Prognosis after heart transplantation

Heart transplantation is in its third decade as a widely accepted treatment for advanced heart failure. What is its prognosis? In the early era of heart transplantation, the perceived alternative to transplantation was imminent death. In 1968, at the beginning of heart transplantation, Peter Medawar, the eminent zoologist and Nobel laureate whose work on tolerance set the scene for successful transplantation, correctly predicted: “The transplantation of human organs will be assimilated into ordinary clinical practice … and there is no need to be philosophical about it. This will come about for the single and sufficient reason that people are so constituted that they would rather be alive than dead.”1 Heart transplantation has a high early mortality—15-20% of recipients die within a year of the operation. 2 3 Thereafter the death rate is constant, at about 4% a year for the next 18 years, so that 50% of patients can expect to be alive after 10 years and 15% after 20 years. Application of heart transplantation has been based almost entirely on doctors' …