Challenges and Growing experience in Heart Transplantation in Adult Congenital Heart Disease

With advances in congenital heart disease (CHD) management, most infants now survive into adulthood. Heart failure (HF) remains the leading cause of death in this growing adult cohort. CHD patients can present with unique characteristics of failure, not only making diagnosis more challenging but also limiting the response to guideline-directed HF strategies. Heart transplantation in those with end-stage failure remains the final treatment option. Distinct from the acquired HF population, CHD patients often present with complex anatomical and physiological features, and comprehensive multidisciplinary evaluation of potential transplant candidates in an expert adult CHD transplant centre is recommended. This review summarizes the current understanding of heart transplantation in CHD patients, with a focus on historical perspective and improved outcomes, surgical considerations, immunological challenges, organ allocation policies, and special considerations in the Fontan population, including the emerging role of combined heart-liver transplantation.