The Registry of the International Society for Heart and Lung Transplantation: Twenty-eighth Adult Heart Transplant Report—2011

Abstract

This Twenty-eighth Report of the International Society for Heart and Lung Transplantation (ISHLT) Transplant Registry is based on data submitted by participating transplant centers worldwide. A total of 388 heart transplant centers have contributed information to the Registry. This year we have also achieved another important milestone: the 100,000th heart transplant recipient was registered in the database.This report reviews important statistics for the entire cohort of patients registered in the database. However, similar to prior reports,1Stehlik J. Edwards L.B. Kucheryavaya A.Y. et al.The Registry of the International Society for Heart and Lung Transplantation: twenty-seventh official adult heart transplant report—2010.J Heart Lung Transplant. 2010; 29: 1089-1103Abstract Full Text Full Text PDF PubMed Scopus (396) Google Scholar, 2Taylor D.O. Stehlik J. Edwards L.B. et al.Registry of the International Society for Heart and Lung Transplantation: twenty-sixth official adult heart transplant report—2009.J Heart Lung Transplant. 2009; 28: 1007-1022Abstract Full Text Full Text PDF PubMed Scopus (358) Google Scholar, 3Taylor D.O. Edwards? Aurora P. et al.Registry of the International Society for Heart and Lung Transplantation: twenty-fifth official adult heart transplant report—2008.J Heart Lung Transplant. 2008; 27: 943-956Abstract Full Text Full Text PDF PubMed Scopus (357) Google Scholar, 4Taylor D.O. Edwards L.B. Boucek M.M. et al.The Registry of the International Society for Heart and Lung Transplantation: twenty-fourth official adult heart transplant report—2007.J Heart Lung Transplant. 2007; 26: 769-781Abstract Full Text Full Text PDF PubMed Scopus (421) Google Scholar, 5Taylor D.O. Edwards L.B. Boucek M.M. et al.The Registry of the International Society for Heart and Lung Transplantation: twenty-third official adult heart transplant report—2006.J Heart Lung Transplant. 2006; 25: 869-879Abstract Full Text Full Text PDF PubMed Scopus (291) Google Scholar many of the more detailed analyses will focus on recent transplant recipients, exploring information relevant to contemporary heart transplantation practice. The first part of the report reviews important donor, recipient, and medical center demographics. The second part provides an overview of immunosuppressive therapies used after transplantation. The third part examines survival, mortality risk factors, and causes of death after adult heart transplantation. The last section focuses on quality of life after transplant.Statistical methodsRecipient and donor demographics, immunosuppressive treatments, morbidity, hospitalization, causes of death, and functional status are summarized using percentages or median with 5th and 95th percentile, as appropriate.Survival rates were calculated using the Kaplan-Meier method6Kaplan E.L. Meier P. Nonparametric estimation from incomplete observations.J Am Stat Assoc. 1957; 53: 457-481Crossref Scopus (47684) Google Scholar and compared using the log-rank test. Multivariable analyses were performed using Cox proportional hazard regression analysis.7Cox D.R. Oakes D. Analysis of survival data. Chapman and Hall, London1984Google Scholar Results of the multivariable analyses are reported as relative risk (RR) with 95% confidence intervals (CI) and/or a corresponding p-value. A RR significantly exceeding 1.0 indicates that the factor examined is associated with an increased likelihood of occurrence of the event of interest (eg, death, rejection, etc). Conversely, a RR significantly below 1.0 indicates that the event is less likely to occur when that factor is present.Multiple imputation was used to handle missing information for continuous data fields, such as ischemia time and donor age.8Harrell Jr, F.E. Regression modeling strategies. Springer, Berlin2001Crossref Google Scholar This method produces an estimated value for the missing value based on the other characteristics of the patient, donor, and/or transplant. The algorithm is performed multiple times, producing new estimates for the missing information. Models are fit on each imputed data set and then combined to produce a final set of estimates from which the RR estimates and p-values are obtained.Heart transplant demographicsTransplant volumesAfter a transient peak in the number of heart transplants reported to the Registry in the mid-1990s, the number of reported heart transplants has remained essentially stable. In the last decade, between 3,600 and 3,850 heart transplants have been registered every year (Figure 1) . We believe this represents approximately 66% of the heart transplant procedures performed worldwide.6Kaplan E.L. Meier P. Nonparametric estimation from incomplete observations.J Am Stat Assoc. 1957; 53: 457-481Crossref Scopus (47684) Google ScholarThere are significant differences in the number of transplants being performed among the centers participating in the Registry. The typical center performs between 10 and 19 transplants every year; 39% of centers fall into this category and perform approximately 33% of all transplants. Smaller centers that perform fewer than 10 transplants per year represent a similar number of centers (40%) and perform 13% of transplants. Finally, 21% of centers perform more than 20 transplants per year and are responsible for half of all transplants.Recipient demographicsIn the last 5 years (January 2005 to June 2010), non-ischemic cardiomyopathy was the leading cause of heart disease for adult heart transplant recipients (53.3% of the recipients), ischemic cardiomyopathy was the second most frequent diagnosis (37.7%), followed by adult congenital heart disease (2.9%), valvular heart disease (2.7%), and repeat transplantation (2.6%). A small number of patients with other diagnoses accounted for the remaining 0.8% of transplants (Figure 2) .Figure 2Etiology of heart disease preceding heart transplant in adults for transplants that occurred from January 2005 through June 2010.View Large Image Figure ViewerDownload Hi-res image Download (PPT)The distribution of the leading diagnoses for which heart transplant is performed has shifted significantly over time. Ischemic cardiomyopathy accounted for more than 50% of all the transplants in the late 1980s, whereas non-ischemic cardiomyopathy has now become the leading indication (Figure 3) . This gradual change toward transplantation for non-ischemic cardiomyopathy has been consistent over the past several years and is seen across the different geographic locations.9International Society for Heart and Lung TransplantationRegistries.www.ishlt.org/registries/Google Scholar It is likely that decreasing prevalence of nicotine use, new therapies for ischemic heart disease, and particularly, additional treatment options provided by the evolving field of mechanical circulatory support have influenced the selection of patients for transplantation.Figure 3Non-ischemic cardiomyopathy vs ischemic cardiomyopathy diagnosis in adult heart transplant recipients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)The median age of an adult heart transplant recipient is 54 years and has not changed significantly over time. The actual age distribution of transplant recipients did change, however, as a higher proportion of patients in their 60s and 70s have received a heart transplant during the last decade (Figure 4) .Figure 4Age at transplant in adult heart transplant recipients, distribution by era.View Large Image Figure ViewerDownload Hi-res image Download (PPT)It is interesting to compare recipient demographics during the past decade with characteristics of recipients who received transplants a decade earlier (Table 1). The proportion of female recipients has increased a few percentage points and is now 22.8%. The proportion of recipients with certain comorbidities at time of transplant continues to increase: 23% have diabetes mellitus, and 41% have hypertension. Despite the increasing proportion of patients receiving allografts for non-ischemic cardiomyopathy, the number of recipients with previous cardiac surgery (43%) remains high. The proportion of patients who are sensitized to human leukocyte antigens (HLA) has also increased, and 12% of patients now have a serum panel reactive antibody (PRA) level higher than 10%. Median allograft ischemic time has also increased, and is 3.0 ± 1.5 hours in the most recent era.Table 1Recipient Characteristics at the Time of Transplant for Two Eras: 1992 Through 2001 and 2002 Through June 2010gBased on 2005–6/2010 transplants.VariableaData are expressed as median ± standard deviation (5th–95th percentiles) or percentages.1992–2001 (n = 39,812)2002–June 2010 (n = 27,387)p-valuePre-transplant diagnosis<0.0001 Ischemic cardiomyopathy45.739.5 Non-ischemic cardiomyopathy46.451.6 Valvular cardiomyopathy3.73.0 Retransplant1.92.4 Congenital heart disease1.92.8 Other causes0.40.7Age, years54.0 ± 11.0 (28.0–65.0)54.0 ± 12.4 (25.0–67.0)0.5756Female sex19.522.8<0.0001Weight, kg75.0 ± 16.7 (51.7–102.1)78.0 ± 17.2 (53.0–108.8)<0.0001Height, cm173.0 ± 11.3 (157.0–188.0)175.0 ± 10.7 (157.5–188.0)<0.0001Body mass index, kg/m225.0 ± 4.3 (18.9–32.8)25.8 ± 4.7 (19.2–34.4)<0.0001History of cigarette use…bData available for 7/2004–6/2010 transplants.46.9bData available for 7/2004–6/2010 transplants.…Comorbidities Diabetes mellitus14.5bData available for 7/2004–6/2010 transplants.22.7<0.0001 Hypertension34.6bData available for 7/2004–6/2010 transplants.40.9<0.0001 Peripheral vascular disease3.9bData available for 7/2004–6/2010 transplants.3.0<0.0001 Chronic obstructive pulmonary disease3.2bData available for 7/2004–6/2010 transplants.3.60.0601 Prior malignancy3.5bData available for 7/2004–6/2010 transplants.5.3<0.0001 Prior cardiac surgery…bData available for 7/2004–6/2010 transplants.43.0bData available for 7/2004–6/2010 transplants.… Serum creatinine (mg/dl)1.2 ± 9.7 (0.7–2.5)1.2 ± 0.9 (0.7–2.3)0.0001 Pulmonary vascular resistance (WU)2.1 ± 2.2 (0.4–6.0)cData available for 4/1994–2001 transplants.2.1 ± 2.0 (0.3–5.6)<0.0001Panel reactive antibody > 10%dUntil mid-2004, panel reactive antibody was collected in the US as a single percentage. After this date, panel reactive antibody was collected separately for class I and class II antibodies. Overall (US 1992–6/2004, non-US 1992–6/2010)7.89.20.0016 Class I (US 6/2004–6/2010)13.3 Class II (US 6/2004–6/2010)9.0Hospitalized at time of transplant58.746.0<0.0001Mechanical ventilation3.53.00.0065Pre-op inotropic/circulatory support Intravenous inotropes55.3bData available for 7/2004–6/2010 transplants.44.8<0.0001 Intra-aortic balloon pump6.76.70.7815 Left ventricular assist device1.7dUntil mid-2004, panel reactive antibody was collected in the US as a single percentage. After this date, panel reactive antibody was collected separately for class I and class II antibodies.19.0<0.0001 Right ventricular assist device…4.1fData available for 4/1995–2001 transplants.… Total artificial heart0.1dUntil mid-2004, panel reactive antibody was collected in the US as a single percentage. After this date, panel reactive antibody was collected separately for class I and class II antibodies.0.5<0.0001 Extracorporeal membrane oxygenation0.3eData available for 11/1999–2001 transplants.0.8<0.0001Donor/recipient HLA mismatches0.0003 0–24.84.2 3–441.640.4 5–653.655.4Allograft ischemic time, hours2.6 ± 1.5 (0.0–4.6)3.0 ± 1.5 (0.0–5.0)<0.0001HLA, human leukocyte antigen; US, United States; WU, Woods units.a Data are expressed as median ± standard deviation (5th–95th percentiles) or percentages.b Data available for 7/2004–6/2010 transplants.c Data available for 4/1994–2001 transplants.d Until mid-2004, panel reactive antibody was collected in the US as a single percentage. After this date, panel reactive antibody was collected separately for class I and class II antibodies.e Data available for 11/1999–2001 transplants.f Data available for 4/1995–2001 transplants.g Based on 2005–6/2010 transplants. Open table in a new tab Compared with a decade ago, the number of patients bridged to transplant with mechanical circulatory support devices has increased dramatically. In the period between January 2002 and June 2010, 19% of recipients had left ventricular assist devices (LVAD). In 2009, the proportion of patients who were bridged to transplant with mechanical circulatory support exceeded 30% for the first time (Figure 5) . Between 2005 and 2009, 3% to 5% of recipients had right ventricular assist device (RVAD) at the time of transplant (RVAD only, or RVAD and LVAD).Figure 5Adult patients bridged to heart transplantation with mechanical circulatory support by left ventricular assist device (LVAD), right ventricular assist device (RVAD) or biventricular support (LVAD + RVAD, total artificial heart).View Large Image Figure ViewerDownload Hi-res image Download (PPT)In summary, the typical recent heart allograft recipient continues to have a higher number of characteristics at time of transplant that might be associated with post-transplant risk of morbidity and death than an average recipient who underwent transplantation in previous eras.Donor demographicsThe median donor age in 2009 was 35 years, which has increased from 27 years in 1990. In 2009, 14% of donors were aged 50 to 60 years, compared with 4% of donors in this age category in 1990. Use of allografts from donors aged 60 years or older remains unusual, but the number of donors in this age category has also been slowly rising: individuals in this age group were donors for 76 transplants (2%) in 2009. There are substantial geographic variations in the use of older donors; in Europe, 22% of donors are 50 years or older, a much higher proportion than in other locations (Figure 6) . It is possible that shorter distances between donor and recipient hospitals, the mode of allocation, or other factors that result in shorter allograft ischemic times in Europe (Figure 7) facilitate transplantation of organs from older donors. Additional donor characteristics are presented in Table 2.Figure 6Donor age distribution by geographic location for adult heart transplants that occurred from January 2000 through June 2010. Mean/median donor age: Europe = 38.3/40.0; North America = 31.7/29.0; other = 32.9/31.0.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 7Allograft ischemic time distribution in different geographic locations for adult heart transplants from January 2000 through June 2010.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Table 2Donor Characteristics at the Time of Transplant for Two Eras: 1992 Through 2001 and 2002 Through June 2010Donor variableaData are expressed as median ± standard deviation (5th–95th percentiles) or percentages.1992–2001 (n = 39,812)2002–June 2010 (n = 27,387)p-valueCause of death<0.0001 Head trauma45.750.2 Stroke28.528.8 Other25.821.1Age, years31.0 ± 12.8 (15.0–54.0)34.0 ± 13.1 (16.0–56.0)<0.0001Female sex31.630.50.0030Weight, kg75.0 ± 17.6 (52.0–103.9)bData are available for April 1994–2001 transplants.78.0 ± 17.1 (55.6–110.0)<0.0001Height, cm175.0 ± 18.9 (155.0–188.0)bData are available for April 1994–2001 transplants.175.0 ± 10.3 (159.0–190.0)<0.0001Body mass index, kg/m224.2 ± 4.5 (18.8–33.0)bData are available for April 1994–2001 transplants.25.2 ± 4.9 (19.7–35.4)<0.0001History of cigarette use37.5bData are available for April 1994–2001 transplants.23.6<0.0001History of hypertension10.8bData are available for April 1994–2001 transplants.12.4<0.0001a Data are expressed as median ± standard deviation (5th–95th percentiles) or percentages.b Data are available for April 1994–2001 transplants. Open table in a new tab Combined organ transplantationThe number of simultaneous combined organ transplants has been gradually increasing; however, the absolute number of these transplants remains low (Figure 8) . During the last 5 years, the Registry received reports of 334 heart-kidney, 51 heart-liver, 4 heart-kidney-liver, and 2 heart-kidney-pancreas transplants. Heart-lung transplants are not included in this figure.Figure 8Combined heart and other solid-organ transplants in adults (excluding heart-lung transplants).View Large Image Figure ViewerDownload Hi-res image Download (PPT)ImmunosuppressionImmunosuppressive induction therapy continues to be used frequently. In the first 6 months of 2010, 52% of patients received immunosuppressive induction (Figure 9) . Interleukin-2 receptor (IL-2R) antagonists were used in 30% of patients, polyclonal anti-lymphocytic antibodies were used in 20%, and induction with alemtuzumab was used in 3% of patients. Use of OKT3 has become negligible. Interestingly, there are marked geographic variations in the use of immunosuppressive induction therapy. In Europe, induction therapy is used in 76% of patients, and polyclonal anti-lymphocytic antibodies are the preferred induction agents. In North America, induction therapy is used in 51% of patients and is more evenly split between IL-2R antagonists and polyclonal antibodies (Figure 10) .Figure 9Immunosuppressive induction therapy for adult heart transplant recipients from 1997, 2002, and January through June 2010. IL, interleukin; ALG, anti-lymphocyte globulin; ATG, anti-thymocyte globulin. Analysis is limited to patients who were alive at the time of the discharge.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 10Immunosuppressive induction therapy for adult heart transplant recipients by geographic location for transplants from January 2002 through June 2010. IL, interleukin; ALG, anti-lymphocyte globulin; ATG, anti-thymocyte globulin. Analysis is limited to patients who were alive at the time of the discharge.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Significant changes have also occurred during the past 10 years in the use of maintenance immunosuppression therapy. Immunosuppressive therapy used at 1 year after transplant in 3 groups of patients who received allografts at different times during the last 10 years is shown in Figure 11. Tacrolimus is now the dominant calcineurin inhibitor, and its use increased from 23% in 2000 to 73% in 2009 through June 2010. The use of cyclosporine has decreased below 20%. Mycophenolate mofetil (MMF)/mycophenolic acid (MPA) were used in 85% of patients in 2009 to June 2010, and azathioprine in only 3%. The use of sirolimus peaked at 15% in 2003. The 2 clinically used mammalian target of rapamycin (mTOR) inhibitors—sirolimus and everolimus—were used in 8% of patients in 2009 through June 2010. Most patients also remain on prednisone therapy. However, the proportion of patients weaned from prednisone within 1 year of transplant has increased: Specifically, in 2000, only 6% of patients had been weaned from prednisone at 1 year after transplant compared with 20% not taking prednisone at 1 year after transplant in 2009 through June 2010. Among patients reaching 5-year follow-up between January 2007 and June 2010, 49% had been weaned from prednisone.9International Society for Heart and Lung TransplantationRegistries.www.ishlt.org/registries/Google ScholarFigure 11Maintenance immunosuppressive agents at 1 year after transplant for adult heart recipients. One year follow-up reported for 2000, 2003, and July 2009 to June 2010. MMF, mycophenolate mofetil; MPA, mycophenolic acid. Note: Different patients are analyzed in each time frame. Analysis is limited to patients who were alive at the time of the discharge.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Post-transplant outcomesSurvivalThe median survival or half-life (the time at which 50% of transplant recipients remain alive) is 11 years for the entire cohort of adult and pediatric heart recipients who received allografts since the initiation of the Registry in 1982. For adult and pediatric patients surviving to 1 year after transplant, the median survival has reached 14 years. Almost 100 patients have now lived past 25 years since their transplant procedure.Post-transplant survival of adult heart transplant recipients continues to improve (Figure 12A). The first year after transplant continues to represent the period with the highest risk of death. Reduction in mortality during this critical period is mostly responsible for the improved survival seen after heart transplantation in the more recent eras. The mortality rate beyond 1 year after transplant has improved only marginally for patients who received allografts after 1992, and there has been no statistically significant improvement in the past 2 decades (Figure 12B). This fairly constant mortality rate of approximately 3 to 4 percentage points per year is higher than that of a general population and it is therefore reasonable to hypothesize that further improvements in post-transplant survival are likely to result from interventions aimed at the processes responsible for this long-term mortality.Figure 12(A) Survival and (B) survival conditional on surviving to 1 year after transplant for adult heart transplants performed between January 1982 and June 2009, stratified by era of transplant.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Additional analyses available in the online Registry data set9International Society for Heart and Lung TransplantationRegistries.www.ishlt.org/registries/Google Scholar explore survival in different recipient age groups as well as in patients stratified by etiology of heart disease leading to the need of transplant. Overall, these analyses show that the improvement in survival has been realized across all recipient ages and across the different heart disease categories. The more recent cohort of patients who received allografts between January 2002 and June 2009 demonstrates smaller differences in survival as a function of recipient age: the survival of patients aged 30 to 39 years is not statistically different from those aged 40 to 49 or 50 to 59 years. Although the survival of the other age groups—18 to 29, 60 to 69, and ≥ 70 years—is statistically worse than in the former 3 age groups, these differences are less pronounced than in previous eras.The etiology of heart disease leading to transplantation remains an important predictor of survival, even in the more recent cohort of patients underwent transplantation between January 2002 and June 2009 (Figure 13) . Those who undergo transplantation for non-ischemic cardiomyopathy have the best survival, followed by those with ischemic cardiomyopathy. Survival of patients who receive allografts because of congenital heart disease, valvular cardiomyopathy, and those in need of retransplant is inferior to the former 2 groups, with the survival differences again being limited to the first post-transplant year.9International Society for Heart and Lung TransplantationRegistries.www.ishlt.org/registries/Google ScholarFigure 13Survival for adult heart transplant recipients by diagnosis for transplants from January 2002 through June 2009.View Large Image Figure ViewerDownload Hi-res image Download (PPT)A number of analyses exploring the effect of bridging to transplantation with mechanical assist devices on post-transplant survival are presented in the online Registry data set.9International Society for Heart and Lung TransplantationRegistries.www.ishlt.org/registries/Google Scholar A survival analysis that included patients who received allografts between January 2002 and June 2009 demonstrated that patients bridged with both pulsatile-flow and continuous-flow LVADs had worse post-transplant survival than patients who did not require an LVAD bridge to transplant. The excess mortality appeared to be limited to the first 6 months after transplant, with 6-month survivors having equivalent survival to up to 7 years after transplant. An analysis that focused on the most recent cohort of patients—those who received allografts between July 2004 and June 2009—showed that there was no longer a statistically significant difference in survival of patients bridged with pulsatile-flow or continuous-flow VADs compared with patients not requiring LVAD bridging. Patients requiring a bridge with biventricular pulsatile support, however, had markedly increased mortality, with a 1-year survival of 79% and 5-year survival of 62% (Figure 14) .Figure 14Survival of adult heart transplant recipients by ventricular assist device (VAD) usage for transplants occurring from July 2004 through June 2009) LVAD, left VAD; RVAD, right VAD.View Large Image Figure ViewerDownload Hi-res image Download (PPT)MortalityRisk factors for 1-year mortalityWe performed a multivariable analysis using a proportional hazards model to analyze risk factors for mortality at 1 year after transplant in contemporary patients who underwent transplantation between January 2004 and June 2009 (Table 3). Categoric risk factors are ordered by strength of their association with mortality (RR). The number of patients with the particular characteristic is also listed along with each of the variables to provide further insight into the clinical relevance of the individual factors. Continuous risk factors are also considered, and a set of graphs in the online Registry slide set describes RRs associated with the different values of the continuous variables.8Harrell Jr, F.E. Regression modeling strategies. Springer, Berlin2001Crossref Google ScholarTable 3Risk Factors for Death Within 1 Year of Transplant for Transplants From January 2004 Through June 2009 (N = 10,271)VariableNo.RR (95% CI)p-valueCategoric variables Temporary circulatory supportaIncludes extra-corporeal membrane oxygenation and Abiomed BVS. There were too few temporary continuous-flow devices to analyze.1803.32 (2.46–4.48)<0.0001 Diagnosis: congenital vs non-ischemic cardiomyopathy2712.23 (1.67–2.97)<0.0001 Temporary continuous-flow device312.10 (1.12–3.92)0.0204 Total artificial heart581.82 (1.04–3.20)0.0365 Recipient history of dialysis2561.72 (1.35–2.19)<.0001 Recipient supported by ventilator at time of transplant2851.59 (1.22–2.07)0.0006 Previous transplant2981.51 (1.14–2.01)0.0046 Chronic continuous-flow device7311.48 (1.18–1.87)0.0008 Chronic pulsatile-flow device1,4011.34 (1.11–1.62)0.0022 Prior transfusion2,0561.26 (1.08–1.46)0.0032 Recipient infection requiring IV drug therapy ≤ 2 weeks pre-transplant1,0211.23 (1.03–1.46)0.019 Donor cause of death: anoxia vs head trauma1,1461.22 (1.02–1.45)0.0275 Diagnosis: coronary artery disease vs cardiomyopathy4,2571.19 (1.04–1.36)0.0126 Balloon pump5780.71 (0.55–0.91)0.0062Continuous variables Recipient age<0.0001 Recipient height<0.0001 Recipient weight0.0064 Donor age<0.0001 Donor weight0.0147 Transplant center volume0.0378 Allograft ischemic time<0.0001 Serum bilirubin<0.0001 Serum creatinine<0.0001 Panel reactive antibody0.0203 Pulmonary capillary wedge pressure0.0075 Pulmonary vascular resistance0.0067CI, confidence interval; IV, intravenous; RR, relative risk.a Includes extra-corporeal membrane oxygenation and Abiomed BVS. There were too few temporary continuous-flow devices to analyze. Open table in a new tab Donor characteristics associated with 1-year post-transplant survival include donor age, donor weight, and anoxia as donor cause of death. Allograft ischemic time also remains a strong predictor of 1-year mortality (Figure 15) . The remaining predictors of 1-year mortality are recipient characteristics and transplant center volume. Need for temporary mechanical support before transplant markedly increases the risk of 1-year mortality: the RR is 3.32 for extracorporeal membrane oxygenation (