Cardiac transplantation can be a life-saving treatment for selected patients with heart failure. However, despite advances in immunosuppressive therapy, acute allograft rejection remains a significant cause of morbidity and mortality. The current 'gold standard' for rejection surveillance is endomyocardial biopsy, which aims to identify episodes of rejection prior to development of clinical manifestations. This is an invasive technique with a risk of false-positive and false-negative results. Consequently, a wide variety of noninvasive alternatives have been investigated for their potential role as biomarkers of rejection. This article reviews the evidence behind proposed alternatives such as imaging techniques, electrophysiological parameters and peripheral blood markers, and highlights the potential future role for biomarkers in cardiac transplantation as an adjunct to biopsy.

A systematic search of Medline, EMBASE and CINAHL electronic databases was performed. Original research articles reporting all-cause mortality following surgery in patients with aortic regurgitation and severe left ventricular systolic dysfunction (LVSD) were identified. Nine of the 10 eligible studies were observational, single-center, retrospective analyses. Survival ranged from 86 to 100% at 30 days; 81 to 100% at 1 year and 68 to 84% at 5 years. Three studies described an improvement in mean left ventricular ejection fraction (LVEF) following aortic valve replacement (AVR) of 5-14%; a fourth study reported an increase in mean left ventricular ejection fraction (LVEF) of 9% in patients undergoing isolated AVR but not when AVR was combined with coronary artery bypass graft and/or mitral valve surgery. Three studies demonstrated improvements in functional New York Heart Association (NYHA) class following AVR. Additional studies are needed to clarify the benefits of AVR in patients with more extreme degrees of left ventricular systolic dysfunction (LVSD) and the potential roles of cardiac transplantation and transaortic valve implantation.

The Freeman Hospital in Newcastle is one of the leading centres for cardiac transplantation and implantation of ventricular assist devices in the UK, receiving referrals to the Advanced Heart Failure Service predominantly from the North of England, but also Northern Ireland and complex cases from other regions. We were keen to establish whether referring clinicians felt they had sufficient knowledge about the service, its role and which patients may benefit from referral.We designed an online survey and sent a link via email to 127 potential referrers (predominantly colleagues who had referred to the service in the past).56 of the 127 clinicians responded, giving a response rate of 44% (Table 1).Abstract 48 Table 1Clinicians who responded to the surveyClinician responding to surveyNumberPercentage (%)Consultant Cardiologist with an interest in heart failure2036Consultant Cardiologist without a special interest in heart failure1018Consultant Cardiologist with special interest in adult congenital heart disease12Cardiology Registrar1221Heart Failure Specialist Nurse59Consultant Physician24General Practitioner with special interest in cardiology24Grade not specified47Although 76% of those responding to the survey had previously referred at least one patient, only 70% reported being fully aware of the role of the Advanced Heart Failure Service, 62% felt they had a clear understanding of which patients to refer and 60% were confident in how to refer. Only 21% felt they had sufficient information about the service and guidelines for referral.The uncertainty amongst clinicians about who to refer influences whether patients are referred for advanced heart failure therapies, and therefore impacts on patient care as patients who may benefit from therapies such as transplantation or ventricular assist devices may not be referred for assessment. Factors prompting clinicians to refer patients with heart failure and relatively few co-morbidites, or which deter them from referring, are detailed in Figures 1 and 2.Abstract 48 Figure 1What conditions would prompt you to consider referral to the Advanced Heart Failure Service in patients with relatively few co-morbites?Abstract 48 Figure 2What factors would deter you from referring a patient to the Advanced Heart Failure Service?Only 51% would consider referring a patient with more than 1 heart failure hospitalisation in the last year and fewer than 50% would consider referring patients with multiple ICD shocks, new renal impairment, or hypotension requiring reduction or discontinuation of ACE inhibitors/beta blockers, despite all of these being recognised adverse prognostic signs in patients with heart failure.The most common factor deterring clinicians from referring was the presence of multiple co-morbidities (74%). Disappointingly, other reasons for not referring included being unsure of who to refer (14%) or how to refer (10%).84% of clinicians would be more likely to refer in the future if NICE approved VADs as ‘destination therapy’ rather than only as a ‘bridge to transplant’...