Cardiac Re-Transplantation - A Reasonable Treatment Option in Selected Patients with Severe Graft Failure?

Abstract

Heart re-transplantation (re-HTx) has been considered controversial due to shortage of donor organs and suboptimal results. We studied the results of cardiac re-Tx and compared it with primary heart transplantation (HTx) at our center. A total of 708 heart transplantations were carried out at our center between 1984 and 2017. 21 of those were re-HTx. One patient had been re-transplanted twice and two other patients had their primary transplantation in London before our program started. In a retrospective study, we evaluated pre-operative characteristics, cause of graft-loss, immunology and outcome among patients undergoing cardiac re-Tx and compared them with the primary HTx population. A total of 20 patients (14 male, 5 female) received a second HTx (n=20) or a third HTx (n=1) at Sahlgrenska University Hospital. Mean age at re-HTx was 35 as compared to 45 years for the primary HTx group. Mean donor age in the re-HTx and primary HTx groups was 42 and 37 years, respectively. The primary cardiac diagnosis for re-HTx patients was DCM (n=11), myocarditis (n=3), IHD (n=2), CHD (n=2) and unknown (n=1). The causes of graft failure and re-HTx were acute rejection (n=5), coronary allograft vasculopathy (CAV) (n=5), and unexplained graft failure (n=10). The median time interval between primary and re-Tx was 49 months (range 0 - 305 months). Patients undergoing re-HTx were more often in need of pre-operative dialysis (37%) as compared with primary HTx (1.5%). Also, the re-HTx group was more often treated with a short-term MCS (37 %; 6 ECMO, 1 BiVAD) than those receiving a primary HTx (19%). The 1-, 5- and 10-year survival rates for re-HTx and primary HTx were 85% (95%CI:60-95) / 58% (95%CI:33-76) / 45% (95%CI:22-66) and 88% (95%CI:86-90) / 80% (95%CI:77-83) / 68% (95%CI:63-71), respectively. Causes of death in the re-Tx group included acute transplant related death (n=1), cardiac death (n=2) and non-cardiac causes (infection/ malignancy, n=3). During a 30-year period, 3% of our HTx population underwent a re-HTx. The most common cause for re-HTx was unexplained graft failure, followed by acute rejection and CAV. Although inferior to primary HTx, cardiac re-HTx offers a reasonable long-term outcome and should therefore be offered to selected patients.