Impact of Left Heart Disease Risk Factors on Outcomes in Pulmonary Arterial Hypertension Therapy

BACKGROUND

Current guidelines recommend initial monotherapy for pulmonary arterial hypertension (PAH) with cardiopulmonary comorbidities, despite limited available evidence to guide management.

RESEARCH QUESTION

Do left heart disease (LHD) risk factors have an impact on treatment response and influence applicability of risk assessment in a real-world cohort of patients with PAH?

STUDY DESIGN AND METHODS

The Ambrisentan and Tadalafil in Patients with Pulmonary Arterial Hypertension (AMBITION) trial criteria was used to define the phenotype of patients with PAH with risk factors for LHD. Treatment strategy, functional outcome, long-term survival, and risk discrimination were compared with a reference PAH cohort using the Pulmonary Hypertension Society of Australia and New Zealand Registry.

RESULTS

A total of 487 incident patients with PAH diagnosed between 2011 and 2020 were included. Of these, 103 (21.1%) fulfilled the definition of PAH with LHD risk factors, with 384 (78.9%) remaining as the reference group. Patients in the PAH with LHD risk factors group were older (66 ± 13 vs 58 ± 19 years; P < .001), had lower pulmonary vascular resistance (393 ± 266 vs 708 ± 391 dyn.s/cm5; P = .031), and had worse 6-min walk distance (286 ± 130 vs 327 ± 136 m; P = .005) at diagnosis. The PAH with LHD risk factors group was less likely to receive initial combination therapy (27% vs 44%; P = .02). Changes in 6-min walk distance at 12 months were similar in both groups (43 ± 77 m in the PAH with LHD risk factors group and 50 ± 90 m in the reference group; P = .50), including when stratified by initial treatment strategy (PAH with LHD risk factors group vs reference PAH group: monotherapy: 40 ± 81 vs 38 ± 95 m, P = .87; combination therapy: 53 ± 78 vs 64 ± 106 m, P = .511). Functional class improvements were also similar in both groups. REVEAL Registry 2.0 risk score effectively discriminated risk in both populations (C statistic = 0.756 for the PAH with LHD risk factors group and C statistic = 0.750 for the reference PAH group). There was no difference in survival between the two groups (log-rank test, P = .29).

INTERPRETATION

In a real-world cohort, patients with PAH with LHD risk factors were less likely to be exposed to initial combination therapy. Nevertheless, selected patients with PAH with LHD risk factors who were treated with initial combination therapy derived similar functional response compared with the reference group. Further studies are needed to phenotype patients with PAH with cardiopulmonary comorbidities who may benefit from initial combination therapy.

Longitudinal analysis left ventricular chamber responses under durable LVAD support

BACKGROUND

Left ventricular assist device (LVAD) support offers remodeling potential in some patients. Our goal was to use noninvasively derived pressure-volume (PV) loops to understand the effect of demographic and device variables on serial changes in cardiac function under pump support.

METHODS

Thirty-two consecutive Medtronic HeartWare Ventricular Assist Device (HVAD) patients (mean 55.9 ± 12.3 years, 81.3% male) were prospectively recruited. Single-cycle ventricular pressure and volume were estimated using a validated algorithm. PV loops (n = 77) and corresponding cardiac chamber dynamics were derived at predefined postimplant timepoints (1, 3, 6 months). Changes in PV loop parameters sustained across the 6-month period were characterized using mixed-effects modeling. The influence of demographic and device variables on the observed changes was assessed.

RESULTS

Across a 6-month period, the mean ventricular function parameters remained stable. Significant predictors of monthly improvement of stroke work include: lower pump speeds (2400 rpm vs 2500-2800 rpm) [0.0.051 mm Hg/liter/month (p = 0.001)], high pulsatility index (>1.0 vs <1.0) [0.052 mm Hg/liter/month (p = 0.012)], and ischemic cardiomyopathy indication for LVAD implantation (vs nonischemic) [0.0387 mm Hg/liter/month (p = 0.007)]. Various other cardiac chamber function parameters including cardiac power, peak systolic pressure, and LV elastance also showed improvements in these cohorts.

CONCLUSIONS

Factors associated with improvement in ventricular energetics and hemodynamics under LVAD support can be determined with noninvasive PV loops. Understanding the basis of increasing ventricular load to optimize myocardial remodeling may prove valuable in selecting eligible recovery candidates.

Tetralogy of Fallot Across the Lifespan: A Focus on the Right Ventricle

Tetralogy of Fallot is a cyanotic congenital heart disease, for which various surgical techniques allow patients to survive to adulthood. Currently, the natural history of corrected tetralogy of Fallot is underlined by progressive right ventricular (RV) failure due to pulmonic regurgitation and other residual lesions. The underlying cellular mechanisms that lead to RV failure from chronic volume overload are characterized by microvascular and mitochondrial dysfunction through various regulatory molecules. On a clinical level, these cardiac alterations are commonly manifested as exercise intolerance. The degree of exercise intolerance can be objectified and aid in prognostication through cardiopulmonary exercise testing. The timing for reintervention on residual lesions contributing to RV volume overload remains controversial; however, interval assessment of cardiac function and volumes by echocardiography and magnetic resonance imaging may be helpful. In patients who develop clinically important RV failure, clinicians should aim to maintain a euvolemic state through the use of diuretics while paying particular attention to preload and kidney function. In patients who develop signs of cardiogenic shock from right heart failure, stabilization through the use of inotropes and pressor is indicated. In special circumstances, the use of mechanical support may be appropriate. However, cardiologists should pay particular attention to residual lesions that may impact the efficacy of the selected device.

Characteristic changes to pulsatile and steady-state load according to pulmonary hypertension classification

It is of increasing importance to understand and predict changes to the systemic and pulmonary circulations in pulmonary hypertension (PH). To do so, it is necessary to describe the circulation in complete quantitative terms. Characteristic impedance (Zc) expresses opposition of the circulation to pulsatile blood flow. Evaluation of systemic and pulmonary Zc relationships according to PH classification has not previously been described. Prospective study of 40 clinically indicated patients referred for CMR and RHC (56 ± 18 years; 70% females, eight mPAP ≤ 25 mmHg, 16 pre-capillary [Pre-cPH], eight combined pre- and post-capillary [Cpc-PH] and eight isolated left-heart disease [Ipc-PH]). CMR provided assessment of ascending aortic (Ao) and pulmonary arterial (PA) flow, and RHC, central Ao and PA pressure. Systemic and pulmonary Zc were expressed as the relationship of pressure to flow in the frequency domain. Baseline demographic characteristics were well-matched across PH subclasses. In those with a mPAP ≤25mHg, systemic Zc and SVR were >2 times higher than pulmonary Zc and PVR. Only Pre-cPH was associated with inverse pulsatile (systemic Zc 58 [45-69] vs pulmonary Zc 70 [58-85]), but not steady-state (SVR 1101 [986-1752] vs. PVR 483 [409-557]) relationships. Patients with CpcPH and IpcPH had concordant pulsatile and steady-state relationships (Graphical Abstract). Measurement of, and the relationship between, systemic and pulmonary Zc in patients according to PH sub-classification has not previously been described. Systemic Zc was routinely higher than pulmonary Zc, except in patients with newly diagnosed Pre-cPH, where inverse pulsatile but not steady-state relationships were observed.

Prognostic role of pulmonary impedance estimation to predict right ventricular dysfunction in pulmonary hypertension

BACKGROUND

The effect of pulmonary hypertension (PH) on right ventricular (RV) afterload is commonly defined by elevation of pulmonary artery (PA) pressure or pulmonary vascular resistance (PVR). In humans however, one-third to half of the hydraulic power in the PA is contained in pulsatile components of flow. Pulmonary impedance (Zc) expresses opposition of the PA to pulsatile blood flow. We evaluate pulmonary Zc relationships according to PH classification using a cardiac magnetic resonance (CMR)/right heart catheterization (RHC) method.

METHODS

Prospective study of 70 clinically indicated patients referred for same-day CMR and RHC [60 ± 16 years; 77% females, 16 mPAP <25 mmHg (PVR <240 dynes.s.cm^-5 /mPCWP <15 mmHg), 24 pre-capillary (PrecPH), 15 isolated post-capillary (IpcPH), 15 combined pre-capillary/post-capillary (CpcPH)]. CMR provided assessment of PA flow, and RHC, central PA pressure. Pulmonary Zc was expressed as the relationship of PA pressure to flow in the frequency domain (dynes.s.cm^-5 ).

RESULTS

Baseline demographic characteristics were well matched. There was a significant difference in mPAP (P < 0.001), PVR (P = 0.001), and pulmonary Zc between mPAP<25 mmHg patients and those with PH (mPAP <25 mmHg: 47 ± 19 dynes.s.cm^-5 ; PrecPH 86 ± 20 dynes.s.cm^-5 ; IpcPH 66 ± 30 dynes.s.cm^-5 ; CpcPH 86 ± 39 dynes.s.cm^-5 ; P = 0.05). For all patients with PH, elevated mPAP was found to be associated with raised PVR (P < 0.001) but not with pulmonary Zc (P = 0.87), except for those with PrecPH (P < 0.001). Elevated pulmonary Zc was associated with reduced RVSWI, RVEF, and CO (all P < 0.05), whereas PVR and mPAP were not.

CONCLUSIONS

Raised pulmonary Zc was independent of elevated mPAP in patients with PH and more strongly predictive of maladaptive RV remodelling than PVR and mPAP. Use of this straightforward method to determine pulmonary Zc may help to better characterize pulsatile components of RV afterload in patients with PH than mPAP or PVR alone.

Impact of left heart disease risk factors on risk stratification and treatment response in pulmonary arterial hypertension

Background

Contemporary registries have documented a change in the epidemiology of PAH patients displaying increasing co-morbidities associated with left heart disease (LHD). These patients are often excluded from randomized clinical trials. It is unclear whether the presence of LHD comorbidities may adversely impact the accuracy of risk stratification and response to PAH therapy.

Method

Data was extracted from the Pulmonary Hypertension Society of Australia and New Zealand registry for incident patients with a diagnosis with idiopathic/heritable/toxin-induced (I/H/D)-PAH and connective tissue disease (CTD) associated PAH from 2011 - 2020. Patients without available medication and follow up data were excluded. We used the AMBITION trial exclusion criteria to define the subpopulation with LHD risk factors and haemodynamic phenotype (PAH-rLHD).

Results

489 patients (I/H/D-PAH=251, CTD-PAH=238) were included in our analysis, with 103 (21.0%) fulfilling the definition of PAH-rLHD (34 had ≥3 risk factors for left heart disease (rLHD-hypertension, diabetes, obesity or ischaemic heart disease) and 76 had borderline haemodynamics (mean capillary wedge pressure 13–15 with pulmonary vascular resistance &lt;500 dynes sec/cm5) including 7 who met both criteria). Compared to classical PAH, patients with PAH-rLHD were older at diagnosis (66±13 vs 58±19, p&lt;0.001), had lower pulmonary vascular resistance (PVR: 393±266 vs 708±391, p=0.031) but worse exercise capacity (6MWD: 286±130m vs 327±136m, p=0.005). PAH-rLHD were more likely to be started on initial monotherapy, compared with “classical” PAH (73% vs 56%, p=0.002). In the monotherapy groups, endothelin receptor antagonists (ERA) were used in 73% PAH-rLHD, compared with 66% in classical PAH group. Both groups exhibited similar response to both mono- and combination therapy with commensurate improvements in WHO functional class (mean change 0.3±0.6 vs 0.3±0.8, p=0.443) and 6-minute walk distance (mean change 44±82 vs 48±101, p=0.723). There was no difference in survival between classical PAH and PAH-rLHD (log rank, p=0.29). The REVEAL 2.0 risk score effectively discriminated risk in both populations at baseline and first follow up (classical PAH: baseline C statistic 0.750, follow up 0.774 and PAH-rLHD: baseline C statistic 0.756, follow up 0.791).

Conclusion

Despite lower PVR at diagnosis, PAH-rLHD patients and “classical” PAH demonstrate similar response to first-line therapy with similar long term survival. The REVEAL 2.0 risk score can be effectively applied to the subpopulation of PAH-rLHD in real life clinical practice.

Funding Acknowledgement

Type of funding sources: None.

Chronic thromboembolic pulmonary hypertension in Australia and New Zealand: An analysis of the PHSANZ registry

BACKGROUND AND OBJECTIVE

Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious condition occurring in 2%-4% of patients after acute pulmonary embolism. Pulmonary endarterectomy (PEA) is a potential cure for technically operable disease. The epidemiology and long-term outcomes of CTEPH have not been previously described in Australia and New Zealand.

METHODS

Data were extracted from the Pulmonary Hypertension Society of Australia and New Zealand (PHSANZ) registry for patients diagnosed with CTEPH between January 2004 and March 2020. Baseline characteristics, treatment strategies, outcome data and long-term survival are reported.

RESULTS

A total of 386 patients were included with 146 (37.8%) undergoing PEA and 240 (62.2%) in the non-PEA group. PEA patients were younger (55 ± 16 vs. 62 ± 16 years, p < 0.001) with higher baseline 6-min walk distance (6MWD; 405 ± 122 vs. 323 ± 146 m, p = 0.021), whilst both groups had similar baseline pulmonary haemodynamics. Pulmonary hypertension-specific therapy was used in 54% of patients post-PEA and 88% in the non-PEA group. The 1-, 3- and 5-year survival rates were 93%, 87% and 84% for the PEA group compared to 86%, 73% and 62%, respectively, for the non-PEA group (p < 0.001). Multivariate survival analysis showed baseline 6MWD was an independent predictor of survival in both operated and medically managed patients.

CONCLUSION

In this first multicentre report of CTEPH in Australia and New Zealand, long-term survival is comparable to that in other contemporary CTEPH registries. However, PEA was only performed in a minority of CTEPH patients (37.8%) and significantly less than overseas reports. Greater awareness of PEA and improved patient access to experienced CTEPH centres are important priorities.

The use of eculizumab as a bridge to retransplantation for chronic antibody-mediated rejection in a heart transplant recipient: a case report

Background

Antibody-mediated rejection (AMR) remains a major management challenge in heart transplantation given the complexity of pathological diagnosis and dearth of evidence for effective management. Eculizumab, an anti-C5 monoclonal antibody which inhibits terminal complement activation, has been reported to decrease early AMR in sensitized renal transplant recipients.

Case summary

We report a case of a 29-year-old gentleman with chronic AMR 8 years after heart transplantation, manifesting as significant graft dysfunction. Donor-specific antibodies to DQ7 were found to be causative. Antibody-mediated rejection was managed with quadruple oral immunosuppressive therapy (mycophenolate, prednisolone, everolimus, and tacrolimus) as well as a sequence of broad-spectrum immunological therapies; intravenous (IV) methylprednisolone, plasmapheresis, IV immunoglobulin, rituximab, bortezomib, tocilizumab, and splenic irradiation. No treatment had a sustained impact on donor-specific anti-HLA antibodies (DSAs) or graft function. After testing showed the DQ7 antibodies were complement-binding, a trial of eculizumab was started. This improved DSAs somewhat, and improved graft function and New York Heart Association functional class substantially. The patient was relisted for heart transplantation and successfully retransplanted in March 2018. Specifically, the new organ and recipient were matched at DQ7. After discontinuation of eculizumab, the patient has remained healthy and well, with normal graft function 28 months after retransplantation.

Discussion

To the best of our knowledge, this is the first case of chronic AMR in a heart transplant patient, successfully stabilized with eculizumab and bridged to retransplantation.

Waitlist and post-transplant outcomes for eisenmenger syndrome: A comparison of transplant strategies

BACKGROUND

End-stage Eisenmenger syndrome (ES) due to unrepaired atrial septal defect (ASD) or ventricular septal defect (VSD) is an indication for lung transplantation (LTx) or heart-lung transplantation (HLTx). Limited evidence exists as to the optimal transplant strategy for this unique population.

AIM

To describe waitlist characteristics and post-transplant outcomes in patients with ES-ASD or ES-VSD.

METHODS

Using the ISHLT Registry, data were extracted for all ES-ASD or ES-VSD patients who underwent transplantation between 1987 and 2018. Additional data were sought for patients listed for LTx or HLTx in the OPTN Registry during the same period. Early era was defined as 1987-2004, and current era was defined as 2005-2018.

RESULTS

In the current era, patients with ES-ASD or ES-VSD represented a lessening proportion of all LTx and HLTx. Compared to LTx for other indications, the odds of transplantation were significantly less for both ES-ASD 0.18 [0.07-0.50] and ES-VSD 0.03 [0.004-0.22]. In the early era, an equivalent survival was observed for ES-ASD who underwent HLTx versus LTx (p = 0.47), and superior survival for ES-VSD (p = 0.015). In contrast, ES-ASD patients who underwent LTx from the current era displayed better survival compared with HLTx, 10-year survival 52% vs 30% p = 0.036. Similar survival were observed for ES-VSD for both transplant strategies (p = 0.68).

CONCLUSION

LTx shows superior survival outcomes in the current era for ES ASD patients, and equivalent outcomes for ES-VSD. In the current era, ES-ASD or ES-VSD patients were less likely to be transplanted than other candidates for LTx.

Pulmonary Vascular Disease as a Systemic and Multisystem Disease

Pulmonary arterial hypertension (PAH) is a disease of progressive pulmonary vascular remodeling due to abnormal proliferation of pulmonary vascular endothelial and smooth muscle cells and endothelial dysfunction. PAH is a multisystem disease with systemic manifestations and complications. This article covers the chronic heart failure syndrome, including the systemic consequences of right ventricle-pulmonary artery uncoupling and neurohormonal activation, skeletal and respiratory muscle effects, systemic endothelial dysfunction and coronary artery disease, systemic inflammation and infection, endocrine and metabolic changes, the liver and gut axis, sleep, neurologic complications, and skin and iron metabolic changes.

Pre-operative pulmonary artery pulsatility index does not predict mortality post cardiac transplantation but PVR is a prognostic tool in LVAD-bridged patients

 

The Pulmonary artery pulsatility index (PAPi) is a novel haemodynamic marker that has been shown to be a strong predictor of right heart failure and mortality in patients with pulmonary hypertension and advanced heart failure. Its utility in predicting post transplant outcomes is currently unknown.

Aim

To determine the prognostic significance of pre-transplant haemodynamic assessment of PAPi, right atrial pressure (RA), and pulmonary vascular resistance (PVR) in predicting mortality post cardiac transplant.

Methods

All patients who underwent cardiac transplantation between January 2010 and June 2016 were retrospectively analyzed. Pre-operative right heart catheter data was obtained. The PAPi was calculated as the systolic pulmonary artery pressure (sPAP)- diastolic pulmonary artery pressure (dPAP) divided by RA. Statistical analysis was carried out using SPSS v25.

Results

A total of 158 patients, with a mean age of 48.6±13.5 were studied (115 non- LVAD, 43 LVAD pre-transplant), and 3 patients were excluded due to missing data. There was no significant difference in the non-LVAD group in RA, PVR or PAPi for mortality post transplant. In the LVAD group there was no significant difference in RA, or PAPi with regards to mortality, however there was a significant difference in mean PVR between those that died post transplant (222±100) and those still alive (138±59)

Conclusion

Despite having a role in prognostication for right heart failure in pulmonary hypertension and post LVAD implantation, PAPi did not discriminate mortality outcomes for patients post cardiac transplantation. PVR remains a marker of mortality in an LVAD cohort bridged to transplant.

Funding Acknowledgement

Type of funding source: None

SEVERE HYPERTRIGLYCERIDEMIA ASSOCIATED WITH EVEROLIMUS TREATMENT AFTER HEART TRANSPLANTATION

Objective

Everolimus, a mammalian target-ofrapamycin (mTOR) inhibitor, is increasingly used post-transplantation due to favorable effects on renal function and malignancy risk when compared to other immunosuppressive treatments such as calcineurin inhibitors. However, it can confer adverse effects such as dyslipidemia, which is not underpinned by any long-term screening and management of dyslipidemia in heart transplant recipients treated with everolimus.

Methods

We report a case of severe hypertriglyceridemia which developed after commencement of everolimus in a heart transplant recipient with a background of Dunnigan-type familial partial lipodystrophy.

Results

The patient is a 36-year-old woman who underwent heart transplantation for dilated cardiomyopathy. About 11 weeks following commencement of everolimus as part of her antirejection medication regime, serum triglyceride level concentration peaked at 5,093 mg/dL (normal, 0.0 to 177.2 mg/dL). There were no clinical complications with triglycerides at this elevated level and it improved substantially following cessation of everolimus and initiation of a high dose intravenous insulin-dextrose infusion.

Conclusion

This case highlights dyslipidemia as a potential complication of everolimus treatment and that appropriate screening is important as lipid lowering medication can effectively control levels and minimize adverse outcomes.

Plugging Paravalvular Leak in Transcatheter Aortic Valves

Paravalvular leak can complicate transcatheter aortic valve replacement with important prognostic implications. Correction of defects requires complex planning and execution. Multiple or irregular lesions, calcified annulus, and high sealing skirts on self-expandable devices are especially challenging. Such defects may be approximated using malleable vascular closure devices. (Level of Difficulty: Intermediate.)

P4698Survival outcomes in patients with Eisenmenger syndrome after heart-lung or bilateral sequential lung transplantation

Background

Eisenmenger syndrome (ES) is defined as pulmonary hypertension secondary to a right to left intracardiac shunt, commonly an atrial septal defect (ASD) or ventricular septal defect (VSD). Heart-lung (HLTx) or bilateral sequential lung transplantation (BSLT) are both treatment options for some candidates. The choice between these two procedures has varied historically and according to transplant centre preference and donor availability. We completed a retrospective study to determine if BSLT with cardiac repair was associated with better outcomes compared to HLTx.

Aim

This study compared post-transplant survival in patients with ES undergoing HLTx or BSLT.

Method

Using the International Society Heart and Lung Transplantation Registry data, we identified all patients with ES between October 1, 1987 and March 31, 2018.

Results

A total of 177 patients underwent HLTx for ES ASD and 101 who underwent BSLT with cardiac repair. Median follow up was 890 days (range 0–9888 days) for the entire post-transplant cohort. 126 HLTx and 66 BSLT patients died in the follow up period.

A total of 173 ES VSD patients underwent HLTx in the database, and 52 underwent BSLT with cardiac repair. Median follow up was 460 days (range 0–8406 days) for the entire post-transplant cohort. 116 HLTx and 36 BSLT patients died during the follow up period.

Figure 1 demonstratres the comparative Kaplan-Meier survival curves following BSLT or HLTx for Eisenmenger's ASD and VSD patients. No statistically significant difference in Eisenmenger survival between combined heart-lung transplantation or bilateral sequential lung transplantation group (ASD log rank test p value = 0.99, VSD log rank test p value = 0.1 performed for the first 6 year).

Figure 1

Conclusions

Our analysis determined that patients with ES and either VSD or ASD had similar long-term survival comparing HLTx with BSLT and cardiac repair.

4974Waitlist outcomes for Eisenmengers patients listed for bilateral sequential lung transplant or heart-lung transplant

Background

Eisenmenger's syndrome (ES) is the end-stage of a longstanding intracardiac shunt, commonly an atrial septal defect (ASD) or ventricular septal defect (VSD). Transplantation is the final option to address the pulmonary hypertension and right heart failure that results. Both combined heart-lung (HLTx) and bilateral sequential lung transplantation (BSLT) have been performed for ES. Overall, BSLT are performed more commonly than HLTx because of donor organ availability. We postulated that ES patients would have higher waitlist mortality and longer time to transplant compared to patients listed for other indications, and BSLT patients would have reduced waitlist mortality and reduced time to transplant compared to HLTx based on availability.

Aim

This study compared waitlist outcomes between ES ASD, ES VSD and all patients listed for BSLT or HLTx.

Methods

We analysed the Organ Procurement and Transplant Network (OPTN) database for all patients listed for BSLT or HLTx between October 1, 1987 and March 31, 2018. Mood's median test was used for all tests of significance.

Results

Table 1 summarises the results of the analysis. A total of 56,698 patients were on the waitlist for BSLT for all aetiologies, which included 176 ES ASD patients and 156 ES VSD patients. A total of 3231 patients were on the waitlist for HLTx for all aetiologies, which included 89 ES ASD and 176 ES VSD patients. Median time to transplant was significantly longer for all ES patients on the waitlist for BSLT or HLTx compare to patients listed for other indications. Comparing time to transplant for BSLT to HLTx for either ES ASD or VSD did not reach statistical significance. Waitlist mortality was substantially higher for all ES patients regardless whether they were listed for BSLT or HLTx compared to patients listed for other indications.

Table 1 ES ASD ES VSD All patients BSLT HLTx BSLT HLTx BSLT HLTx Total number of patients listed 176 89 156 176 56698 3231 Transplanted 58 (33.0%) 38 (42.7%) 41 (25.8%) 78 (44.3%) 36441 (64.3%) 1229 (38.0%) Median time to transplant in days 330 (24 to 2723)* 431 (11 to 4527)$ 517 (10 to 2345)# 292 (16 to 2399)& 99 (0 to 6592) 174 (0 to 3606) p=0.54 p=0.08 *p≤0.001, #p=≤0.0001 $p=0.000, &p=0.003 Wait list mortality 27 (15.3%) 25 (28.1%) 23 (14.5%) 46 (26.1%) 2366 (4.2%) 371 (11.5%)

Conclusion

Our analysis identified longer waitlist time and higher mortality for all ES patients listed for BSLT or HLTx in the United States. These findings indicate current listing methods and prognostication place the ES population at disadvantage for thoracic transplantation.