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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Over 40 years after the first successful heart transplant in humans&#44; it remains the treatment of choice for a selected group of patients with advanced heart failure &#40;HF&#41;&#44; despite the considerable progress made in HF treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Improved medical therapy has doubled the life expectancy of patients with HF and left ventricular &#40;LV&#41; systolic dysfunction&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> while in some patients cardiac resynchronization therapy can improve functional class&#44; reduce the frequency of hospitalizations and increase survival&#44; and implantable cardioverter-defibrillators reduce sudden death and late mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> A significant number of patients with coronary and&#47;or valve disease are currently accepted for conventional cardiac surgery or ventricular volume reduction surgery&#44; with good medium-term results&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Successive advances in ventricular assist devices&#44; now in their fourth generation&#44; mean that from the clinical standpoint&#44; there are a variety of options available&#44; ranging from temporary support and a bridge to possible transplantation to permanent therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although it is still the gold standard treatment for advanced HF&#44; with expected survival of more than 10 years and improved functional capacity and quality of life&#44; heart transplantation is reserved for a small group of patients&#44; both because there are other therapeutic options for less advanced HF&#44; and due to the inherent limitations of the technique&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The pool of potential donors is relatively small&#44; despite the fact that there is clinical consensus on optimizing management of donor hearts and increasing the use of marginal donors in particular circumstances&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The cardiological criteria for the indication of heart transplantation are generally agreed&#44; but a significant number of potential recipients are never considered for transplantation&#44; either due to contraindication to a lifetime of immunosuppression or because of their age and&#47;or comorbidities&#44; given the need to optimize use of a scarce resource&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Although there has been gradual but sustained improvement in long-term outcomes following transplantation&#44; there are barriers&#44; so far insuperable&#44; to significant progress&#46; These include deterioration of graft function caused by chronic rejection&#44; and progressive increases in malignancy and serious infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> At least as important are the cost of the procedure and ethical and legal considerations&#44; which differ from country to country&#44; as well as the local availability of effective and reliable ventricular assist devices&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Heart transplantation is&#44; therefore&#44; increasingly an option for only a limited number of patients at very high risk&#44; as the number of critical candidates&#44; many of them under mechanical support&#44; rises&#44; and the number of outpatient candidates falls&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> The combination of these factors has meant that the demand for heart transplantations has fallen to 5&#8211;7 per million population from the perceived need for 10 transplantations per million population 20 years ago&#46; Furthermore&#44; in wealthier countries&#44; implantation of permanent ventricular assist devices or biventricular pacemakers is predicted to overtake heart transplantation&#44; especially as clinical trials of LV assist devices have shown excellent short- and medium-term results in terms of quality-adjusted life years&#44; although these tend to fall over time&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This state of affairs warrants some comment&#44; especially in a country like Portugal&#44; in which financial resources are scarce&#46; The results of heart transplantation are better and more cost-effective when patients are treated before they reach a critical stage&#44; and risk stratification can be improved with existing clinical decision instruments&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Furthermore&#44; greater efforts should be made to take full advantage of potential donors&#44; since at the moment it does not appear feasible to establish a ventricular assist device program&#44; the cost-effectiveness ratio of which is still unacceptable for a country like Portugal&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Finally&#44; the work of heart transplantation teams &#40;arguably the first heart teams of all&#41; should be integrated into clinical units with knowledge and experience of state-of-the-art treatment of advanced HF&#46; As the volume of procedures needs to remain high to ensure quality of treatment&#44; other factors&#44; such as the availability of alternative medical and surgical options as well as of different forms of circulatory support&#44; and the size and demographics of referral areas&#44; should also be taken into consideration&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The 10-year experience of the University Hospital of Coimbra reported in the article published in this issue of the <span class="elsevierStyleItalic">Journal</span> is an important contribution to our knowledge of the current situation regarding heart transplantation in Portugal&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> By Iberian standards&#44; the Coimbra center&#39;s annual volume of activity is high&#44; and they have accumulated considerable experience with over 250 procedures&#46; Their long-term results are good&#44; as are waiting times&#44; graft ischemia times and candidates&#8217; hemodynamic status&#46; The authors provide a detailed description of recipients&#8217; preoperative clinical characteristics&#44; perioperative data and the early and late complications inherent to such procedures&#46; It would have been interesting to see a comparison between different periods of the experience presented&#44; as this would have shed light on recent developments in heart transplantation&#44; such as changes in candidates&#8217; degrees of priority&#44; the results of using marginal donors&#44; and the effects of modifying treatment protocols&#46; These will undoubtedly be the subject of future studies&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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