Cardiac transplantation: The Stanford experience in the cyclosporine era

Abstract

We analyzed our experience with 496 patients who underwent primary cardiac transplantation since the introduction of cyclosporine immunosuppression (Dec. 16, 1980, to Jan. 7, 1993). There were 388 male and 108 female patients. Mean recipient age was 40 ± 16 years (range 0.1 to 70 years, median 44 years). Recipient diagnoses included coronary disease in 188, idiopathic cardiomyopathy in 196, viral cardiomyopathy in 35, and congenital heart disease in 28 patients. Donor age was 25 ± 10 years (range 1 to 53 years, median 24 years). Graft ischemic time was 148 ± 57 minutes (range 38 to 495 minutes, median 149 minutes). Operative mortality (hospital death) rate was 7.9% ± 1.3% (70% confidence intervals). Multivariate logistic regression analysis revealed that (higher) pulmonary vascular resistance and gender (female) were the only independent predictors of hospital death ( p < 0.05). Actuarial survival estimates for all patients at 1, 5, and 10 years are 82% ± 1.7% (83% ± 1.8% adult, 77% ± 5.2% pediatric), 61% ± 2.5% (65% ± 2.5% adult, 64% ± 6.6% pediatric), and 41% ± 3.7% (40% ± 4% adult, 54% ± 8.6% pediatric), respectively. For 232 patients treated with triple-drug immunosuppression and induction with OKT3 since 1987, survival estimates at 1 and 5 years are 82% ± 2.6% and 67% ± 3.7%, respectively. Causes of death for the entire group were rejection in 29 (14% of deaths), infection in 69 (34%), graft coronary disease in 36 (18%), nonspecific graft failure in 6 (3%), malignancy in 19 (10%), stroke in 6 (3%), pulmonary hypertension in 6 (3%), and other causes in 30 (15%) patients. Actuarial freedom from rejection at 3 months, 1 year, and 5 years was 21% ± 1.9%, 14% ± 1.7%, and 7.2% ± 1.5%, respectively (±1 standard error of the mean). Estimates of freedom from rejection-related death at 1, 5, and 10 years were 96% ± 1%, 93% ± 1.4%, and 93% ± 1.4%, respectively. Actuarial freedom from any infection at 3 months and at 1 and 5 years was 40% ± 2.3%, 27% ± 2.1%, and 15% ± 2.0% and from infection-related death, 95% ± 1.0%, 93% ± 1.2%, and 85% ± 1.9%, respectively. Actuarial freedom from (angiographic or autopsy proved) graft coronary artery disease at 1, 5, and 10 years was 95% ± 1.2%, 73% ± 2.7%, and 65% ± 3.6% and from coronary disease–related death or retransplantation 98% ± 0.7%, 84% ± 2.2%, and 66% ± 4.3%, respectively. Multivariate (Cox model) proportional hazard regression analysis revealed that (older) recipient age and race (nonwhite) were independent predictors of late (as opposed to hospital) death ( p < 0.05). Immunosuppressive protocol was an independent predictor ( p < 0.05) of freedom from rejection (but not from late death or from rejection-related death). These data demonstrate satisfactory long-term results of cardiac transplantation for treatment of patients with end-stage heart disease. (J T HORAC C ARDIOVASC S URG 1994;108:240-52)