Emergency cardiac re-transplantation: is it justified? Data from the National Heart Transplant registry

Abstract

Background: For many years, high-emergency cardiac re-transplantation (HE-CR) has been considered as the choice therapeutic option for patients with irreversible primary graft failure during the early postoperative period of a previous heart transplantation (HT). HE-CR is also occasionally considered for HT patients in a critical clinical condition due to late graft failure secondary to chronic rejection. Aims: To describe the early postoperative and long-term outcomes of patients undergoing HE-CR and to compare them with those of patients undergoing a first heart transplantation under a high-emergency status (FHT-HE). Methods: Multicenter registry including 711 patients aged >18 who underwent high-emergency HT between January 1, 2000 and December 31, 2009 in fifteen out of the sixteen hospitals provided with an adult HT program. All patients suffered from severe cardiac failure depending on intravenous inotropes or mechanical circulatory support, or complicated with refractory arrythmic storm. Data were collected from the National Heart Transplant Registry database and clinical records. Early postoperative outcomes and long-term survival of HE-CR and FHT-HE patients were compared. Data on patients' vital status were available as for October 31, 2010. Kaplan-Meier post-transplant long-term survival curves were estimated, and then compared by means of the log-rank test. Results: 31 (4.5%) patients underwent HE-CR and 680 patients underwent FHT-HE. Mean age was 50 years, and 20% were women. No significant differences regarding basal clinical characteristics of recipients or donors were observed between the two groups, with the exception that HE-CR patients showed a higher mean serum creatinin (1.7±0.7 versus 1.3±0.7 mg/dl, p=0.01). The proportion of patients supported on a short-term VAD was 26% in the HE-CR group and 15% in the HE-FHT group (p=0.09). During the early postoperative period, the HE-CR group presented significantly higher rates of major surgical bleeding (48% versus 24%, p=0.02), primary graft failure (52% versus 24%, p<0.001), and in-hospital death (45% versus 26%, p=0.02) than the FHT-HE group. Post-transplant long-term survival of the HE-CR group was significantly reduced in comparison with the FHT-HE group (p=0.031). Long-term survival of patients who survived the early postoperative period was not significantly different between both groups. Conclusion: HE-CR is associated with a high risk of adverse postoperative outcomes and mortality. In the current era of increasing donor scarcity, the indication of this procedure should be restricted.