Survival In Heart Transplant Recipients Research Articles

Quantitative flow ratio computed from invasive coronary angiography as a predictor for cardiac allograft vasculopathy after cardiac transplant.

Cardiac allograft vasculopathy (CAV) is a significant determinant of long-term survival in heart transplant recipients. Standard CAV screening typically utilizes invasive coronary angiography (ICA). Quantitative flow ratio (QFR) is a computational method for functional testing of coronary stenosis, and may add diagnostic value to ICA in assessing CAV. Consecutive subjects who received heart transplantation and underwent two separate routine coronary angiograms between January 2013 and April 2016 were enrolled. Coronary angiograms and IVUS were performed per local protocol at 1, 2, 3 and 5years post-transplant. QFR was calculated offline. CAV was assessed semi-quantitively based on coronary angiogram results. Twenty-two patients were enrolled. Mean time from transplant to first included ICA was 2.1years. QFR in at least 1 coronary vessel was interpretable in 19/22 (86%) of initial ICA (QFR1). QFR1 correlated well with the CAV score derived from the second ICA (CAV2) with a clustering of CAV at lower QFR values. In a receiver-operating characteristic (ROC) analysis, an optimal QFR threshold of 0.88 yielded 0.94 sensitivity and 0.67 specificity (AUC of 0.79) for at least non-obstructive subsequent CAV. Initial angiographically and intravascular ultrasound derived CAV severity poorly predicted subsequent CAV severity. QFR derived from invasive coronary angiography predicts subsequent development of CAV more accurately than angiography and intravascular ultrasound. This novel method of coronary flow assessment in recipients of heart transplantation may be useful to diagnose and predict subsequent CAV development.

De Novo Donor-Specific Antibodies after Heart Transplantation: A Comprehensive Guide for Clinicians

Antibodies directed against donor-specific human leukocyte antigens (HLAs) can be detected de novo after heart transplantation and play a key role in long-term survival. De novo donor-specific antibodies (dnDSAs) have been associated with cardiac allograft vasculopathy, antibody-mediated rejection, and mortality. Advances in detection methods and international guideline recommendations have encouraged the adoption of screening protocols among heart transplant units. However, there is still a lack of consensus about the correct course of action after dnDSA detection. Treatment is usually started when antibody-mediated rejection is present; however, some dnDSAs appear years before graft failure is detected, and at this point, damage may be irreversible. In particular, class II, anti-HLA-DQ, complement binding, and persistent dnDSAs have been associated with worse outcomes. Growing evidence points towards a more aggressive management of dnDSA. For that purpose, better diagnostic tools are needed in order to identify subclinical graft injury. Cardiac magnetic resonance, strain techniques, or coronary physiology parameters could provide valuable information to identify patients at risk. Treatment of dnDSA usually involves plasmapheresis, intravenous immunoglobulin, immunoadsorption, and ritxumab, but the benefit of these therapies is still controversial. Future efforts should focus on establishing effective treatment protocols in order to improve long-term survival of heart transplant recipients.

CD14highCD16+ monocytes are the main producers of Interleukin-10 following clinical heart transplantation.

Following heart transplantation, a cascade of immunological responses is initiated influencing the clinical outcome and long-term survival of the transplanted patients. The anti-inflammatory cytokine interleukin-10 (IL-10) was shown to be elevated in the blood of heart transplant recipients directly after transplantation but the releasing cell populations and the composition of lymphocyte subsets following transplantation have not been thoroughly studied. We identified immune cells by immunophenotyping and analyzed intracellular IL-10 production in peripheral blood mononuclear cells (PBMC) of heart transplanted patients (n= 17) before, directly after and 24h post heart transplantation. The cells were stimulated with lipopolysaccharide or PMA/Ionomycin to enhance cytokine production within leukocytes in vitro. We demonstrate that intermediate monocytes (CD14highCD16+), but not CD8+ T cells, CD4+ T cells, CD56+ NK cells or CD20+ B cells appeared to be the major IL-10 producers within patients PBMC following heart transplantation. Consequently, the absolute monocyte count and the ratio of intermediate monocytes to classical monocytes (CD14+CD16-) were specifically increased in comparison to pre transplant levels. Hence, this population of monocytes, which has not been in the focus of heart transplantation so far, may be an important modulator of clinical outcome and long-term survival of heart transplant recipients. Alteration of blood-circulating monocytes towards a CD14highCD16+ phenotype could therefore shift the pro-inflammatory immune response towards induction of graft tolerance, and may pave the way for the optimization of immunosuppression.

Impact of myocardial bridging on coronary artery plaque formation and long-term mortality after heart transplantation

ObjectivesThis study aimed to explore the impact of myocardial bridging (MB) on early development of cardiac allograft vasculopathy and long-term graft survival after heart transplantation. BackgroundMB has been reported to be associated with acceleration of proximal plaque development and endothelial dysfunction in native coronary atherosclerosis. However, its clinical significance in heart transplantation remains unclear. MethodsIn 103 heart-transplant recipients, serial (baseline and 1-year post-transplant) volumetric intravascular ultrasound (IVUS) analyses were performed in the first 50 mm of the left anterior descending (LAD) artery. Standard IVUS indices were evaluated in 3 equally divided LAD segments (proximal, middle, and distal segments). MB was defined by IVUS as an echolucent muscular band lying on top of the artery. The primary endpoint was death or re-transplantation, assessed for up to 12.2 years (median follow-up: 4.7 years). ResultsIVUS identified MB in 62% of the study population. At baseline, MB patients had smaller intimal volume in the distal LAD than non-MB patients (p = 0.002). During the first year, vessel volume decreased diffusely irrespective of the presence of MB. Intimal growth diffusely distributed in non-MB patients, whereas MB patients demonstrated significantly augmented intimal formation in the proximal LAD. Kaplan-Meier analysis revealed significantly lower event-free survival in patients with versus without MB (log-rank p = 0.02). In multivariate analysis, the presence of MB was independently associated with late adverse events [hazard ratio 5.1 (1.6–22.2)]. ConclusionMB appears to relate to accelerated proximal intimal growth and reduced long-term survival in heart-transplant recipients.

Does donor treatment with inotropes and/or vasopressors impact post-transplant outcomes?

The purpose was to evaluate the effects of the most commonly used cardiac donor inotropes/vasopressors on subsequent post-heart transplant survival. Adult heart transplant recipients from January 2000 to June 2022 were identified in the United Network for Organ Sharing (UNOS) database. Exclusion criteria included: multiorgan transplants, donor age<15, and recipient age<18. Donors receiving vasoactive medications at the time of procurement were compared to donors not receiving these medications. Those on vasoactive medications were stratified by medication: phenylephrine, dopamine, dobutamine, norepinephrine and epinephrine, the combination of these agents, and the concomitant administration of vasopressin with any single agent alone or in combination. The primary area of interest was short-and-long-term survival. Survival at 30 days, 1 year, and long-term (Median=13.6 years) was compared using logistic and Cox models to quantify survival endpoints. A total of 45,198 donors met inclusion criteria and had data on the use of vasoactive agents available. Mean donor age was 32.3 years with 71% male. Vasoactive medications and potential combinations included phenylephrine in 8156 donors (18.0%), dopamine in 9550 (21.1%), dobutamine in 718 (1.6%), epinephrine in 332 (.73%), and norepinephrine in 4854 (10.7%). A total of 25,856 donors (57.2%) were receiving vasopressin at the time of procurement. There was no impact of donor inotropes on 30-day survival. Donors receiving one inotrope and no vasopressin were associated with increased 1 year mortality (OR 1.14; p=.021), as were donors receiving 2+ inotropes and no vasopressin (OR 1.26; p=.006). For individual agents, 1 year mortality was increased for dopamine (OR 1.11; p=.042) and epinephrine (OR 1.59; p=.004). There is no difference in heart transplant recipient survival at 30 days when the donor is receiving inotropes without vasopressin at the time of procurement. Inotropic support without vasopressin is associated with greater 1 year mortality. The impact of donor inotropic support on long term heart transplant survival, and the interaction with vasopressin warrants further study.

Donor Noradrenaline Support Is Not Associated with Decreased Survival in Heart Transplant Recipients.

Objective: Although the application of higher doses of norepinephrine (NE) in potential organ donors is a frequent reason for heart decline, its associations with outcomes after heart transplantation (HTx) are discussed controversially. Therefore, we aimed to explore donor NE support’s potential impact on outcomes in our single-center heart transplant cohort. Methods: All patients who had undergone HTx in our center between September 2010 and April 2022 (n = 241) were screened for eligibility. From those, all patients with complete data on donor NE support (n = 238) were included. Recipients were divided into three groups according to their donor NE support: without support (n = 26), with low support of 0.01−0.2 µg/kg/min (n = 132), and with high support of > 0.2 µg/kg/min (n = 80). Receiver operating characteristics (ROC) and Kaplan Meier analysis was used to investigate the association of donor NE support and mortality after heart transplantation. Recipient and donor variables, including peri- and postoperative characteristics, were reviewed and compared. Results: NE support in donors ranged between 0 and 2.94 µg/kg/min (median 0.13 µg/kg/min, IQR 0.05−0.26 µg/kg/min). No association between donor NE support and mortality after HTx was observed (AUC for overall survival 0.494). Neither Kaplan-Meier analysis in survival up to 5 years after transplantation (Log Rank p = 0.284) nor group comparisons showed significant differences between the groups. With few exceptions, baseline characteristics in recipients and donors were comparable between the groups. Regarding peri- and postoperative parameters, increasing donor NE support was associated with a longer duration of mechanical ventilation (68 h and 95 h vs. 47 h), longer postoperative IMC/ICU stay (14 vs. 15 vs. 19 days), and a higher need for mechanical life support post-HTx (26% and 39% vs. 12%). Conclusion: In this retrospective analysis, NE support in donors prior to heart transplantation was unrelated to differing survival after heart transplantation. However, higher doses of donor NE were associated with prolonged ventilation, longer duration on IMC/ICU, and a higher need for extracorporeal life support in recipients post-HTx.

The Effects of Donor Thyroid Hormone Supplementation on Heart Transplant Recipient Survival

The Effects of Donor Thyroid Hormone Supplementation on Heart Transplant Recipient Survival

Intracerebral bleeding in donors is associated with reduced short-term to midterm survival of heart transplant recipients.

AimThe quality of the donor heart is known to have a crucial effect on outcome after heart transplantation (HTx). Although leading to brain death in the end, the initial cause of death of the donor and its potential influences on organ quality are heterogeneous. However, it is still controversial to which extent the donor cause of death is associated with outcome or survival post‐HTx.Methods and resultsWe included all patients undergoing HTx in our centre between September 2010 and June 2021 (n = 218). Recipients were divided in five groups related to their donor cause of death: intracerebral bleeding (‘ICB’, n = 95, 44%), traumatic brain injury (‘trauma’, n = 54, 25%), hypoxic brain damage (‘hypoxic’, n = 34, 16%), cerebrovascular (‘vascular’, n = 15, 7%), or other cause (n = 20, 9%). Baseline characteristics, perioperative parameters, and survival after 30 and 90 days as well as 5 years after transplantation were collected.ResultsIntracerebral bleeding in donors compared with traumatic brain injury is associated with higher probability of need for ECLS post‐HTx (35% vs. 19%, P = 0.04) and significantly reduced survival up to 5 years post‐HTx (i.e. 1 year survival: 61% vs. 95%, P < 0.0001). Although other conditions also show significant changes in outcome and survival, the effect is strongest for ICB, where survival is also reduced compared with all other causes (1 year: 61% vs. 89%, P < 0.0001).ConclusionsIn this retrospective analysis, donor cause of death is associated with differing outcome and survival after HTx. Intracerebral bleeding hereby shows strongest decline in outcome and survival in comparison with all other causes.

High Sensitivity Troponin I as a Predictor of Survival in Heart Transplant Patients

<h3>Purpose</h3> Although high sensitivity troponin I (hsTnI) levels are predictive of incident adverse cardiovascular outcomes in the general population and those with cardiovascular diseases, their prognostic significance in heart transplant (HT) patients is unknown. We hypothesized that hsTnI levels will also predict survival in heart transplant patients. <h3>Methods</h3> Heart transplant recipients enrolled in the Emory Cardiovascular Biobank had hsTnI levels measured (Abbott Laboratories) and were followed for a median of 10 years for all-cause mortality. Kaplan-Meier curves and log rank test were used to evaluate whether hsTnI levels (above/below median) predicted survival. Cox proportional hazard analysis was used to adjust for age, age at transplant, donor age, sex, race, smoking history, BMI, diabetes, hypertension, total cholesterol, low-density lipoprotein, and creatinine. <h3>Results</h3> In 156 HT recipients (mean age 54, 82% male, 53% chronic kidney disease), hsTnI levels were measured at a median 10 years after transplant [interquartile range (IQR) 4.0-14.8 years]. The median hsTnI level was 4.9 [IQR 2.9 - 9.9] pg/mL. 77 patients (49%) died at a median 6.2 years after hsTnI measurements. HsTnI levels were higher in patients who died compared to those alive (median 7.0 vs. 3.9 pg/mL, p<0.001). Both unadjusted (p=0.0002, figure) Kaplan-Meier analysis and adjusted Cox models (p=0.017) demonstrated worse survival in patients with higher hsTnI level. The adjusted hazard ratio was 2.64 (confidence interval 1.19-5.86) for those with hsTnI level greater than median (4.9 pg/ml) compared to those with less than median values. <h3>Conclusion</h3> HsTnI levels provide an independent estimate of survival in heart transplant recipients.

Education and Its Impact on Post-Heart Transplant Survival?

<h3>Purpose</h3> The purpose of this study was to evaluate the effect of education on survival after orthotopic heart transplantation. Few studies have explored the impact of education from quality of life and adherence to medication and follow-up, thus a paucity of literature exists in understanding education and its impact on survival. <h3>Methods</h3> We evaluated the United Network for Organ Sharing (UNOS) registry for all adult heart transplant recipients (HTR) from 1999 to 2018. Recipients were grouped based upon their education level. We had two groups in our analysis: group 1 = education level > high school and group 2 = education level < high school. Kaplan-Meier survival analysis and Cox regression modelling were used in our analysis for confounders like age, gender, status of HF, ethnicity, etc. <h3>Results</h3> We had a total of 30,999 heart transplant recipients (HTR) in our analysis, of which 1,122 HTR with less than high school education and 29,877 with education above high school. Kaplan-Meier survival analysis of the patient survival time showed a higher survival in HTRs with education level above high school (Figure 1). Education level < high school had 17% increased risk of death (p=0.0024). On adjusting for confounders like age, gender, status of HF, ethnicity, etc., education still had a positive impact on survival. Lower episodes of rejection and better follow-up were also seen in HTR with an education level higher than high school. (data not shown) <h3>Conclusion</h3> Higher level of education has a positive impact on survival. This relationship can be explained by the notion that HTRs with higher education status may be better informed, more adherent to medication, and more likely to follow-up. All of these factors contribute to earlier identification of complications and fewer rejection episodes, ultimately leading to greater outcomes of survival. Further studies are required to further understand this complex relationship.

Outcomes of Heart Transplant Recipients Bridged with Percutaneous versus Durable LVADs

<h3>Purpose</h3> The new UNOS heart allocation policy prioritizes patients with percutaneous ventricular support devices over durable LVADs. We examined one-year survival of heart transplant recipients successfully bridged with Impella versus durable LVADs in the most recent era. <h3>Methods</h3> We retrospectively reviewed all primary adult orthotopic heart transplant recipients in the UNOS registry between Jan 1, 2016 to June 12, 2020. Recipients were identified as having an isolated durable LVAD or Impella device at the time of transplant. Those bridged with ECMO, RVAD, BIVAD, or TAH were excluded. One-year survival was examined with the Kaplan Meier method and multivariable Cox proportional hazards regression. <h3>Results</h3> Of 10,492 heart transplant recipients in the study period, 4610(44%) were bridged with a durable LVAD and 158(2%) with Impella. Impella use increased following the UNOS allocation policy change (3% vs 1% of transplants, p<0.01) and a higher proportion were status 1 or 2 compared to those bridged with durable LVADs (96% vs 26%, p<0.01). Median days between listing and transplant were 40, 218, and 13 days for no MCS, durable LVAD, and Impella, respectively (p<0.01). Impella-bridged recipients were less likely to be obese (26% vs 41%, p<0.01), have diabetes (24% vs 31%, p<0.01), ischemic cardiomyopathy (28% vs 35%, p<0.01), prior cardiac surgery (27% vs 73%, p<0.01), and were more likely to be on inotropes at the time of transplant (65% vs 6%, p<0.01). On multivariate analysis, neither bridge with durable LVAD (aHR 1.25, 95% CI 0.97-1.62, p = 0.08) nor Impella (aHR 1.07, 95% CI 0.55-2.08, p=0.84) was associated with a difference in one-year survival following heart transplantation. <h3>Conclusion</h3> Impella utilization as bridge to transplant has tripled in the current era of heart transplantation with no significant difference in one-year survival compared to those bridged with durable LVADs. Percutaneous LVAD platforms can be cautiously considered in the sickest patients requiring LVAD bridge to transplantation.

Kidney Allograft and Recipient Survival After Heart Transplantation by Induction Type in the United States.

Induction choices for kidney-after-heart transplant recipients are variable. We examined the impact of kidney induction types on kidney graft and patient survival in heart transplant recipients. We analyzed the Scientific Registry of Transplant Recipient database from inception through the end of 2018 to study kidney and patient outcomes in the United States after heart transplantation. We only included recipients who were discharged on tacrolimus and mycophenolate maintenance. We grouped recipients by induction type into 3 groups: depletional (N = 307), nondepletional (n = 253), and no-induction (steroid only) (n = 57). We studied patients and kidney survival using Cox PH regression, with transplant centers included as a random effect. We adjusted the models for heart induction, recipient and donor age, gender, time between heart and kidney transplant, heart transplant indication, HLA mismatches, payor, live-donor kidney, transplant year, dialysis status, and diabetes mellitus at the time of kidney transplant. The 1-y kidney rejection rates and creatinine levels were similar in all groups. The 1-y rehospitalization rate was higher in the depletional group (51.7%) and nondepletional group (50.7%) than in the no-induction group (39.1%) although this was not statistically significant. There were no differences in recipient or kidney survival by kidney induction type. Live-donor kidney was associated with improved patient (hazard ratio, 0.74; 95% confidence interval, 0.54-1.0; P = 0.05) and kidney survival (hazard ratio, 0.45; 95% confidence interval, 0.24-0.84; P = 0.012]. Type of kidney induction did not influence patient or kidney graft survival in heart transplant recipients. No-induction may be the preferred choice due to the lack of clinical benefits associated with induction use.

The effects of increased donor support time from organ donation referral to donor procurement on heart transplant recipient survival.

Given the known deleterious cardiac effects of brain death (BD) physiology, we hypothesized that time from cardiac donation referral to procurement (donor support time [DST]), would negatively impact cardiac transplant recipient survival. The United Network for Organ Sharing database was queried from 2007 to 2018, identifying 22,593 donor hearts for analysis. Multivariate logistic models for 30-day and 1-year survival, as well as Cox models for overall survival and posttransplant rejection, were used to assess adjusted outcomes. median DST was 3 days (interquartile range: 2-5 days). Ischemic time; distance between donor and recipient hospitals; and recipient age, creatinine, waitlist time, and length of stay were adjusted predictors of survival and rejection. DST was not associated with either outcome in aggregate; however, differential association by donor race was identified, with DST in any race recipient associated with 4% higher odds of 1-year mortality (p = .001; p value for interaction.005) but only a trend towards worse overall mortality (p = .064; p value for interaction.046). Thus, duration of exposure to BD physiology may have a differential impact on recipient outcomes based on donor race, suggesting that additional research is needed on donor immunologic, socioeconomic, and healthcare access factors that may impact cardiac transplant recipient outcomes.

In-hospital outcomes after percutaneous coronary interventions in cardiac allograft recipients.

Introduction:The average age and survival of heart transplant recipients have improved significantly over the last 10 years. In these long-term survivors, coronary allograft vasculopathy is one of the most common causes of death. There is a paucity of large-data research highlighting the short-term outcomes of percutaneous coronary interventions in cardiac allograft recipients.Methods:We compared the in-hospital outcomes of heart transplant recipient and non-transplant recipients following percutaneous coronary intervention using data from the National inpatient sample (NIS). All adult patients (age ⩾ 18 years) who had percutaneous coronary intervention in the index admissions from January of 2005 to December of 2014 were included in the analysis. They were then divided into two groups based on their heart transplant status. The primary outcome was in-hospital mortality. Secondary outcomes were stroke, cardiac arrest, duration of hospitalization, and total hospital charges. Logistic regression models were used to compare in-hospital outcomes between the two groups.Results:Of 1,316,528 patients who had percutaneous coronary intervention, 618 (0.05%) were heart transplant recipients and 1,315,910 (99.95%) were not. The heart transplant recipient group was significantly younger with lower rates of obesity and peripheral vascular disease but higher rate of chronic kidney disease, iron deficiency anemia, and chronic liver disease. There was significantly higher in-hospital mortality in transplant recipients below 65 years of age (adjusted odds ration = 2.3, p value < 0.0001). Subjects in the heart transplant recipient group also had longer hospital stays (p value = 0.002).Conclusion:Heart transplant recipients younger than 65 years had higher in-hospital mortality. Subjects in the heart transplant recipient group were also younger and had longer duration of hospitalization than the non-transplant cohorts.

Impacts of social inequalities on the survival of heart transplant recipients in a developing country.

Heart transplant (HT) is an alternative for patients with advanced heart failure (HF). Social inequalities may influence survival, but are still not well understood. The aim of this study was to assess the impact of social and clinical inequalities on the survival of HT recipients. Retrospective cohort study conducted at a Brazilian hospital from 2006 to 2018. Three hundred and two patients were analyzed. Most HT recipients were male (205, 67.9%), mixed race 146 (48.3%), retired (166, 56.5%), median age 47 (38-57) years, and had studied no more than eight years (191, 65.8%), were younger than 60years old (256, 84.7%). 149 (51.7%) had per capita monthly income inferior to one Brazilian minimum wage, equivalent to US$250. 123 (95.4%) out of 129 patients had allograft cellular rejection 2R or 3R. Median donor age was 32 (23-39) years. The overall survival was 76.6%, 62.2%, and 58.2%, at 1, 5, and 10years, respectively. Age <60years old and higher income were associated with a greater chance of survival (p-values .009 and <.001, respectively). Younger age and higher per capita income had positive impact on HT recipient survival. The level of education did not affect survival in this cohort.

Poor Functional Status Prior to Bridge-to-transplant Left Ventricular Assist Device Therapy is not Associated with Reduced Survival in Heart Transplant Recipients: Analysis of the United Network for Organ Sharing (UNOS) Registry

Introduction Left ventricular assist devices (LVAD) are commonly used as a bridge-to-transplant (BTT) therapy for patients with advanced heart failure. Poor functional status (FS) is known to negatively affect post-transplant outcomes after heart transplant (HTX). In this study, we sought to evaluate the impact of poor FS prior to BTT-LVAD implantation on post-HTX outcomes. Methods Data from the UNOS database from 2008-2017 were obtained for HTX recipients that underwent continuous-flow LVAD implantation after being listed for HTX with complete Karnofsky Performance Status (KPS) score both at listing (Pre-LVAD) and time of HTX. Poor FS was defined by KPS ≤ 40 (require total assistance) and good FS was defined by KPS > 40 (require some or no assistance). Improvement of FS was defined as a change from pre-LVAD poor FS to good FS at HTX. Multivariate logistic regression adjusting for baseline/pre-HTX characteristics was performed to assess the association of pre-LVAD FS and post-HTX survival and predictors of FS improvement. Results We included 2,812 patients (mean age 52 years, 80% male, 41% on inotrope) listed for HTX before LVAD implantation. Median time from listing to LVAD surgery was 21 (IQR 4-114) days. A total of 48% had poor FS at listing before LVAD. Patients with poor FS were younger, had lower body mass index (BMI), more likely to be on inotrope at listing and had worse hemodynamics. Time to LVAD implantation was shorter in poor FS group but no difference in LVAD support duration. There was no significant difference between poor FS and good FS group in 30-day (96.5% vs. 96.1%, p=0.59) and 1-year post-HTX survival (90.2% vs. 88.7%, p=0.23). Poor FS did not significantly affect 30-day (adjusted OR = 0.9, p=0.64) or 1-year post-HTX survival (adjust OR = 0.9, p=0.54). Of 1,342 patients with pre-LVAD poor FS, 715 (53%) had improvement in FS at HTX. Predictors of FS improvement were longer LVAD support duration and lower BMI. Among pre-LVAD poor FS group, patients with improved FS had significantly higher 1-year post-HTX survival (92.1% vs. 88.0%, p=0.015) but no significant difference in 30-day post-HTX survival (97.0 % vs. 95.8%, p=0.223). Improved FS in patients with pre-LVAD poor FS was significantly associated with higher 1-year survival (adjusted OR = 1.6, p= 0.03). Conclusions Poor functional status was observed in up to 50% of BTT-LVAD candidates; however, it doesn't negatively affect post-HTX survival. After BTT-LVAD support, half of patients with pre-LVAD poor FS have improved FS which is significantly associated with higher post-HTX survival. Urgent BTT-LVAD in selected patients with poor FS is a reasonable option prior to HTX.

Long-term Survival After Heart Transplantation: A Population-based Nested Case-Control Study

Heart transplantation is the mainstay of treatment for patients in end-stage heart failure. This study sought to contrast survival after transplantation with that of the general population to quantify standardized mortality rates using a nested case-control study design. Control subjects were noninstitutionalized inhabitants of the United States identified through the National Longitudinal Mortality study. Case subjects were adults who underwent heart transplantation between 1990 and 2007 and identified through the Organ Procurement and Transplantation Network. Propensity-matching (5:1, nearest neighbor, caliper= 0.1) was utilized to identify suitable control subjects based on age, sex, race, and state of permanent residency. The primary study endpoint was 10-year survival. In all, 31,883 heart transplant recipients were matched to 159,415 noninstitutionalized residents of the United States. The 10-year survival of heart transplant recipients was 53%. The population expected mortality rate was 15.9 deaths per 100 person-years with an observed rate of 45.1 deaths per 100 person-years (standardized mortality rate [SMR] 2.84; 95% confidence interval, 2.82 to 2.87). The broadest gaps between observed and expected survival were evident in female (SMR 3.63), black (SMR 3.67), and Hispanic (SMR 4.12) recipients. Standardized mortality ratios declined over time (1990 to 1995, 3.09; 1996 to 2000, 2.90; 2001 to 2007, 2.58). The long-term standardized survival of older recipients was closest to that expected for their age. Heart transplant recipients have considerable long-term survival and have a threefold higher standardized long-term mortality rate than that of the noninstitutionalized population. Long-term mortality rates have consistently declined over time and will likely continue to decrease.

The Impact of Beta Blockers on Survival in Heart Transplant Recipients: Insights from the Zabrze HTx Registry.

Introduction The data assessing the impact of beta blocker (BB) medication on survival in patients after heart transplantation (HTx) are scarce and unequivocal; therefore, we investigated this population. Methods We retrospectively analyzed the HTx Zabrze Registry of 380 consecutive patients who survived the 30-day postoperative period. Results The percentage of patients from the entire cohort taking BBs was as follows: atenolol 24 (17%), bisoprolol 67 (49%), carvedilol 11 (8%), metoprolol 28 (20%), and nebivolol 8 (6%). The patients receiving BBs were older (56.94 ± 14.68 years vs. 52.70 ± 15.35 years, p=0.008) and experienced an onset of HTx earlier in years (11.65 ± 7.04 vs. 7.24 ± 5.78 p ≤ 0.001). They also had higher hematocrit (0.40 ± 0.05 vs. 0.39 ± 0.05, p=0.022) and red blood cells (4.63 (106/μl) ± 0.71 vs. 4.45 (106/μl) ± 0.68, p=0.015). Survival according to BB medication did not differ among the groups (p=0.655) (log-rank test). Univariate Cox proportional hazard regression analysis revealed that the following parameters were associated with unfavorable diagnosis: serum concentration of albumin (g/l) HR: 0.87, 95% CI (0.81–0.94), p=0.0004; fibrinogen (mg/dl) HR: 1.006, 95% CI (1.002–1.008), p=0.0017; and C-reactive protein (mg/l) HR: 1.014, 95% CI (1.004–1.023), p=0.0044. Conclusions The use of BBs in our cohort of patients after HTx was not associated with survival benefits.

Molecular‐level HLA mismatch is associated with rejection and worsened graft survival in heart transplant recipients – a retrospective study

The aim was to evaluate the association of molecular‐level human leukocyte antigen (HLA) mismatching with post‐transplant graft survival, rejection, and cardiac allograft vasculopathy (CAV). We retrospectively analyzed all primary cardiac transplant recipients between 01/1984‐06/2016. 1167 patients fulfilled inclusion criteria and had HLA typing information available. In 312 donor‐recipient pairs, typing at serological split antigen level was available. We used the Epitope MisMatch Algorithm to calculate the number of amino acid differences in antibody‐verified HLA eplets (amino acid mismatch load (AAMM)) between donor and recipient. Patients with a higher HLA‐DR AAMM load had inferior 1‐year graft survival (hazard ratio [HR], 1.14; 95% confidence interval [CI], 1.01–1.28). The HLA‐AB AAMM load showed no impact on graft survival. In the subgroup with available split‐level information, we observed an inferior graft survival for a higher HLA‐DR AAMM load 3 months after transplantation (HR, 1.22; 95% CI, 1.04–1.44) and a higher risk for rejection for an increasing HLA‐AB (HR, 1.70; 95% CI, 1.29–2.24) and HLA‐DR (HR, 1.32; 95% CI, 1.09–1.61) AAMM load. No impact on the development of CAV was found. Molecular‐level HLA mismatch analysis could serve as a tool for risk stratification after heart transplantation and might take us one step further into precision medicine.

Education and Its Impact on Post-Heart Transplant Survival

The purpose of this study was to evaluate the effect of education on survival after orthotopic heart transplantation. Few studies have explored the impact of education from quality of life and adherence to medication and follow-up, thus a paucity of literature exists in understanding education and its impact on survival. We evaluated the United Network for Organ Sharing (UNOS) registry for all adult heart transplant recipients (HTR) from 1999 to 2018. Recipients were grouped based upon their education level. We had two groups in our analysis: group 1 = education level > high school and group 2 = education level < high school. Kaplan-Meier survival analysis and Cox regression modelling were used in our analysis for confounding variables like age, gender, status of HF, ethnicity, etc. RESULTS: 30,999 heart transplant recipients (HTR) in our analysis, 29,877 in group 1 and 1,122 in group 2. Kaplan-Meier survival analysis of the patient survival time showed a higher survival in HTRs with education level above high school (Figure). Group 2 had 17% increased risk of death (p=0.0024). On adjusting for confounding variables including age, gender, status of HF, ethnicity, etc., education level continued to have a positive impact on survival. Lower episodes of rejection and better follow-up were also seen in HTR with an education level higher than high school. (data not shown) CONCLUSION: Higher level of education has a positive impact on survival. This relationship can be explained by the notion that HTRs with higher education status may be better informed, more adherent to medication, and more likely to follow-up. All of these factors contribute to earlier identification of complications and fewer rejection episodes, ultimately leading to greater outcomes of survival. Further studies are required to further understand this complex relationship.