Purpose of review: Cardiac transplantation has been the therapy for advanced heart failure that is associated with the best and most durable outcomes. This has been a result of improvements in immunosuppression, specifically the widespread adoption of more potent immunosuppressive agents such as tacrolimus and mycophenolate mofetil in place of cyclosporine and azathioprine and more protocol-driven immunosuppressive regimens which minimize both rejection and complications of immunosuppression such as infections and nephrotoxicity. The rejection rates have fallen over the past 2 decades as posttransplant survival has improved. Despite these successes, long-term survival is limited by cardiac allograft vasculopathy and malignancies. The purpose of this review is to discuss new approaches to immunosuppression, which may address the long-term outcomes after transplant.
Recent findings: Recent findings in clinical trials have shown that proliferation signal inhibitors or mammalian target of rapamycin inhibitors can reduce the incidence and severity of cardiac allograft vasculopathy and are used in higher doses as anticancer agents, but their uses are associated with side-effects.
Summary: Consequently, there is considerable interest in developing newer immunosuppressive agents that will be more effective in treating and preventing these long-term complications with fewer side-effects. At present, there are no new agents other than Rituximab, which are being studied, in clinical trials.