**7. Alternative therapies**

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

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

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 shift towards broader acceptance of this procedure.
