**9. Conclusions**

There are no clear guidelines on the post-operative care for patients undergoing ReTx. Theoretically, it may not be necessary to add induction therapy if patients have been maintained on high doses of immunosuppression, since their immune response is already significantly blunted. This is not the case for patients undergoing ReTx for refractory rejection or patients who are highly sensitized. However, most transplant centers have used similar induction and immunosuppressive regimens for their primary transplant and ReTx patients. Following induction, it may be reasonable to de-escalate immunosuppression more quickly than would be typical after initial transplantation in order to reduce the long-term risks asso-

Unfortunately, there are no established alternatives to ReTx for patients who have developed late complications of cardiac transplantation. There are no effective strategies for managing end-stage CAV and mortality rates are very high. Similarly, there are no established medical therapies for patients who have developed late graft dysfunction. Columbia has reported the use of mechanical circulatory support as a bridge to re-transplantation [34]. However, given the prevalence of restrictive filling dynamics and right ventricular dysfunction, longterm mechanical support is unlikely to be successful in many patients. Therefore, there are no clearly viable alternatives to ReTx and the default therapy has been, and will continue to be, palliative care. Therefore, it is important to review end-of-life planning and consider pallia-

A complete discussion of the ethical considerations of ReTx beyond the scope of this chapter and readers would be well-served to read dedicated manuscripts [18, 35–37]. Donor hearts are a limited resource and need to be valued appropriately. The number of patients listed for cardiac transplantation greatly outstrips this supply and will continue to do so until we use a much larger proportion of potential donor hearts, an alternate source of grafts is established, or fewer patients require cardiac transplantation. None of these events are likely to occur in the near future. Given the ongoing scarcity of donor hearts, it is important to offer organs to those patients who would derive the most benefit. This is a strong argument against ReTx for acute indications, where outcomes are consistently poor. ReTx for CAV or chronic graft dysfunction is also associated with worse survival compared to initial transplantation, but it is not clear if this is a sufficient reason to exclude all ReTx. Finally, there has been concern regarding the possible injustice inherent in ReTx. Many patients will not survive to receive a single heart transplant and it may not seem equitable for a single patient to receive two, or even three organs when there are patients who die before receiving their first. This debate will continue, but if clinical outcomes continue to improve in ReTx populations, there may be a

tive care consultation in patients who develop long-term complications.

**8. Ethical considerations in re-transplantation**

shift towards broader acceptance of this procedure.

ciated with malignancy and infection.

**7. Alternative therapies**

206 Heart Transplantation

ReTx represents a small proportion of heart transplant procedures today; however, survival following cardiac transplantation has improved dramatically and more patients are surviving until they develop late complications such as CAV or graft failure. ReTx is the only therapy that offers meaningful improvement in survival to these patients. Survival after ReTx seems to be reduced, but may be acceptable in appropriately chosen patients. Tailored surgical and post-operative care is critical to improving patient outcomes in those accepted for ReTx.
