Heart transplantation with and without prior sternotomy: analysis of the United Network for Organ Sharing database

International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024

The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.

Anticoagulation and Antiplatelet Regimen in Cardiac Transplant. Clinical Characteristics, Outcomes, and Blood Product Transfusion

BACKGROUND

We aimed to evaluate the characteristics, clinical outcomes, and blood product transfusion (BPT) rates of patients undergoing cardiac transplant (CT) while receiving uninterrupted anticoagulation and antiplatelet therapy.

METHODS

A retrospective, single-center, and observational study of adult patients who underwent CT was performed. Patients were classified into four groups: (1) patients without anticoagulation or antiplatelet therapy (control), (2) patients on antiplatelet therapy (AP), (3) patients on vitamin K antagonists (AVKs), and (4) patients on dabigatran (dabigatran). The primary endpoints were reoperation due to bleeding and perioperative BPT rates (packed red blood cells (PRBC), fresh frozen plasma, platelets). Secondary outcomes assessed included morbidity and mortality-related events.

RESULTS

Of the 55 patients included, 6 (11%) received no therapy (control), 8 (15%) received antiplatelet therapy, 15 (27%) were on AVKs, and 26 (47%) were on dabigatran. There were no significant differences in the need for reoperation or other secondary morbidity-associated events. During surgery patients on dabigatran showed lower transfusion rates of PRBC (control 100%, AP 100%, AVKs 73%, dabigatran 50%, p = 0.011) and platelets (control 100%, AP 100%, AVKs 100%, dabigatran 69%, p = 0.019). The total intraoperative number of BPT was also the lowest in the dabigatran group (control 5.5 units, AP 5 units, AVKs 6 units, dabigatran 3 units; p = 0.038); receiving significantly less PRBC (control 2.5 units, AP 3 units, AVKs 2 units, dabigatran 0.5 units; p = 0.011). A Poisson multivariate analysis showed that only treatment on dabigatran reduces PRBC requirements during surgery, with an expected reduction of 64.5% (95% CI: 32.4%-81.4%).

CONCLUSIONS

In patients listed for CT requiring anticoagulation due to nonvalvular atrial fibrillation, the use of dabigatran and its reversal with idarucizumab significantly reduces intraoperative BPT demand.

Prognostic implications of inactive status in highest urgency categories among heart transplantation recipients in the new donor heart allocation system

BACKGROUND

Patients on the waiting list for heart transplantation (HT) can become inactive or made status seven because of medical reasons, such adverse events, complications, or psychosocial circumstances. If the condition that caused the inactivation is resolved, patients are re- activated. Information about the prognostic implications of Status 7 in the new donor heart allocation system has not been described. To bridge this knowledge gap, we performed an analysis of the United Network of Organ Sharing (UNOS) registry.

METHODS

Data on adult patients who underwent HT between October 18th, 2018 and October 2021, were queried from the UNOS registry. The main outcomes were post- transplant all-cause mortality, 1-year all-cause mortality and treated acute rejection. Since re-transplantation is a competing event for all-cause mortality, we performed competing risk survival analysis and reported sub distribution hazard ratios (SHR) from the Fine and Gray model to examine the relationship between inactive status and all-cause mortality.

RESULTS

A total of 5267 adult patients underwent HT and were previously listed as Status 1 or Status 2 in the new allocation system. We identified 946 HT recipients temporarily inactivated while on HT list (18%). The number of temporarily inactive patients remained stable since the implementation of the new donor allocation system (p = .37). Approximately, two-thirds of temporarily inactive patients (65.9%) were inactivated for being too sick, whereas other frequent justifications for inactivity included left ventricular assist device implantation (7.8%) and insurance related issues (4.8%). Temporarily inactive HT recipients were more likely to be African Americans, males, have a higher body mass index (BMI) and significantly longer waiting time (391.6 ± 600 vs. 72.3 ± 223 days, p < .001) compared with never inactivated patients. In the unadjusted analyses 30-day mortality did not differ between groups, but both 1-year and overall all-cause mortality was significantly higher in temporarily inactive patients (1-year: SHR: 1.3; 95% confidence intervals [CI]: 1.03, 1.64; p = .028, overall mortality SHR: 1.31; 95% CI: 1.06, 1.64; p = .014). After adjustment for donor and recipient characteristics, a trend towards higher 1-year and overall mortality remained (1-year: SHR 1.32; 95% CI .99, 1.76, p = .006, overall mortality SHR: 1.29; 95% CI: .98-1.68, p = .065). No differences in treated acute allograft rejection at 1 year were found between groups.

CONCLUSIONS

Temporary inactive status while waiting for HT occurs in approximately one in five HT recipients listed in higher urgency categories after the implementation of the new allocation system. A signal of adverse long-term outcomes was found, and this could be explained by differences in recipient characteristics. Further research is required to elucidate pathways involved and possible implications for clinical practice.

Left ventricular assist device bridging to heart transplantation: Comparison of temporary versus durable support

BACKGROUND

Since the revision of the United States heart allocation system, increasing use of mechanical circulatory support has been observed as a means to support acutely ill patients. We sought to compare outcomes between patients bridged to orthotopic heart transplantation (OHT) with either temporary (t-LVAD) or durable left ventricular assist devises (d-LVAD) under the revised system.

METHODS

The United States Organ Network database was queried to identify all adult OHT recipients who were bridged to transplant with either an isolated t-LVAD or d-LVAD from 10/18/2018 to 9/30/2020. The primary outcome was 1-year post-transplant survival. Predictors of mortality were also modeled, and national trends of LVAD bridging were examined across the study period.

RESULTS

About 1,734 OHT recipients were analyzed, 1,580 (91.1%) bridged with d-LVAD and 154 (8.9%) bridged with t-LVAD. At transplant, the t-LVAD cohort had higher total bilirubin levels and greater prevalence of pre-transplant intravenous inotrope usage and mechanical ventilation. Median waitlist time was also shorter for t-LVAD. At 1 year, there was a non-significant trend of increased survival in the t-LVAD cohort (94.8% vs 90.1%; p = 0.06). After risk adjustment, d-LVAD was associated with a 4-fold hazards for 1-year mortality (hazard ratio 3.96, 95% confidence interval 1.42-11.03; p = 0.009). From 2018 to 2021, t-LVAD bridging increased, though d-LVAD remained a more common bridging strategy.

CONCLUSIONS

Since the 2018 allocation change, there has been a steady increase in t-LVAD usage as a bridge to OHT. Overall, patients bridged with these devices appear to have least equivalent 1-year survival compared to those bridged with d-LVAD.

Review of Postoperative Care for Heart Transplant Recipients

The early postoperative management strategies after heart transplantation include optimizing the function of the denervated heart, correcting the causes of hemodynamic instability, and initiating and maintaining immunosuppressive therapy, allograft rejection surveillance, and prophylaxis against infections caused by immunosuppression. The course of postoperative support is influenced by the quality of allograft myocardial protection prior to implantation and reperfusion, donor-recipient heart size matching, surgical technique of orthotopic heart transplantation, and patient factors (eg, preoperative condition, immunologic compatibility, postoperative vasomotor tone, severity and reversibility of pulmonary vascular hypertension, pulmonary function, mediastinal blood loss, and end-organ perfusion). This review provides an overview of the early postoperative care of recipients and includes a brief description of the surgical techniques for orthotopic heart transplantation.

Outcomes of expanded polytetrafluoroethylene pericardial membrane implantation in left ventricular assist device explantation and heart transplantation

OBJECTIVES

Redo sternotomy and explantation of left ventricular assist devices (LVAD) for heart transplantation (HT) involve prolonged dissection, potential injury to mediastinal structures and/or bleeding. Our study compared a complete expanded polytetrafluoroethylene (ePTFE) wrap versus minimal or no ePTFE during LVAD implantation, on outcomes of subsequent HT.

METHODS

Between July 2005 and July 2018, 84 patients underwent a LVAD implant and later underwent HT. Thirty patients received a complete ePTFE wrap during LVAD implantation (Group 1), and 54 patients received either a sheet of ePTFE placed in the anterior mediastinum or no ePTFE (Group 2).

RESULTS

Baseline characteristics were similar between Groups 1 and 2. Surgeons reported subjective improvements in speed, predictability, and safety of dissection with complete ePTFE compared with minimal or no ePTFE. Time from incision to initiation of cardiopulmonary bypass (CPB) were similar between groups (97 ± 38 vs. 89 ± 29 min, p = .3). Injury to mediastinal structures during the dissection was similar between groups (10% vs. 11%, p > .9). While surgeons reported less intraoperative bleeding in Group 1 (43% vs. 61%), this trend did not reach significance (p = .1). In-hospital mortality, intensive care unit length of stay and hospital length of stay were similar between both groups.

CONCLUSIONS

In patients undergoing LVAD explant-HT, there was a trend toward reduced surgeon reported intraoperative bleeding with ePTFE placement. Despite qualitatively reported greater ease and speed of mediastinal dissection with ePTFE membrane placement, time to initiation of CPB did not differ, likely because surgeons remained cautious, allowing extra time for unanticipated difficulties.

Primary Graft Dysfunction after Heart Transplantation - Unravelling the Enigma

Primary graft dysfunction (PGD) remains the main cause of early mortality following heart transplantation despite several advances in donor preservation techniques and therapeutic strategies for PGD. With that aim of establishing the aetiopathogenesis of PGD and the preferred management strategies, the new consensus definition has paved the way for multiple contemporaneous studies to be undertaken and accurately compared. This review aims to provide a broad-based understanding of the pathophysiology, clinical presentation and management of PGD.

Predictors of one-year outcome after cardiac re-transplantation: Machine learning analysis

BACKGROUND

As cardiac re-transplantation is associated with inferior outcomes compared with primary transplantation, allocating scarce resources to appropriate re-transplant candidates is important. The aim of this study is to elucidate the factors associated with 1-year mortality in cardiac re-transplantation using the random forests algorithm for survival analysis.

METHODS

We retrospectively reviewed the United Network for Organ Sharing registry and identified all adult (>17 years old) recipients who underwent cardiac re-transplantation between January 2000 and March 2020. The random forest algorithm on Cox modeling was used to calculate the variable importance (VIMP) of independent variables for contributing to one-year mortality.

RESULTS

A total of 1294 patients underwent cardiac re-transplantation. Of these, 137 patients were re-transplanted within one year of their first transplant, while 1157 patients were re-transplanted more than one year after their first transplant. One-year mortality was significantly higher for patients receiving early transplantation compared with those receiving late transplantation (Early 40.6% vs. Late 13.6%, log-rank P<0.001). Machine learning analysis showed that total bilirubin (>2 mg/dl) (VIMP, 2.99%) was an independent predictor of one-year mortality after early re-transplant. High BMI (>30.0 kg/m2) (VIMP, 1.43%) and ventilator dependence (VIMP, 1.47%) were independent predictors of one-year mortality for the late re-transplantation group.

CONCLUSION

Machine learning showed that optimal one-year survival following cardiac re-transplantation was significantly related to liver function in early re-transplantation, and to obesity and preoperative ventilator dependence in late re-transplantation. This article is protected by copyright. All rights reserved.

Impact of prior sternotomy on survival and allograft function after heart transplantation: A single center matched analysis

BACKGROUND

Orthotopic heart transplantation (OHT) remains the gold standard for the treatment of end-stage heart failure. The number of patients who have had at least one prior sternotomy while awaiting transplantation has increased over the years reaching 50% in the last ISHLT registry report. We analysed our institutional transplant activity focusing on prior-sternotomy setting to identify the real burden of this preoperative variable and its potential consequences.

METHODS

Between 2000 and 2020, a total of 512 consecutive adult patients underwent OHT. We divided them into two groups according to the previous sternotomy variable: a prior sternotomy group (PS-group, n = 131, 25.6%) and a heart transplant as first sternotomy group (FS-group, n = 381, 74.4%). After propensity score matching, a total of 106 matched-pairs were identified for the final analysis.

RESULTS

The overall 30-day mortality was similar in the two groups (7.5% vs. 5.7%, p = .58). The prior sternotomy was not an independent risk factor for 90-day mortality (odds ratio: 0.89, p = .81). In the matched sample, prior cardiac surgery was not predictive for any major postoperative complication: primary graft failure, AKI, bleeding, acute respiratory insufficiency, need for extra-corporeal life support (p > .05). The log-rank test revealed no significant difference between the two groups in the unmatched and matched pools (p = .93 and 0.69 respectively. At univariable analysis prior sternotomy was not associated with an increased risk of posttransplant mortality (hazard ratio: 0.87, p = .599).

CONCLUSIONS

Despite it increases surgical complexity, the reoperation alone does not represent a proper risk factor and among different co-variates that may affect post-OHT outcomes.

Heart transplantation in adults with congenital heart disease: a 17-year single center experience

BACKGROUND

Heart transplantation (HTx) in adults with congenital heart disease (ACHD) remains challenging because of structural anomalies and often previous procedure. The aim of this retrospective study was to describe the outcomes of heart transplantation (HTx) in a cohort of ACHD patients at our tertiary centre.

PATIENTS AND METHODS

Between January 1993 and December 2010, 223 consecutive adult patients (age > 18 years) underwent HTx at our institution. Fifteen (6.7%) were ACHD patients. Outcomes were reviewed using our institution's HTx database. We looked at 30-day, 1, 5 and 10-years survival, as well as post-transplantation complications.

RESULTS

The mean age at HTx of the groups of ACHD was 42 ± 14.4 years, vs 54.2 ± 9.8 years for the non-CHD patients. Prior to transplant, thirteen of the fifteen ACHD had undergone one or more surgical procedures including palliative or corrective open-heart procedures in 66.6% of them. Seven of the fifteen ACHD (47%) required additional surgical procedures at transplantation. The mean follow-up was 95,44 ± 84.3 months. There was no significant difference in survival (ACHD vs non-CHD) at 30 days (87% vs. 90%), 1 year (73% vs. 74.5%) or 5 years (53% vs. 55%). Survival at 10 years was respectively 53% and 41% for ACHD patients and non-CHD patients.

CONCLUSION

Despite the surgical challenge, HTx in ACHD has a good long-term result. However, the small sample size of our cohort limits any definitive conclusions.

Effect of novel bicaval anastomosis technique for transplantation with and without prior cardiac surgery history

Background

To evaluate the graft outcomes after orthotopic heart transplantation (HTx) with a novel bicaval anastomosis technique between recipients with and without a history of prior cardiac surgery.

Methods

Of 70 patients who underwent HTx with a novel four-corners traction bicaval anastomosis technique from August 2017 to November 2019, 60 recipients underwent the HTx procedure as their first cardiac surgery (group A), while 10 recipients underwent HTx after prior cardiac surgery (group B). Patients in the two groups were compared in terms of their preoperative baseline variables such as etiological categories, history of blood transfusion and panel reactive antibody (PRA), intraoperative operation time and blood infusion volume, postoperative treatment time, and complications such as acute rejection and 30-day mortality as well as survival rates.

Results

Preoperative variables were comparable in group A and group B except for the history of blood transfusion (0% vs. 90.0%, P<0.001, respectively); the level of PRA was 7.5%±5.8% and 9.5%±10.9% for group A and B, respectively (P=0.583), but the time of the operation was nearly 1 hour longer for group B than group A (all P<0.05). No cases of left atrial thrombosis and donor heart distortion were observed in either group. Reoperation (1.7% vs. 10.0%, P=0.267), infection (0% vs. 10.0%, P=0.142), other postoperative complications as well as the 30-day mortality (1.7% vs. 10.0%, P=0.267), and postoperative survival rates (91.5% vs. 90.0%, P=0.805) were comparable between the two groups (all P>0.05).

Conclusions

Four-corner traction bicaval anastomosis combined with a continuous everting suture technique may result in approximately comparable prognoses for heart recipients with a history of cardiac surgery when compared with those without a history of cardiac surgery and this technique may reduce the incidence of left atrial thrombosis and distortion. Further follow-up of the long-term outcomes will be required to validate these results.

Recipient and surgical factors trigger severe primary graft dysfunction after heart transplant

BACKGROUND

Primary graft dysfunction (PGD) is a major cause of early mortality following heart transplant (HT). The International Society for Heart and Lung Transplantation (ISHLT) subdivides PGD into 3 grades of increasing severity. Most studies have assessed risk factors for PGD without distinguishing between PGD severity grade. We sought to identify recipient, donor and surgical risk factors specifically associated with mild/moderate or severe PGD.

METHODS

We identified 734 heart transplant recipients at our institution transplanted between January 1, 2012 and December 31, 2018. PGD was defined according to modified ISHLT criteria. Recipient, donor and surgical variables were analyzed by multinomial logistic regression with mild/moderate or severe PGD as the response. Variables significant in single variable modeling were subject to multivariable analysis via penalized logistic regression.

RESULTS

PGD occurred in 24% of the cohort (n = 178) of whom 6% (n = 44) had severe PGD. One-year survival was reduced in recipients with severe PGD but not in those with mild or moderate PGD. Multivariable analysis identified 3 recipient factors: prior cardiac surgery, recipient treatment with ACEI/ARB/ARNI plus MRA, recipient treatment with amiodarone plus beta-blocker, and 3 surgical factors: longer ischemic time, more red blood cell transfusions, and more platelet transfusions, that were associated with severe PGD. We developed a clinical risk score, ABCE, which provided acceptable discrimination and calibration for severe PGD.

CONCLUSIONS

Risk factors for mild/moderate PGD were largely distinct from those for severe PGD, suggesting a differing pathophysiology involving several biological pathways. Further research into mechanisms underlying the development of PGD is urgently needed.

Cardiac transplantation in adult congenital heart disease with prior sternotomy

BACKGROUND

Adult congenital heart disease (ACHD) patients who require orthotopic heart transplantation are surgically complex due to anatomical abnormalities and multiple prior surgeries. In this study, we investigated these patients' outcomes using our institutional database.

METHODS

ACHD patients who had prior intracardiac repair and subsequent heart transplant were included (2008-2018). Adult patients without ACHD were extracted as a control. A comparison of patients with functional single ventricular (SV) and biventricular (BV) hearts was performed.

RESULTS

There were 9 SV and 24 BV patients. The SV group had higher central venous pressure/pulmonary capillary wedge pressure (P = .028), hemoglobin concentration (P = .010), alkaline phosphatase (P = .022), and were more likely to have liver congestion (P = .006). Major complications included infection in 16 (48.5%), temporary dialysis in 12 (36.4%), and graft dysfunction requiring perioperative mechanical support in 7 (21.2%). Overall in-hospital mortality was 15.2%. Kaplan-Meier analysis showed a higher, but not statistically significant, survival after 10 years between the ACHD and control groups (ACHD 84.9% vs. control 67.5%, P = .429). There was no significant difference in 10-year survival between SV and BV groups (78% vs. 88%, P = .467).

CONCLUSIONS

Complex ACHD cardiac transplant recipients have a high incidence of early morbidities after transplantation. However, long-term outcomes were acceptable.

Impact of Less Invasive Left Ventricular Assist Device Implantation on Heart Transplant Outcomes

Left ventricular assist device implantation without sternotomy (LIS) may simplify heart transplantation (HTX) by avoiding adhesions and eliminating the need for a re-sternotomy. This study investigates the impact of LIS LVAD implantation on HTX outcomes. A retrospective comparison of 46 patients undergoing HTX between 07/13 and 06/19 after conventional LVAD implantation with a full sternotomy (FS) and LIS LVAD implantation (LIS: n = 27 patients, 59%; FS: n = 19 patients, 41%) was performed. Endpoints were perioperative data including blood product use, de-novo formation of donor specific antibodies (DSAs) and survival. Patient demographics (mean age FS: 60.3 ± 9.3 years vs LIS 58.0 ± 7.7 years, P = 0.313; male gender FS: 84% vs LIS: 82%, P = 1.000; urgent HTX FS: 16% vs LIS 18%, P = 1.000) were comparable between LIS and FS patients. The primary finding was a significantly higher risk to develop de novo donor specific antibodies (DSAs) after HTX in patients of the FS group (FS: 36% vs LIS: 4%; P = 0.006). LIS patients had a significant reduction of intraoperative packed red blood cells (PRBCs) use (LIS: 4 (IQR 2-7) Units vs FS: 7 (IQR 4-8) Units; P = 0.045). Other adverse events rates and in-hospital mortality (LIS: 7% vs FS 5%, P = 1.000) were comparable between both groups. LIS LVAD reduces formation of donor specific antibodies after HTX.

Post-transplant survival in adult congenital heart disease patients as compared to dilated and ischemic cardiomyopathy patients; an analysis of the thoracic ISHLT registry

Previous studies have shown that adult congenital heart disease (ACHD) is associated with high early post-transplant mortality but improved long-term survival in comparison to the overall heart transplant population. We aimed to evaluate survival outcomes of ACHD in adult transplant recipient patients as specifically compared to ischemic (ICM) and dilated cardiomyopathy (DCM) groups. Adult heart transplant recipients between 2004 and 2014 were identified from the ISHLT registry. We used Kaplan-Meier analysis to evaluate overall survival, 1-year survival, and 1-year conditional survival among etiology groups and multivariable Cox proportional hazard (PH) models to assess the association between etiology of cardiomyopathy and 1-year and long-term all-cause mortality and cause-specific mortality. We included 30 130 heart transplant recipients. One-year survival was 78.3% in ACHD, 84.3% in ICM, and 86.2% in DCM patients (P < .001). By multivariable analysis, during first post-transplant year, ACHD and ICM patients were at significantly higher mortality risk than DCM. Adjusted post-transplant mortality risk, conditional on 1-year survival, was not statistically different in ACHD and DCM while ICM patients had 17% higher long-term mortality risk than DCM patients leading to overall worse outcomes in ICM patients. Therefore, ICM patients have poorer outcomes in comparison to both DCM and ACHD patients.

Comparison of Heart Transplantation Outcomes: Adult Congenital Heart Disease vs Matched Cardiac Patients in a Quaternary Reference Centre

BACKGROUND

The number of transplantations performed for adult congenital heart disease (ACHD) patients is increasing. We sought to compare survival and post-transplantation complications, including graft failure, rejection, dialysis, and use of a right ventricular assist device, between ACHD and a cohort of dilated (DCM) and ischemic (ICM) cardiomyopathy patients matched by age and year of transplantation.

METHODS

We retrospectively reviewed our single-institution heart transplantation database and selected all patients who had surgery from 1988 to 2017. In our primary analysis, we looked at survival and post-transplantation complications across cardiomyopathy groups. Our secondary analysis was matched to mitigate era effects as well as differences in age at transplant.

RESULTS

We analyzed a cohort consisting of 303 heart transplant patients with cardiomyopathy due to either 1) ACHD (n = 38), 2) ICM (n = 110), or 3) DCM (n = 155). Kaplan-Meier analysis and a multivariable Cox proportional hazard regression model were used for all-cause mortality, and cause-specific hazard regression for cause-specific mortality and morbidity. There was no statistically significant survival difference across groups. The 1-year survival was 68.5% for ACHD, 85.4% for ICM, and 85.5% for DCM. In multivariable analysis, ICM and DCM patients showed a 66% lower risk of death relative to the ACHD group. The matched analysis showed no significant difference in survival across groups.

CONCLUSIONS

ACHD patients represent a growing high-risk patient cohort referred for transplantation. To improve survival outcomes we need to address modifiable risk factors.

Early and long-term results of heart transplantation with reoperative sternotomy

Background

This study aims to investigate the effects of reoperative sternotomy on early and long-term outcomes after heart transplantation.

Methods

We retrospectively reviewed data of a total of 92 patients (72 males, 20 females; mean age 36 years; range, 3 to 61 years) who underwent orthotopic heart transplantation between May 1998 and July 2014. The patients were divided into three groups. Group A (n=23) included patients who underwent previous cardiac surgery with sternotomy other than ventricular assist device implantation; Group B (n=12) included patients who were bridged-to-transplant with a ventricular assist device; and Group C (n=57) included patients who for the first time underwent heart transplantation without previous sternotomy. Preoperative and operative data of the three groups were compared. The short- and long-term outcomes of all groups were analyzed.

Results

There was no significant difference among the groups, except for the age and preoperative international normalized ratio. Total ischemia time in the ventricular assist device group was longer than Group C. The length of intensive care unit stay was also longer in the ventricular assist device group than the other groups. The amount of postoperative chest tube drainage and blood transfusion was higher in Group A. Early mortality rate was significantly higher in Group A. There was no significant difference in survival among the three groups in the long-term. According to the logistic regression analysis, no variable was found to be a significant risk factor for mortality.

Conclusion

Reoperative sternotomy other than ventricular assist device implantation was found to be a risk factor for early mortality; however, mid and long-term survival rates were similar to patients in whom transplantation was the primary procedure. In patients with reoperative sternotomy, heart transplantation can be performed with similar risks to patients without resternotomy with careful selection and accurate pre- and intraoperative surgical approach.

Primary graft dysfunction after heart transplantation: a thorn amongst the roses

Primary graft dysfunction (PGD) remains the leading cause of early mortality post-heart transplantation. Despite improvements in mechanical circulatory support and critical care measures, the rate of PGD remains significant. A recent consensus statement by the International Society of Heart and Lung Transplantation (ISHLT) has formulated a definition for PGD. Five years on, we look at current concepts and future directions of PGD in the current era of transplantation.

ISHLT Primary Graft Dysfunction Incidence, Risk Factors, and Outcome: A UK National Study

BACKGROUND

Heart transplantation (HTx) remains the most effective long-term treatment for advanced heart failure. Primary graft dysfunction (PGD) continues to be a potentially life-threatening early complication. In 2014, a consensus statement released by International Society for Heart and Lung Transplantation (ISHLT) established diagnostic criteria for PGD. We studied the incidence of PGD across the United Kingdom.

METHODS

We analyzed the medical records of all adult patients who underwent HTx between October 2012 and October 2015 in the 6 UK heart transplant centers Preoperative donor and recipient characteristics, intraoperative details, and posttransplant complications were compared between the PGD and non-PGD groups using the ISHLT definition. Multivariable analysis was performed using logistic regression.

RESULTS

The incidence of ISHLT PGD was 36%. Thirty-day all-cause mortality in those with and without PGD was 31 (19%) versus 13 (4.5%) (P = 0.0001). Donor, recipient, and operative factors associated with PGD were recipient diabetes mellitus (P = 0.031), recipient preoperative bilateral ventricular assist device (P < 0.001), and preoperative extracorporeal membranous oxygenation (P = 0.023), female donor to male recipient sex mismatch (P = 0.007), older donor age (P = 0.010), and intracerebral haemorrhage/thrombosis in donor (P = 0.023). Intraoperatively, implant time (P = 0.017) and bypass time (P < 0.001) were significantly longer in the PGD cohort. Perioperatively, patients with PGD received more blood products (P < 0.001). Risk factors identified by multivariable logistic regression were donor age (P = 0.014), implant time (P = 0.038), female: male mismatch (P = 0.033), recipient diabetes (P = 0.051) and preoperative ventricular assist device/extracorporeal membranous oxygenation support (P = 0.012).

CONCLUSIONS

This is the first national study to examine the incidence and significance of PGD after HTx using the ISHLT definition. PGD remains a frequent early complication of HTx and is associated with increased mortality.

HeartMate II pump exchange with HeartMate III implantation to the descending aorta

Removal of the HeartMate II left ventricular assist device (LVAD) usually requires a sternotomy. We report a case of HeartMate III LVAD implantation to the descending aorta via a left thoracotomy while leaving most of the HeartMate II device in place to avoid redo-sternotomy.

Reoperative sternotomy is associated with primary graft dysfunction following heart transplantation

OBJECTIVES

Prior sternotomy is associated with increased morbidity and mortality following heart transplantation. However, its effect on primary graft dysfunction (PGD), a major contributor to early mortality, is unknown. Herein, this effect is studied using the International Society for Heart and Lung Transplantation consensus definition for PGD.

METHODS

Medical records of consecutive adult cardiac transplants between 2012 and 2016 were reviewed. Baseline characteristics, postoperative findings and 1-year survival were compared between patients with and without prior sternotomy.

RESULTS

Among 255 total patients included, 139 (55%) had undergone prior sternotomy; these recipients were older, more often male, had higher body mass index, higher frequencies of united network for organ sharing (UNOS) 1A status and ischaemic cardiomyopathy and experienced longer waitlist times when compared with those without prior sternotomy (all P < 0.018). Postoperatively, the prior sternotomy group exhibited higher rates of mild to severe PGD (32% vs 18%; P = 0.015) and higher short-term mortality (P = 0.017) and 1-year mortality (P = 0.047). They required more blood transfusions, had more postoperative pneumonia, wound infection and longer hospital stays. A stepwise multivariable regression model identified prior sternotomy as a predictor of PGD (odds ratio 2.7). Multiple prior sternotomies was associated with even more UNOS 1A status, ischaemic cardiomyopathy and pneumonia. However, logistic modelling did not show a difference in the rate of PGD between those with 1 or ≥2 prior sternotomies.

CONCLUSIONS

Our data suggest that prior sternotomy is a risk factor for PGD. Consistent with previous reports, prior sternotomy is associated with increased morbidity, blood product utilization and 1-year mortality following cardiac transplantation.

Comparison of Clinical Characteristics, Complications, and Outcomes in Recipients Having Heart Transplants <65 Years of Age Versus ≥65 Years of Age

Advanced recipient age remains a limiting factor for heart transplant candidacy, with many centers reluctant to transplant older patients. Here, we report our experience with recipients aged ≥65 years compared with younger recipients in terms of baseline characteristics, intraoperative and immediate postoperative experiences, and post-transplant morbidity and survival. The main study outcome was primary graft dysfunction (PGD), which has not been widely studied in this population. Donor and recipient data from 255 heart transplantations performed between 2012 and 2016 were reviewed. Seventy (27%) recipients were ≥65 years and 185 were younger. The older group had a higher frequency of ischemic cardiomyopathy and more frequently had a previous sternotomy than the younger recipients (all p <0.007). We found no significant differences in post-transplant morbidity (intensive care unit and hospital stay, pneumonia, infections, reoperation for bleeding, stroke, renal failure, or in-hospital mortality; all p >0.12). One-year survival was also similar in the 2 groups (p = 0.88). The incidence of moderate or severe PGD was lower in the older group (6%) than in the younger group (16%; p = 0.037). Multivariate logistic regression found pretransplant creatinine and donor undersizing by predicted heart mass to be predictors of moderate to severe PGD, whereas recipient age ≥65 years was identified as protective against PGD in this cohort. In conclusion, our study showed comparable survival and outcomes in recipients ≥65 years of age with otherwise similar nutritional status and body mass composition.

Microaxial Flow Left Ventricular Assist Device as a Bridge to Transplantation after LVAD Malfunction

Evolving technology and improvements in the design of modern, continuous-flow left ventricular assist devices have substantially reduced the rate of device malfunction. As the number of implanted devices increases and as survival prospects for patients with a device continue to improve, device malfunction is an increasingly common clinical challenge. Here, we present our initial experience with an endovascular microaxial flow left ventricular assist device as a successful bridge to transplantation in a 54-year-old man who experienced left ventricular assist device malfunction.

Prior sternotomy increases the mortality and morbidity of adult heart transplantation

BACKGROUND

This study investigated the effect of prior sternotomy (PS) on the postoperative mortality and morbidity after orthotopic heart transplantation (HTx).

METHODS

Of 704 adults who underwent HTx from December 1988 to June 2012 at a single institution, 345 had no PS (NPS group) and 359 had ≥ 1 PS (PS group). Survival, intraoperative use of blood products, intensive care unit (ICU) and hospital stays, frequency of reoperation for bleeding, dialysis, and >48-hour ventilation were examined.

RESULTS

The NPS and PS groups had similar 60-day survival rates (97.1 ± 0.9% vs 95.3 ± 1.1%; P = .20). However, the 1-year survival was higher in the NPS group (94.7 ± 1.2% vs 89.7 ± 1.6%; hazard ratio [HR], 1.98; 95% CI, 1.12-3.49; P = .016). The PS group had longer pump time and more intraoperative blood use (P < .0001 for both). Postoperatively, the PS group had longer ICU and hospital stays, and higher frequencies of reoperation for bleeding and >48-hour ventilation (P < .05 for all comparisons). Patients with 1 PS (1PS group) had a higher 60-day survival rate than those with ≥ 2 PS (2+PS group; 96.7 ± 1.1% vs 91.1 ± 3.0%; HR, 2.70; 95% CI, 1.04-7.01; P = .033). The 2+PS group had longer pump time and higher frequency of postoperative dialysis (P < .05 for both). Patients with prior VAD had lower 60-day (91.1 ± 3.0% vs 97.1 ± 0.9%; P = .010) and 1-year (87.4 ± 3.6% vs 94.7 ± 1.2%; P = .012) survival rates than NPS group patients. Patients with prior CABG had a lower 1-year survival than NPS group patients (89.0 ± 2.3% vs 94.7 ± 1.2%; P = .018).

CONCLUSION

The PS group had lower 1-year survival and higher intraoperative blood use, postoperative length of ICU and hospital stays, and frequency of reoperation for bleeding than the NPS group. Prior sternotomy increases morbidity and mortality after HTx.

Cardiac surgery 2014 reviewed

For the year 2014, more than 17,000 published references can be found in Pubmed when entering the search term "cardiac surgery". The last year has been characterized by a vivid discussion in the fields where classic cardiac surgery and modern interventional techniques overlap. Specifically, there have been important contributions in the field of coronary revascularization with either percutaneous coronary intervention or bypass surgery as well as in the fields of interventional valve therapy. Here, the US core valve trial with the first demonstration of a survival advantage at 1 year with transcatheter valves compared to surgical aortic valve replacement or the 5-year outcome of the SYNTAX trial with significant advantages for bypass surgery has been the landmark. However, in addition to these most visible publications, there have been several highly relevant and interesting contributions. This review article will summarize the most pertinent publications in the fields of coronary revascularization, surgical treatment of valve disease, heart failure (i.e., transplantation and ventricular assist devices) and aortic surgery. This condensed summary will provide the reader with "solid ground" for up-to-date decision-making in cardiac surgery.

Early postoperative management of heart transplant recipients with current ventricular assist device support in Japan: experience from a single center

PURPOSE

This study reviews our experience with the perioperative management of heart transplant (HT) recipients and explores how prior ventricular assist device (VAD) support affects the requirements for postoperative mechanical ventilation and circulatory support.

METHODS AND RESULTS

A retrospective database review was performed from 2007 to 2014. Early postoperative outcomes were compared between VAD and non-VAD groups. Forty-four patients were studied. The mean age was 38 ± 13 years, 30% were female, and 88% experienced non-ischemic heart failure. Forty patients (91%) required VAD support at the time of HT, with a mean duration of 864 ± 351 days. The median postoperative mechanical ventilation times in the VAD and non-VAD groups were 54 [95% confidence interval (CI) 42.9-297.3] and 15 (95% CI 4.8-30.0; p = 0.0199) hours, respectively. The VAD group experienced increased bleeding during the first 48 h after HT (6.7 ± 3.5 vs. 1.8 ± 0.75 l, p = 0.004). Mechanical circulatory support with intra-aortic balloon pumping or venoarterial extracorporeal membrane oxygenation was required in 30% of VAD group patients. Increased bleeding and primary graft failure were the main causes of prolonged mechanical ventilation.

CONCLUSIONS

HT recipients with VAD support required longer mechanical ventilation periods and mechanical circulatory support in the postoperative period.