Cardiac transplantation in patients over 60 years of age

Similar Mortality and Morbidity of Orthotopic Heart Transplantation for Patients 70 Years of Age and Older Compared With Younger Patients

BACKGROUND

The upper age limit of heart transplantation remains controversial. The goal of the present study was to investigate the mortality and morbidity of orthotopic heart transplantation (HT) for recipients ≥70 compared with those <70 years of age.

METHODS

Of 704 adults who underwent HT from December 1988 to June 2012 at our institution, 45 were ≥70 years old (older group) and 659 were <70 years old (younger group). Survival, intraoperative blood product usage, intensive care unit (ICU) and hospital stays, and frequency of reoperation for chest bleeding, dialysis, and >48 hours ventilation were examined after HT.

RESULTS

The older group had 100% 30-day and 60-day survival compared with 96.8 ± 0.7% 30-day and 95.9 ± 0.8% 60-day survival rates in the younger group. The older and younger groups had similar 1-year (93.0 ± 3.9% vs 92.1 ± 1.1%; P = .79), 5-year (84.2 ± 6.0% vs 73.4 ± 1.9%; P = .18), and 10-year (51.2 ± 10.7% vs 50.2 ± 2.5%; P = .43) survival rates. Recipients in the older group had higher preoperative creatinine levels, frequency of coronary artery disease, and more United Network for Organ Sharing status 2 and fewer status 1 designations than recipients in the younger group (P < .05 for all). Pump time and intraoperative blood usage were similar between the 2 groups (P = NS); however, donor-heart ischemia time was higher in the older group (P = .002). Older recipients had higher postoperative creatinine levels at peak (P = .003) and at discharge (P = .007). Frequency of postoperative complications, including reoperation for chest bleeding, dialysis, >48 hours ventilation, pneumonia, pneumothorax, sepsis, in-hospital and post-discharge infections, were similar between groups (P = NS for all comparisons). ICU and hospital length of stays were similar between groups (P = .35 and P = .87, respectively). In Cox analysis, recipient age ≥70 years was not identified as a predictor of lower long-term survival after HT.

CONCLUSIONS

HT recipients ≥70 years old had similar 1, 5, and 10-year survival rates compared with younger recipients. Both patient groups had similar intra- and postoperative blood utilization and frequencies of many postoperative complications. Older and younger patients had similar morbidity and mortality rates following HT. Carefully selected older patients (≥70 years) can safely undergo HT and should not be excluded from HT consideration based solely on age.

Heart transplantation in the elderly patients: midterm results

Background

Heart transplantation in elderly patients has raised concerns because of co-morbidities and limited life expectancy in the era of donor shortage. We examined the outcomes after heart transplantation in elderly patients.

Materials and Methods

From March 1994 to December 2011, 81 patients (male:female=64:17, 49.1±14.0 years) underwent heart transplantation. The outcomes after heart transplantation in the younger patients (<60 years; group Y, n=60) were compared with those in the elderly patients (≥60 years; group O, n=21). The follow-up duration was 51.8±62.7 months.

Results

Early mortality (≤30 days) occurred in 5.0% (3/60) and 4.8% (1/21) of groups Y and O, respectively (p>0.999). There were no differences in overall survival between the two groups (p=0.201). Freedom from rejection was higher in group O than in group Y (p=0.026). Multivariable analysis revealed that age ≥60 years was not a significant risk factor for long-term survival; postoperative renal failure was the only significant risk factor for long-term survival (p=0.011).

Conclusion

Early and mid-term results of heart transplantation in elderly patients were similar to those in younger patients.

Aging augments IL-17 T-cell alloimmune responses

As increasing numbers of elderly patients require solid organ transplantation, the need to better understand how aging modifies alloimmune responses increases. Here, we examined whether aged mice exhibit augmented, donor-specific memory responses prior to transplantation. We found that elevated donor-specific IL-17, but not IFN-gamma, responses were observed in aged mice compared to young mice prior to transplantation. Further characterization of the heightened IL-17 alloimmune response with aging demonstrated that memory CD4(+) T cells were required. Reduced IL-2 alloimmune responses with age contributed to the elevated IL-17 phenotype in vitro, and treatment with an anti-IL-17 antibody delayed the onset of acute allograft rejection. In conclusion, aging leads to augmented, donor-specific IL-17 immune responses that are important for the timing of acute allograft rejection in aged recipients. IL-17 targeting therapies may be useful for averting transplant rejection responses in older transplant recipients.

Aging impairs recipient T cell intrinsic and extrinsic factors in response to transplantation

Background

As increasing numbers of older people are listed for solid organ transplantation, there is an urgent need to better understand how aging modifies alloimmune responses. Here, we investigated whether aging impairs the ability of donor dendritic cells or recipient immunity to prime alloimmune responses to organ transplantation.

Principal Findings

Using murine experimental models, we found that aging impaired the host environment to expand and activate antigen specific CD8⁺ T cells. Additionally, aging impaired the ability of polyclonal T cells to induce acute allograft rejection. However, the alloimmune priming capability of donor dendritic cells was preserved with aging.

Conclusion

Aging impairs recipient responses, both T cell intrinsic and extrinsic, in response to organ transplantation.

Orthotopic heart transplantation in elderly patients: A 10-year experience at a single center

INTRODUCTION

A consensus has not yet been reached regarding the indications for orthotopic heart transplantation (OHT) in elderly patients or the age limit contraindicating the procedure. The objective of this study was to assess OHT outcomes to determine whether elderly patients benefit from the procedure.

METHODS

From February 1993 to February 2003, 178 OHTs were performed on recipients of mean age 47.4 +/- 15 years (range, 4 to 74) including 80.3% men. The population was divided into two groups: group A included patients >/= 60 years, and group B those younger than that age. Survival was analyzed for the overall population and for both age groups during a 10-year follow-up period.

RESULTS

Group A included 36 patients (20.8%) and group B 142 patients (79.2%). Mean age was 63.7 +/- 2.9 years (60 to 74) in A, and 43 +/- 13.9 years (4 to 59) in B. In-hospital mortality was significantly higher among group A (n = 11, 31.4%) compared to B (n = 17, 12.1%, P =.008). Survival at 1, 5, and 10 years was 61.5% +/- 8%, 58.1% +/- 8.3%, and 49.8% +/- 10.5% group A; and 84.2% +/- 3%, 73.7% +/- 4.1%, and 69.9% +/- 4.7 for group B. Elderly patients showed a lower survival rate (49.8%) compared with the younger group (69.9%) at 10-year follow-up (P =.007). Conditional survival at 9 years failed to show significant differences (A 72.2% vs B 79.6%, P =.4).

CONCLUSION

In our population, elderly recipients showed a higher in-hospital mortality. However, when the first post-OHT year was excluded, we found similar survival rates for both age groups.

Long-term results of cardiac transplantation in patients 65 years of age and older: a comparative analysis

BACKGROUND

Advanced age is viewed by some transplant centers as a contraindication for heart transplantation secondary to concerns regarding decreased survival.

METHODS

Between January 1992 and June 2002, 63 of 881 (7.2%) orthotopic heart transplants were performed in patients above 65 years. These patients were compared to 63 recipients below age 65 who were matched for sex, etiology of heart failure, United Network for Organ Sharing status, and immunosuppression therapy era.

RESULTS

Mean age was 67.1 +/- 2.3 years (range, 65.0 to 74.8) for the older group and 48.1 +/- 14.5 years (range, 18.3 to 64.4) for the younger group (p < 0.001). There was no significant difference in the incidence of diabetes, hypertension, chronic obstructive pulmonary disease, or peripheral vascular disease between the groups (p = not significant) although there were more patients with prior myocardial infarctions in the older group (p < 0.001). There was no significant difference in overall survival between the groups, with 1-, 3-, 5-, and 10-year actuarial survival of 85.8%, 80.3%, 73.1%, and 49.9% for the older group; and 86.9%, 83.4%, 75.0%, and 57.0% for the younger group (p = 0.597). Postoperative intensive care unit stay and overall hospital stay were similar for the two groups (p = not significant). There was no significant difference between the groups in freedom from infection or rejection at 1, 3, or 5 years after transplant (p = not significant) although the incidence of transplant coronary artery disease was higher in the older group (p = 0.025).

CONCLUSIONS

These data demonstrate similar short-term and long-term results for elderly and young recipients undergoing cardiac transplantation. This supports proceeding with transplantation in carefully selected elderly patients.

Longer-term risks associated with 10-year survival after heart transplantation in the cyclosporine era

BACKGROUND

Long-term survival after heart transplantation is common in the cyclosporine era. However, there are few data documenting pre-transplant/peri-operative factors predictive of truly long-term survival (>10 years). The purpose of this study is to identify factors associated with 10-year survival after heart transplantation.

METHODS

Our study population included 197 adults who survived >6 months and died <10 years after heart transplant (medium-term group) and 140 adults who survived >10 years after heart transplant (long-term group) between December 1980 and May 2001. A comparison was done between the two groups and we used multivariate analysis to identify which factors predicted 10-year survival.

RESULTS

The long-term group had younger recipient and donor age, lower recipient body mass index at transplant, shorter waiting time and lower percentages of ischemic etiology/male recipient/non-white recipient. Kaplan-Meier plots of freedom from graft coronary artery disease and malignancy showed later onset patterns in the long-term group compared with the medium-term group. Multivariate analysis showed that white recipient, younger recipient and lower recipient body mass index at heart transplant were factors significantly associated with 10-year survival.

CONCLUSIONS

Several pre-transplant/peri-operative factors were associated with survival beyond 10 years after heart transplantation. Stratified/tailored strategies based on these factors may be helpful to attain longer-term survival of recipients with higher risks.

Long-term results of heart transplantation in patients older than 60 years

BACKGROUND

Advanced age has been traditionally considered a relative contraindication for heart transplantation. Older patients are now considered as potential candidates for heart transplantation. The objective of this study was to evaluate the long-term results of heart transplantation in patients older than 60 years.

METHODS

Between 1986 and 2001, 81 patients aged between 60 and 70 years (mean, 63 +/- 2 years) underwent heart transplantation. These patients were compared with 403 adult recipients younger than 60 years (mean, 47 +/- 11 years) who underwent transplantation during the same period.

RESULTS

Thirty-day mortality was 6% (5/81) and 6% (25/403) in the older and younger patients, respectively (P = NS). Actuarial survival at 1, 5, and 10 years was 88% +/- 4% versus 83% +/- 2%, 75% +/- 5% versus 69% +/- 2%, and 50% +/- 9% versus 51% +/- 3% in the older and younger patients, respectively (P = NS). Older patients had significantly fewer rejection episodes (P =.003). Freedom from allograft coronary artery disease at 1, 5, and 10 years was 98% +/- 2% versus 92% +/- 2%, 85% +/- 6% versus 76% +/- 3%, and 81% +/- 7% versus 68% +/- 3% (P =.1). The incidences of infectious complication, cytomegalovirus infection, and posttransplant lymphoproliferative disorder were similar between the 2 groups, but older recipients were more likely to have a nonposttransplant lymphoproliferative disorder cancer (P =.002). Age at transplantation was not identified as an independent risk factor for early and late death.

CONCLUSION

Heart transplantation in selected patients aged 60 years and older results in survival comparable with that of younger patients. Older patients have a lower risk of rejection but an increased risk of development of a nonposttransplant lymphoproliferative disorder cancer. Advanced age per se should not be considered as an exclusion criterion for transplantation.

Does the pretransplant UNOS status modify the short- and long-term cardiac transplant prognosis?

BACKGROUND

We compared the morbidity and mortality rates of patients who had urgent heart transplantation or transplantation after bridging with a ventricular assist device, with the rates of patients whose clinical stability allowed them to wait at home.

METHODS

From March 1985 to December 2000, 404 patients underwent heart transplantation in a single center. There were 273 patients with UNOS status 2 (US 2), 103 patients with UNOS Status 1A (US 1A), and 28 patients with UNOS Status 1B (US 1B). We compared the groups retrospectively with respect to pretransplantation status and operative results.

RESULTS

Despite more severely impaired hemodynamics and a significantly higher preoperative infection rate in US 1A and 1B patients, there were no statistically significant differences in survival rates among the three groups. Donor sex and age, cytomegalovirus and toxoplasmosis, mismatch rate, ischemic time, method of myocardial protection, and operative technique did not differ statistically among the three groups. Length of intensive care unit stay, postoperative morbidity, first year postoperative rejection rate, and graft occlusive vascular disease rate were statistically similar among the three groups. Although pretransplantation cancer assessment was less complete in US 1A and 1B than in US 2 patients, the late-cancer rate was not statistically different among the three groups.

CONCLUSIONS

These data suggest that urgently transplanted patients have both early and long term morbidity and mortality similar to those of patients waiting for transplantation at home or with a ventricular assist device.

Recipient selection in cardiac transplantation: contraindications and risk factors for mortality

Currently the only acknowledged, definitive treatment for refractory heart failure is heart transplantation (HTx). During the past 10 years, selection criteria for heart transplant recipients have been developed that use an analysis of risk factors associated with mortality, which were identified by consensus opinion and by single-center and multi-center database review. A number of other studies also have been designed to evaluate specific risk factors for transplant such as advanced age, diabetes, and sex. This review identifies variables that continue to provoke controversy during the candidate selection process or variables that have changed from absolute to relative contraindications for HTx. Clinicians may use the data summarized in this review as a guide to making decisions about patient candidacy for HTx. One could conclude from this analysis that a more formalized and objective scale to select patients and to assess risk of death after HTx is necessary. Moreover, as alternative therapies to HTx become reality, a better instrument for triaging patients to one form of therapy or another may be necessary.

Heart transplantation in patients seventy years of age and older: A comparative analysis of outcome

OBJECTIVE

Advanced age has traditionally been considered a contraindication for heart transplantation because of the reported adverse effect of increased age on long-term survival. However, as the field of transplantation continues to evolve, the criteria regarding the recipient's upper age limit have been expanded and older patients are being considered as potential candidates. We analyzed the outcome of heart transplantation in patients 70 years of age and older and compared these results with those in younger patients (<70 years) over a 4-year period.

METHOD

We retrospectively analyzed the results of 15 patients 70 years of age and older who underwent heart transplantation between November 1994 and May 1999 and compared them with results in 98 younger patients undergoing transplantation during the same period

RESULTS

The older age group had a higher preoperative left ventricular ejection fraction (P =.02), higher incidence of female donors (P =.02), and longer cardiac allograft ischemic time (P =.01). No differences were found regarding incidence of diabetes mellitus, donor age, donor/recipient weight ratio, and mismatch (<0.80). The 30-day or to-discharge operative mortality was similar in both groups (0% in the older vs 5.1% in younger patients). Actuarial survival at 1 year and 4 years was not statistically different between the older and younger patients (93.3% +/- 6.4% vs 88.3% +/- 3.3% and 73.5% +/- 13.6% vs 69.1% +/- 5.8%, respectively). The length of intensive care unit stay and total post-transplantation hospital stay, incidence of rejection, and incidence of cytomegalovirus infection were similar between the groups.

CONCLUSIONS

Heart transplantation in selected patients 70 years of age and older can be performed as successfully as in younger patients (<70 years of age) with similar morbidity, mortality, and intermediate-term survival. Advanced age as defined (> or =70 years) should not be an exclusion criterion for heart transplantation. The risks and benefits of transplant surgery should be applied individually in a selective fashion.

How old is too old for heart transplantation?

Heart transplantation is considered the treatment of choice for patients with advanced heart failure. Given the excellent results with transplantation, there has been growing pressure to liberalize eligibility criteria, especially with regard to age. Registry data and early reports have indicated that there may be increased posttransplantation mortality in older patients. A number of single-center reports have shown that survival of older patients may be similar to that of younger patients. The limited supply of donor hearts makes it imperative that careful consideration be given to transplantation results in older recipients and to the overall impact that expanding eligibility criteria for transplantation will have. The limited supply of donor hearts has also led to increased interest in the use of hearts from older donors. This review presents a current perspective on outcomes after heart transplantation in older recipients, use of older donor hearts, and the matching of donor and recipient risk.