction, continuous infusion of intravenous inotropes, or prostaglandin E1to maintain patency of a ductus arteriosus, mechanical ventilatory and/or mechanical circulatory support) associated with systemic ventricular dysfunction in [individuals] with cardiomyopathies or previous repaired or palliated congenital heart disease,
  • Stage C heart failure (interpreted as abnormal cardiac structure and/or function and past or present symptoms of heart failure) associated with pediatric heart disease and severe limitation of exercise and activity, in [individuals] with cardiomyopathies or previously repaired or palliated congenital heart disease and heart failure associated with significant growth failure attributed to heart disease, pediatric heart disease with associated near sudden death and/or life-threatening arrhythmias untreatable with medications or an implantable defibrillator, or in pediatric restrictive cardiomyopathy disease associated with reactive pulmonary hypertension;
  • The guidelines state that heart transplantation is feasible in the presence of other indications for heart transplantation, “in [individuals] with pediatric heart disease and an elevated pulmonary vascular resistance index >6 Woods units/m2and/or a transpulmonary pressure gradient >15 mm Hg if administration of inotropic support or pulmonary vasodilators can decrease pulmonary vascular resistance to <6 Woods units/m2or the transpulmonary gradient to <15 mm Hg.”

European Society of Cardiology-2016

The European Society of Cardiology (2016) guidelines on the diagnosis and treatment of acute and chronic heart failure recommended considering heart transplantation for [individuals] with end-stage heart failure with severe symptoms, poor prognosis, and no alternative treatment options.Active infection, severe peripheral arterial or cerebrovascular ischemia, pharmacologically irreversible pulmonary hypertension, cancer, renal insufficiency, systemic disease with multi-organ involvement, pre-transplant body mass index greater than 35 kg/m2, current alcohol or drug abuse, and insufficient social support to achieve compliant care in the outpatient setting were considered relative contraindications for heart transplantation.

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