Status Of Heart Transplantation Research Articles

In the era of outpatient ventricular assist devices, is it time to reconsider the practice of bridging older children to transplant on outpatient inotropes?

ObjectiveVentricular assist devices (VADs) and inotropes are feasible modalities to bridge children to heart transplant (HT) in outpatient settings. However, it is unclear which modality yields superior clinical status at HT and posttransplant survival. MethodsThe United Network for Organ Sharing was used to identify patients aged 18 years or younger, weighing >25 kg, from 2012 to 2022 who were outpatients at HT (n = 835). Patients were grouped by bridging modality at HT: VAD (n = 235 [28%]), inotropes (n = 176 [21%]), or neither (no support) (n = 424 [50%]). ResultsVAD patients were of similar age (P = .260) but heavier (P = .007) and more likely to have dilated cardiomyopathy (P < .001) than their inotrope counterparts. VAD patients had similar clinical status at HT but superior functional status (performance scale >70%) (59% vs 31%) (P < .001). Overall posttransplant survival in VAD patients (1-year and 5-year survival, 97% and 88%, respectively) was comparable to patients with no support (93% and 87%, respectively) (P = .090) and those on inotropes (98% and 83%, respectively) (P = .089). One-year conditional survival was superior for VAD vs inotrope (2-year and 6-year survival, 96% and 91%, respectively vs 97% and 79%, respectively) (P = .030) and 5-year conditional survival for VAD patients was superior to inotrope (7-year and 10-year survival, 100% and 100%, respectively vs 100% and 88%, respectively) (P = .022) and no support (100% and 83%, respectively) (P = .011). ConclusionsConsistent with prior studies, short-term outcomes for pediatric patients bridged to HT in the outpatient setting with VAD or inotropes is excellent. However, compared with outpatients bridged to HT on inotropes, outpatient VAD support allowed for better functional status at HT and superior late posttransplant survival.

P50: Heart and Kidney Transplant and Recovery after Left Ventricular Assist Device and Intermittent Hemodialysis: Systematic Review and Individual-Participant-Data Meta-analysis

Background: Patients with left ventricular assist devices (LVADs) who require chronic intermittent dialysis (iHD) are considered to have poor prognosis despite paucity of supportive evidence, most of which is limited to case reports and very small single-center cohorts. This systematic review and individual-participant-data meta-analysis aims to study the main outcomes of patients receiving iHD during durable LVAD support, including heart, kidney, and heart-kidney transplantation (HT, KT, HKT, respectively) and mortality. Methods: We retrieved citations from ClinicalTrials.gov, Cochrane, Embase, PubMed, and Web of Science through systematic searches. We selected cohort studies (with n ≥5) of patients who were started on iHD at any point during durable LVAD support, excluding patients who exclusively received continuous renal replacement therapy but no actual iHD. We conducted Kaplan-Meier survival estimations and graphs, and compared mortality data between groups using the Gehan-Breslow-Wilcoxon test. P <.05 was considered statistically significant. We did not pursue inputations for missing data. Results: Six studies with a total of 64 patients met selection criteria. Their median age was 57.5 (46-64.5) years, 49 (76.6%) were men, 46 (86.8%) patients had a HeartMate (HM) 2, whereas 5 (9.4%) had a HM3, and 2 (3.8%) had an HVAD. Twenty-eight (66.7%) patients had LVADs as bridge to HT, and 14 (33.3%) as destination therapy. Only 26 (65%) were reported to have a history of CKD. Patients were initiated on iHD at a median of 18 (7-48) days after LVAD implantation, and remained on iHD for 68 (36-185) days. Eleven (17.2%) patients received HT, and at least 1 additional patient achieved myocardial recovery with LVAD explantation. Four (4.3%) patients became recipients of HKT, including one patient who had recovered enough of their renal function as to stop needing iHD prior to transplantation. Twenty-seven (42.2%) experienced renal recovery. Thirty-one (48.4%) patients died at 103 (64-308) days after initiation of iHD. According to Kaplan-Meier survival calculations, median survival was estimated at 153 (SE 217.5; CI 65-835) days (Figure 1). Survival after initiation of iHD was statistically significantly longer for patients who received HT (mortality: 2 [6.4%] vs 16 [11.6%]; p=.0346; median survival: 1972 [SE 98.8; 799-] days vs 93 [SE 10.3; CI 57-404] days), as evidenced in Figure 2. Survival comparisons between groups stratified based on other outcomes (HKT, renal recovery, composite HKT/renal recovery) did not reach statistical significance. Conclusions: The 18.8% of patients who achieved dual heart and kidney recovery and/or transplantation after being supported with LVAD and iHD experienced a significantly longer median survival. Only one patient experienced dual heart-kidney recovery. Larger contemporary multicenter cohort studies are warranted on this topic.Figure 1. Kaplan-Meier Survival Estimate (for the whole sample)Figure 2. Kaplan-Meier Survival Estimate According to Heart Transplant Status

Abstract 55: Statin Type Does Matter: Decreasing Incorrect Statin Administration For Hospitalized Heart Transplant Patients

Background: Statin therapy has been shown to prevent the development of transplant coronary artery disease (TCAD) in heart transplant (HT) patients. Pravastatin is used in HT patients as it does not depend on CYP3A4 metabolism. Other widely used statins, such as simvastatin, have significant drug-drug interactions with the calcineurin inhibitors, which are used as standard immunosuppression therapy for all HT patients. Objective: Our goal was to increase correct statin administration for HT patients from 41-43% to 80% by June 2021 through electronic medical record (EMR) modification and interprofessional communication with the pharmacy department. Methods: Previous to our intervention, the EMR would recommend ordering simvastatin when ordering pravastatin, due to simvastatin being the hospital formulary preferred statin. The EMR did not cross reference HT status, and that pravastatin should be ordered instead. Our intervention was to remove the EMR notification for HT patients recommending simvastatin, as well as working with the clinical heart transplant pharmacists to mediate communication with primary teams. Monthly data was obtained through retrospective chart review. Results: Following our intervention in March 2021, pravastatin was ordered for 67%, 78%, and 81% of heart transplant readmissions in April, May, and June 2021, respectively (Table 1). Conclusion: Our intervention of EMR modification as well as interprofessional communication has almost doubled the correct administration of pravastatin in HT admissions from 41% to 81% over the course of seven months. Prescribing the proper statin for HT patients prevents unwanted toxicities, as well as TCAD - a major limitation to longevity amongst HT patients. Further educational interventions will be implemented for providers to achieve 100% correct statin administration to patients with heart transplant.

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.

Heart transplantation in patients with localized prostate cancer—Are we denying a life‐saving therapy due to an indolent tumor?

Prostate cancer (PC) is the most common non-cutaneous cancer in men. Approximately 90% of these cancers are localized (LPC) with a cancer-specific survival rate of 99% at 10years. Some heart transplant centers (HTCs) regard PC as an absolute contraindication to heart transplantation (HT). This study aims to understand the current status of HT in patients with advanced heart failure (AHF) and concurrent LPC in the United States. Adult HTCs in the United States were asked to fill out an email questionnaire addressing their current approach to HT in AHF patients with concurrent LPC. Fifty of the 90 HTCs that received the questionnaire responded. Only 16% of HTCs had a formal policy regarding HT in patients with LPC, while only 10% had patients with LPC on the HT waitlist at the time of the survey. Overall, 84% of the HTCs had never performed HT in a patient with LPC in the history of their transplant program. An overwhelming majority of HTCs in the United States do not consider HT an option for AHF patients with concurrent LPC and lack a formal policy regarding the same.

Clinical characteristics and in hospital outcomes of heart transplant recipients undergoing percutaneous coronary intervention: Insights from the National Inpatient Sample.

Cardiac transplant patients are at increased risk of Coronary Allograft Vasculopathy which requires percutaneous coronary intervention (PCI). We aim to determine national epidemiology describing trends, mortality, and morbidity risks in patients with heart transplant undergoing PCI. We used Nationwide Inpatient Sample (NIS) data from 2002 to 2014 to identify adult hospitalizations with PCI using ICD 9 codes. Acute myocardial infarction (AMI), cardiac transplant status and complications were identified using validated ICD-9-CM diagnosis codes. Endpoints were in-hospital mortality and peri-procedural complications. Propensity match analysis was performed to compare the end-points between DES and BMS. Total 8,613,900 patients underwent PCI, of which 1,531(0.002%) patients had prior heart transplant status. Among these 1,531 PCIs, 311(20%) were due to AMI including 125(8%) due to STEMI. 74% of PCIs were done in males and 78% of the PCIs were performed in the 60-79 age group. Out of 1,380 stents placed, 1,090 were DES (79%) and 290 (21%) were BMS. Mortality was higher in the BMS versus DES (8.34% vs. 3.45%, p = .012), CONCLUSION: We concluded that majority of the population who underwent PCI were older males. DES was used more than BMS. The use of BMS is associated with increased mortality, cardiac complications and Acute Kidney Injury requiring dialysis compared with DES which likely is representative of preferential use of DES in these patient population.

Effect of Laparoscopic Sleeve Gastrectomy on Heart Transplant Status in 4 Patients with Left Ventricular Assist Devices.

Bariatric surgery helps many morbidly obese patients lose substantial weight. However, few data exist on its long-term safety and effectiveness in patients who also have continuous-flow left ventricular assist devices and in whom heart transplantation is contemplated. We retrospectively identified patients at our institution who had undergone ventricular assist device implantation and subsequent laparoscopic sleeve gastrectomy from June 2015 through September 2017, and we evaluated their baseline demographic data, preoperative characteristics, and postoperative outcomes. Four patients (3 men), ranging in age from 32 to 44 years and in body mass index from 40 to 57, underwent sleeve gastrectomy from 858 to 1,849 days after left ventricular assist device implantation to treat nonischemic cardiomyopathy. All had multiple comorbidities. At a median follow-up duration of 42 months (range, 24-47 mo), median body mass index decreased to 31.9 (range, 28.3-44.3) at maximal weight loss, with a median percentage of excess body mass index lost of 72.5% (range, 38.7%-87.4%). After achieving target weight, one patient was listed for heart transplantation, another awaited listing, one was kept on destination therapy because of positive drug screens, and one regained weight and remained ineligible. On long-term follow-up, laparoscopic sleeve gastrectomy appears to be safe and feasible for morbidly obese patients with ventricular assist devices who must lose weight for transplantation consideration. Additional studies are warranted to evaluate this weight-loss strategy after transplantation and immunosuppression.

The impact of Centre\u2019s heart transplant status and volume on in-hospital outcomes following extracorporeal membrane oxygenation for refractory post-cardiotomy cardiogenic shock: a meta-analysis

BackgroundPostcardiotomy cardiogenic shock (PCS) that is refractory to inotropic support remains a major concern in cardiac surgery and is almost universally fatal unless treated with mechanical support. While reported mortality rates on ECMO vary from center to center, aim of the current report is assess if the outcomes differ between centres according to volume and heart transplantation status.MethodsA systematic search was performed according to PRISMA statement using PubMed/Medline databases between 2010 and 2018. Relevant articles were scrutinized and included in the meta-analysis only if reporting in-hospital/30-day mortality and heart transplantation status of the centre. Paediatric and congenital heart surgery-related studies along with those conducted in the setting of veno-venous ECMO for respiratory distress syndrome were excluded. Differences were assessed by means of subgroup meta-analysis and meta-regression.ResultsFifty-four studies enrolling N = 4421 ECMO patients were included. Of those, 6 series were performed in non-HTx centres (204 pts.;4.6%). Overall 30-day survival (95% Confidence Intervals) was 35.3% (32.5–38.2%) and did not statistically differ between non-HTx: 33.3% (26.8–40.4%) and HTx centres: 35.7% (32.7–38.8%); Pinteraction = 0.531. There was no impact of centre volume on survival as well: ßcoef = 0.0006; P = 0.833. No statistical differences were seen between HTx and non-HTx with respect to ECMO duration, limb complications, reoperations for bleeding, kidney injury and sepsis. There were however significantly less neurological complications in the HTx as compared to non-HTx centres: 11.9% vs 19.5% respectively; P = 0.009; an inverse relationship was seen for neurologic complications in centres performing more ECMOs annually ßcoef = − 0.0066; P = 0.031. Weaning rates and bridging to HTx and/or VADs were higher in HTx facilities.ConclusionsThere was no apparent difference in survival after ECMO implantation for refractory PCS according to centre’s ECMO volume and transplantation status. Potentially different risk profiles of patients in these centres must be taken account for before definite conclusions are drawn.

Comparison of Mortality Rate after In-Hospital Cardiac Arrest in Heart Transplant Recipients versus Non-Transplant Patients

Purpose Limited data exist on mortality rate after in-hospital cardiac arrest in heart transplant recipients. We sought to compare the mortality rate after in-hospital cardiac arrest in heart transplant recipients to the general population Methods National Inpatient Sample NIS database (2005-2014) was used to identify 199,366 hospital stays for adults (≥18 yrs) who had in-hospital cardiac arrest (ICD 9: 99.60 or 99.63). Heart transplant status was defined in 144 hospital stays using ICD 9 (V421). Hospital stays for heart transplant surgery were excluded. The primary outcome was in-hospital mortality rate. Results Heart transplant recipients in comparison to non-transplant patients were noted to be younger & have male gender predominance & a lower prevalence of chronic pulmonary disease, paralysis, renal failure, AFib, dementia & smoking history (p Conclusion Heart transplant recipients have a modestly higher risk-adjusted chance of death after in-hospital cardiac arrest.

In-Hospital Vital Status and Heart Transplants After Intervention for Congenital Heart Disease in the Pediatric Cardiac Care Consortium: Completeness of Ascertainment Using the National Death Index and United Network for Organ Sharing Datasets.

BackgroundThe long‐term outcomes of patients undergoing interventions for congenital heart disease (CHD) remain largely unknown. We linked the Pediatric Cardiac Care Consortium (PCCC) with the National Death Index (NDI) and the United Network for Organ Sharing Dataset (UNOS) registries to study mortality and transplant occurring up to 32 years postintervention. The objective of the current analysis was to determine the sensitivity of this linkage in identifying patients who are known to have died or undergone heart transplant.Methods and ResultsWe used direct identifiers from 59 324 subjects registered in the PCCC between 1982 and 2003 to test for completeness of case ascertainment of subjects with known vital and heart transplant status by linkage with the NDI and UNOS registries. Of the 4612 in‐hospital deaths, 3873 were identified by the NDI as “true” matches for a sensitivity of 84.0% (95% CI, 82.9–85.0). There was no difference in sensitivity across 25 congenital cardiovascular conditions after adjustment for age, sex, race, presence of first name, death year, and residence at death. Of 455 known heart transplants in the PCCC, there were 408 matches in the UNOS registry, for a sensitivity of 89.7% (95% CI, 86.9–92.3). An additional 4851 deaths and 363 transplants that occurred outside the PCCC were identified through 2014.ConclusionsThe linkage of the PCCC with the NDI and UNOS national registries is feasible with a satisfactory sensitivity. This linkage provides a conservative estimate of the long‐term death and heart transplant events in this cohort.

(357) - Heart-Lung Transplantation: A Viable Option for Systemic Sclerosis

Systemic Sclerosis (SSc) is an autoimmune connective tissue disease that can involve the heart and lung. Cardiac abnormality can stem from pulmonary hypertension or primary cardiac disease. While lung transplantation (LTx) has been effective for patients (pts) with pulmonary involvement, it is unknown how outcomes of heart-lung transplantation (HLTx) compare to LTx. The aim of this study is to evaluate HLTx utilizing a US national database. HLTx pts from 2000-2014 reported by the UNOS database were assessed and compared to both LTx pts with SSc and HLTx pts for all other indications (HLTx-OI). The primary outcome was all cause mortality. 1 and 4-year survival was determined using the Kaplan Meier method. Risk factors for survival (adjusted for recipient age/gender, donor age, ischemia time, heart transplant status) were analyzed using multi variable Cox proportional hazard regression. The secondary endpoint was freedom from 1st year rejection. 430 of 21,928 LTx (1.96%) and 8 of 466 HLTx (1.72%) pts had a primary indication of SSc. Demographics (recipient age/gender, donor age, time on the waiting list, CMV mismatch) between the 2 comparison groups were similar. Ischemic time was lower for HLTx-SSc (3.80 hrs) v. LTx-SSc (5.31 hrs) (p = 0.012). Status 1 was more common for HLTx-SSc (1A 25%, 1B 75%) v. HLTx-OI (1A 34%, 1B 20%) (p= 0.011). 1 and 4-year survival was lower but not significantly different between HLTx-SSc v. LTx-SSc as well as compared to HLTx-OI (Table). Freedom from 1-year rejection was not significantly different among the two comparison groups. SSx is a rare indication for HLTx as well as LTx (<2%). Review of national data confirms that, despite being somewhat sicker at the time of transplant as evidenced by a higher rate of Class 1 status, outcomes of HLTx-SSc pts are similar to that for LTx and HLTx-OI with respect to survival and freedom from rejection. HLTx appears to be a viable option for pts with SSc and significant cardiac involvement.

Status on Heart Transplantation in China.

Status on Heart Transplantation in China.

(112) - The Current Status of Heart Transplantation and Mechanical Circulatory Support in Turkey: Facts and Factors

The purpose of this presentation will be to inform the international society about the current donor rates and distributions among regions, the effect of religious factors, the annual rates of heart transplant and device implantation rates, and their regional distribution, the license procedures and general interest of doctors for heart failure both in instutitional basis and overall country of Turkey.

Current Status of Heart Transplantation in Japan

Current Status of Heart Transplantation in Japan

The Status of Heart Transplantation in Taiwan, 2005–2010

Heart transplantation (HT) is the standard therapy used to treat end-stage heart disease. Taiwan Organ Registry and Sharing Center (TORSC) is a registry and database of organ donations and transplantations. To understand the profiles of heart donors and recipients is crucial for efficient utilization. Data was provided by the TORSC and 487 HT were performed from 2005 to 2010. The main causes of donor brain death were head injury (n = 243; 51.1%) and cerebrovascular accidents/strokes (n = 147; 30.9%). The mean age of the recipients was 46.3 ± 14.6 years, and 80.3% were men (n = 391). Physicians and nurses were responsible for most organ procurement. In multivariate analysis, considering donor and recipient gender, donor and recipient age, and donor-to-recipient weight ratio as independent variables, factors that were significantly predictive of graft survival were donor age (hazard rate [HR], 1.02; 95% confidence interval [CI], 1.00–1.03; P = .01) and recipient age (HR, 1.03; 95% CI, 1.01–1.04; P < .01). Our results showed that age is a determinant of allograft survival and healthcare professionals are the primary impetus for obtaining consent for organ donation.

Current Status of Heart Transplantation in Taiwan

PurposeWe reviewed the national results of heart transplantation in Taiwan. MethodsFrom July 1987 to December 2012, 1354 patients underwent heart transplantation in 18 qualified heart centers in Taiwan. The transplantation volume and survival rate were reviewed. ResultsThe median age of recipients was 49 years at surgery, with 37% in the International Society for Heart and Lung Transplantation (ISHLT)-1A, 30% in ISHLT-1B, and 32% in ISHLT-2. The allograft 1-, 3-, 5-, and 10-year survival rates were 78%, 68%, 61%, and 47%, respectively. Mostly difficult recipients were bridged by extracorporeal membrane oxygenation (ECMO) instead of ventricular assist device (VAD). ConclusionThe results of heart transplantation in Taiwan are comparable with ISHLT world results. In Taiwan, we use more ECMO than VAD for mechanical circulatory support to bridge critical recipients to heart transplantation.

(720) - Current Status of Heart Transplantation in the Kingdom of Saudi Arabia

(720) - Current Status of Heart Transplantation in the Kingdom of Saudi Arabia

Current Status of Heart Transplantation and Left Ventricular Assist Device: Major Changes in the Last Decade

Heart transplantation is the last treatment option in refractory end stage heart failure, which can prolong survival. The number of heart transplantations has increased and the survival rate has improved during the last few decades which was contributed by advanced understanding of immunologic mechanism of rejection, pharmaceutical development and clinical management of donors and recipients. However, only a fraction of patients can be offered to transplantation due to shortage of donor heart and many patients suffer high mortality while waiting. Meanwhile, technical advancement of mechanical assist device in recent years enabled long term implantable left ventricular assist devices (LVAD) to bridge the patients with high mortality in the waiting list to transplantation and to assist as a long term destination therapy for patients who are not eligible for transplantation. Development of solid phase assay increased the sensitivity and the specificity of detection of anti-human leukocyte antigen (HLA) antibodies in the recipient. It enabled identifying unacceptable HLA antigens, acquire calculated Panel Reactive Antibodies and perform virtual cross match that can enhance the efficacy of donor allocation system to decrease the waiting time, obviate prospective cross match to decrease ischemic time and to assess the risk of rejection in presensitized patients. Antibody mediated rejection is a challenging entity in diagnosis and management. However, standardized classification of histology and immunology of endomyocardial biopsies was made recently and immunotherapy is moving toward targeted therapies directed at antibody production and function. This review focuses on those major changes in the heart transplantation field in the last decade.

Current status of heart transplantation in Turkey

Heart failure is a clinical picture that occurs when the heart is unable to provide sufficient blood to the tissues and organs due to low performance. In end-stage heart failure, quality of life and survival rates are affected adversely. Heart transplantation is still the best method of treatment in many end-stage heart failure patients who remain symptomatic despite guideline-directed medical therapy. The current situation of heart transplantation in Turkey is discussed in this review.

Currenst Status of Heart Transplantation after Revision of the Japanese Organ Transplant Act

Currenst Status of Heart Transplantation after Revision of the Japanese Organ Transplant Act