Mid-term survival after heart retransplantation in late cardiac allograft failure

Abstract

Introduction Among patients who survive heart transplant, recurrent end-stage heart failure is a major cause of morbidity and mortality secondary to acute rejection, primary graft failure or coronary artery vasculopathy, and heart retransplantation (HRT) offers the potential for long-term survival. However, there is controversy about the appropriateness of retransplantation because of limited organ availability and outcomes that tend to be worse than in primary transplantation. Internationally, between 2 and 4% of the available donor hearts are distributed to retransplant patients.1 The aim of this study was to determine the mid-term survival after heart retransplantation. Methods After obtaining Institutional Review Board approval, the authors retrospectively studied all consecutive adult patients who underwent orthotopic heart transplantation between January 2009 and December 2018 at a tertiary care university hospital and followed them up until December 2019. Patients included in the analysis had undergone HRT and were 18 years or older. Recipient demographic data, hemodynamic profile and postoperative outcomes were analyzed. Results During the study period, 250 patients underwent orthotopic heart transplantation. Among these patients, 2% (n=5) underwent HRT. The end-stage heart failure diagnoses leading to first heart transplant in our study were hypertrophic cardiomyopathy (40%), idiopathic cardiomyopathy (40%) and myocarditis (20%); and the major indications for HRT were chronic rejection (60%) and cardiac allograft vasculopathy (40%). Grafts failed at a median follow-up of 9 (5) years after first heart transplantation. The majority of patients (80%) required combined simultaneous second cardiac and first renal transplantation. Heart-kidney combined transplantation were performed with organs coming from the same donor and with no-staged modality. Actuarial survival rate was 60%, after a median follow-up of 17.8 (39.6) months. Discussion Although HRT survival is still inferior to primary transplantation, it has improved over the decades and is a viable treatment option for patients with late failing allografts. Outcome after HRT strongly depends on the indication for retransplantation and the interval between first and second transplantation. Different studies suggest that a diagnosis of cardiac allograft vasculopathy or chronic rejection and an interval between first and second transplantation greater than 1 year have a significantly favorable impact on mortality.2 3 Judicious patient selection and careful perioperative care are of utmost importance considering limited allograft availability.