International Society For Heart And Lung Transplantation Registry Research Articles

Informing preconception counseling: Outcomes among female heart transplant recipients in the ISHLT registry

The numbers of women of child-bearing age undergoing heart transplantation (HT) and female pediatric HT recipients surviving to child-bearing age have increased, along with improvements in post-transplant survival. Data regarding life expectancy and comorbidities in reproductive-aged female HT recipients are needed to inform shared decision-making at the time of preconception counseling. The International Society for Heart and Lung Transplantation (ISHLT) Thoracic Organ Transplant Registry was investigated for HT recipients between January 1, 2000 and June 30, 2017. Women of childbearing age were defined as those aged 15-45 years, either at transplant, or at the respective post-transplant follow-up. Characteristics and outcomes of female recipients of childbearing age at transplant, 5-, 10-, and 15-year follow-up were compared to females>45 years of age, males 15-45 years and males>45 years of age at the corresponding time intervals. Outcomes included survival, development of diabetes (DM), severe renal dysfunction (CKD), and cardiac allograft vasculopathy (CAV). During the study period, 71,585 HT recipients were included: 24% (n=17,194) were female and 9.2% (n=6602) were of childbearing age at HT. A pre-transplant diagnosis of peripartum cardiomyopathy was associated with significantly worse post-transplant survival, a finding that remained independent of panel reactive antibody levels. The presence of pre-transplant DM and/or severe CKD was significantly associated with lower survival as were the presence of CAV, DM, and CKD post-HT. Knowledge of the impact of pre-existing comorbidities and complications post-HT on survival are important for risk stratification for preconception counseling post-HT.

Impact of co-morbidities on survival after heart transplant in females of childbearing age: analysis of the International Society for Heart and Lung Transplantation (ISHLT) Registry

Abstract Background Data on life expectancy specific to female heart transplant (HT) recipients of reproductive age are lacking, but are needed to inform shared decision making at the time of pre-conception counseling. We analyzed the ISHLT registry for post-transplant survival and studied the impact of co-morbidities in women of childbearing age. Methods Female HT recipients reported to the ISHLT registry who were aged 15–45 yrs at time of HT were included in this retrospective analysis. Primary outcome was post-transplant survival. Secondary outcomes included the impact of co-morbidities on conditional survival at 5, 10 and 15 years. Results Of 121,501 HT recipients (Jan 1992–June 2018), 30,179 (24.8%) were women. 9,229 (7.6%) were 15–45 yrs at time of HT. Overall median post-transplant survival was 15.2 yrs. Diabetes mellitus (DM) and/or severe chronic kidney disease (CKD) at HT adversely impacted long-term survival (Figure 1). Co-morbidities including cardiac allograft vasculopathy (CAV), DM and CKD negatively impacted 5yr and 10yr conditional survival, individually as well as a combination (Figure 2). 15yr conditional survival confirmed the negative impact of DM and CKD, while CAV did not reach statistical significance. Conclusion Female HT recipients of childbearing age have favorable survival post-HT. Conditional survival at 5 and 10 yrs is negatively impacted by CAV, DM and CKD. The quantification of survival outcomes after heart transplant in women of childbearing age may improve counseling as part of pre-conception informed decision making. Funding Acknowledgement Type of funding sources: None.

Impact of primary diagnosis on survival after heart transplant in female recipients of childbearing age: an analysis of the International Society for Heart and Lung Transplantation (ISHLT) Registry

Abstract Background Women undergoing heart transplantation (HT) for peripartum cardiomyopathy (PPCM) have been reported to have inferior post-transplant survival. Specific data on the impact of pre-transplant diagnosis on survival in female HT recipients of childbearing age are lacking, but important for pre-conception counseling of women considering a pregnancy. Methods Retrospective data analysis was conducted using the ISHLT Registry. The primary aim was to study the impact of pre-transplant diagnosis and alloimmunisation on post-transplant survival in women aged 15–45 yrs at time of HT. Secondary outcomes included the impact of primary diagnosis on conditional survival at 5, 10 and 15-yrs post HT. Results Of 121,501 HT recipients (Jan 1992–June 2018), 30,179 (24.8%) were women. 9,229 (7.6%) were 15–45 yrs at time of HT. Peripartum cardiomyopathy (PPCM) and congenital heart diseases (CHD) was the primary diagnosis in 8.9% and 9.3%, respectively. Overall median post-transplant survival was 15.2 yrs. Female with PPCM were associated with higher alloimmunisation (Figure 1). PPCM was associated with lower survival (median survival in PPCM vs CHD vs other: 9.1 years vs 15.2 years vs 15.5 years respectively, p<0.05). This was not entirely explained by higher alloimmunisation in this group (Figure 2A). Five-year conditional survival of recipients of childbearing age was significantly affected by primary diagnosis of PPCM, and by pediatric status at HT, defined as age <18-yrs (PPCM vs other diagnosis p<0.05; pediatric vs non-pediatric p 0.003), whilst 10- and 15-year conditional survival was not. The difference in 5-year conditional outcome between PPCM and other diagnosis, was not significant however when female recipients were grouped according to their level of alloimmunisation (Figure 2B). Conclusion PPCM as the primary indication for HT is associated with a worse post HT survival. Our data suggest that this is not entirely explained by alloimmunisation. The impact of previous PPCM appears to be greatest in the first 5 yrs post HT. Further research is needed to fully elucidate the mechanisms associated with worse survival in this group and help inform pre-conception counseling in those HT recipients considering a subsequent pregnancy. Funding Acknowledgement Type of funding sources: None.

Epidemiology, risk factors, and outcomes of lung retransplantation: An analysis of the International Society for Heart and Lung Transplantation Thoracic Transplant Registry.

Lung retransplantation is a complex surgical decision that represents the only potential treatment option for recipients suffering from lung allograft failure. We sought to describe the modern landscape of lung retransplantation and to compare the relative importance of selected clinical, donor, and recipient factors on mortality in the year following lung retransplantation. We conducted a retrospective cohort study of first-time adult recipients of deceased donor lung retransplants reported to the International Society for Heart and Lung Transplantation (ISHLT) Thoracic Transplant Registry from May 2005 through June 2017. In addition to describing the characteristics of lung retransplant recipients, we examined 1 year survival overall, and by initial transplant-retransplant procedure type, recipient age, retransplant indication, and time-to-lung retransplantation (i.e., inter-transplant interval). We used the Somers' Dxy rank correlation statistic for censored data to assess the relative importance of several potential prognostic risk factors for mortality in the year following lung retransplantation. Our cohort included 1,597 lung retransplant recipients. 2005 was the first year with more than 100 retransplants, and since 2007, 138 to 188 retransplants (approximately 4%-6% of all transplants) were reported annually to the ISHLT Registry. The median inter-transplant interval was 3.4 years (interquartile range: 1.6-6.2 years). Forty-three percent of the cohort had an obliterative bronchiolitis retransplant indication, whereas 17% had primary graft failure. One-third (32%) were retransplanted within 2 years of their primary transplant, and 64% received a double lung transplant both times, whereas 36% received consecutive single lung transplants. Six-month and 1 year survival (82% and 76%) were higher for double-double lung retransplant recipients than for single-single recipients (76% and 69%). The 3 strongest prognostic factors for 1 year mortality were the inter-transplant interval (decreasing hazard with longer intervals), donor age (increasing hazard with older age), and need for mechanical ventilation preceding lung retransplantation. Retransplants comprise approximately 5% of annual lung transplants worldwide. The factor most strongly associated with 1 year mortality in this population was the duration of time since the primary lung transplant, with a persistent reduction in risk as more time elapses.

Induction Therapy after Heart Transplantation

The use of induction therapy for orthotopic heart transplant (OHT) recipients is inconsistent between centers and there are limited data that explore the association with post-transplant outcomes. We used the International Society for Heart and Lung Transplantation (ISHLT) Thoracic Transplant Registry to investigate induction therapy use after OHT and its relationship to 1-year survival. This is a retrospective cohort study from the global ISHLT Registry of adult patients who received a first OHT between 1/2005 and 6/2017. We excluded multi-organ transplant recipients, and those with missing induction data or no post-transplant follow up. We describe recipient and donor characteristics, stratified by induction therapy use. We used Kaplan-Meier methods to estimate 1-year mortality for induction therapy use and non-use, with comparison by the log-rank test. Of 27,400 OHT recipients included in this analysis, 13,711 (50%) received induction therapy at the time of transplant. The use of induction therapy remained stable over the study period. Both groups had median age of 55 years and had nonischemic cardiomyopathy as the most frequent diagnosis. There was a higher rate of females in the induction group (25.5% vs 24.2%). Recipients who received induction therapy had higher rates of pre-transplant dialysis (2.5% vs 2.1%) and ventilator use (2.6% vs 1.1%) but not ventricular assist device use (35.5% vs 39.9%). Atgam/thymoglobulin and basiliximab were the most frequently used therapies (N=5139 [37.5%] and N=7691 [56.1%], respectively). There was no significant difference in 1-year unadjusted survival between those who received induction therapy and those who did not. (Figure) CONCLUSION: In a large international cohort, approximately half of OHT recipients received induction therapy after heart transplantation, with similar one-year survival compared to those who did not receive induction therapy. Further study is warranted to determine which recipients warrant consideration for induction therapy and the optimal agent.

Donation after circulatory death in lung transplantation—five-year follow-up from ISHLT Registry

This study aimed to examine intermediate-term outcomes of lung transplantation (LTx) recipients from donors after circulatory death (DCD). We examined the International Society for Heart and Lung Transplantation (ISHLT) Thoracic Transplant Registry data for patients transplanted between January 2003 and June 2017 at 22 centers in North America, Europe, and Australia participating in the DCD Registry. The distribution of continuous variables was summarized as median and interquartile range (IQR) values. Wilcoxon rank sum test was used to compare distribution of continuous variables and chi-square or Fisher's exact test for categorical variables. Kaplan-Meier survival rates after LTx from January 2003 to June 2016 were compared between DCD-III (Maastricht category III withdrawal of life-sustaining therapy [WLST]) only and donors after brain death (DBD) using the log-rank test. Risk factors for 5-year mortality were investigated using Cox multivariate proportional-hazards model. The study cohort included 11,516 lung transplants, of which 1,090 (9.5%) were DCD lung transplants with complete data. DCD-III comprised 94.1% of the DCD cohort. Among the participating centers, the proportion of DCD-LTx performed each year increased from 0.6% in 2003 to 13.5% in 2016. DCD donor management included extubation in 91%, intravenous heparin in 53% and pre-transplant normothermic ex vivo donor lung perfusion in 15%. The median time interval from WLST to cardiac arrest was 15 minutes (IQR: 11-22 minutes) and to cold flush 32 minutes (IQR: 26-41minutes). Compared with DBD, donor age was higher in DCD-III donors (46 years [IQR: 34-55] vs 40 years [IQR: 24-52]), bilateral LTx was performed more often (88.3% vs 76.6%), and more recipients had chronic obstructive pulmonary disease and emphysema as their transplant indication. Five-year survival rates were comparable (63% vs 61%, p = 0.72). In multivariable analysis, recipient and donor ages, indication diagnosis, procedure type (single vs bilateral and double LTx), and transplant era (2003-2009 vs 2010-2016) were independently associated with survival (p < 0.001), but donor type was not (DCD-III vs DBD; hazard ratio, 1.04 [0.90-1.19], p = 0.61). This ISHLT DCD Registry report with 5-year follow-up demonstrated similar favorable long-term survival in DCD-III and DBD lung donor recipients at 22 experienced centers globally. These data indicate that more extensive use of DCD-LTx would increase donor organ availability and may reduce waiting list mortality.

A Recipient Risk Prediction Tool for Short-term Mortality After Pediatric Heart Transplantation.

The first year after heart transplantation (HT) has the highest risk of mortality. We aim to derive and validate a recipient risk prediction tool for early mortality after pediatric HT. The International Society for Heart and Lung Transplantation (ISHLT) registry was used to identify patients (≤18 y) who underwent primary HT during January 2000-December 2014. Independent predictors of 1-year mortality were identified based on recipient characteristics at HT. Risk scores were assigned based on the magnitude of relative odds of 1-year mortality. The predictive capability of the ISHLT registry derived recipient risk score was externally validated using the Scientific Registry of Transplant Recipients registry data from 2015 to 2017 to ensure a cohort of patients completely exclusive from the derivation cohort. A total of 5045 eligible patients were included in the analysis. The 20-point risk scoring system incorporated 8 recipient variables, including age at HT, diagnosis, pre-HT ventilator use, extracorporeal membrane oxygenation, inhaled nitric oxide use, infection, estimated glomerular filtration rate, and serum bilirubin. Compared with low-risk score group, high-risk group had 7-fold increased risk of 1-year mortality (hazard ratio 7.4; 95% CI [5.2-9.1]; P < 0.001). The C-statistics (0.77) and Hosmer-Lemeshow goodness of fit (0.9) for recipient risk score using derivation cohort from ISHLT registry performed well and was similar to the internal and external validation cohort (C-statistics 0.75, 0.78 and Hosmer-Lemeshow goodness of fit P = 0.4, 0.3, respectively). This study derived and externally validated a simple risk predictive model based on recipient characteristics at HT that has good prediction characteristics for 1-year post-HT mortality. This model may help clinicians identify candidates who are at a higher risk for post-HT mortality and may optimize organ sharing.

Post-Transplant Outcomes in Pediatric Patients Receiving Mechanical Circulatory Support: A Multicenter Study from the International Society for Heart and Lung Transplantation (ISHLT) Registry

Purpose While extracorporeal membrane oxygenation (ECMO) was previously the most common type of mechanical circulatory support (MCS) as a bridge to transplant in pediatric heart transplant recipients, the use of ventricular assist devices (VADs) has grown dramatically. The difference in risk profile between VADs and ECMO in patients bridged to transplant is documented, yet there are limited data on the effect of type of MCS on post-transplant outcome. We compare outcomes in pediatric patients bridged to transplant with MCS from an international cohort. Methods The 1998-2017 ISHLT registry data was used to identify patients Results 7050 patients were included with 28.4% Conclusion Patients on ECMO prior to transplant are younger, with more complex anatomy than those supported with VADs. Adjusting for pre-transplant characteristics, ECMO has an increased risk of death compared with VAD, suggesting investigation into VAD support for younger patients and those with CHD may have important clinical implications.

Epidemiology of infection in mechanical circulatory support: A global analysis from the ISHLT Mechanically Assisted Circulatory Support Registry.

Despite advances in device technology and treatment strategies, infection remains a major cause of adverse events (AEs) in mechanical circulatory support (MCS) patients. To characterize the epidemiology of MCS infection, we examined the type, location, and timing of infection in the International Society for Heart and Lung Transplantation Registry (ISHLT) for Mechanically Assisted Circulatory Support (IMACS) over 3 years, 2013 to 2015. Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) definitions were used to categorize AE infections occurring in MCS patients within IMACS. The IMACS infection variables were mapped to ISHLT definitions for infection where feasible. Three categories of MCS infection were defined as ventricular assist device (VAD) specific, VAD related, and non-VAD. There were 10,171 patients enrolled from January 2013 through December 2015. Infection was the most common AE, with 3,788 patients (37%) experiencing ≥ 1 infection, and 6,758 AE infections reported overall. Non-VAD infection was the largest category, 4,501: 34.0% pneumonias, 30.6% non-VAD-related bloodstream infections (BSIs), 24.15% urinary tract infections (UTIs), and 10.2% gastrointestinal infections. VAD-specific infection was the second largest category, 1,756: 82.9% driveline, 12.8% pocket, and 4.3% pump/or cannula infections. VAD-related infection was the smallest category, 501: 47.5% BSIs, 47.5% mediastinitis, and 5.0% mediastinitis/pocket infections. All 3 categories were more frequently reported ≤ 3 months after implant. Non-VAD infection, including pneumonia, BSI, UTI, and gastrointestinal infection, was the leading category of infection in MCS patients and the most frequently reported ≤ 3 months after implant. These results provide evidence to support resourcing and strengthening infection prevention strategy early after implantation in MCS.

Cardiac transplantation across preformed HLA-antibody barriers

Cardiac transplantation across preformed HLA-antibody barriers

Donor–recipient size matching and mortality in heart transplantation: Influence of body mass index and gender

The International Society for Heart and Lung Transplantation (ISHLT) guidelines advise against inappropriate weight match (IWM) for heart transplant, defined as donor weight <70% of recipient's weight. Few studies have explored in detail this size-matching recommendation, especially with regard to body mass index (BMI) and gender matching. We aimed to determine whether any difference could be observed between size-matching in obese and non-obese recipients with regard to mortality after cardiac transplantation. Data from 52,455 adult heart transplants (recipients ≥18 years of age) between 1994 and 2013 were obtained from the ISHLT Registry. We defined the following subgroups of patients based on BMI: underweight, BMI <18.5; non-obese, BMI 18.5 to 30; and obese, BMI >30. The end-points were all-cause 30-day mortality and cumulative mortality. IWM was associated with increased 30-day mortality (odds ratio [OR] = 1.20, 95% confidence interval [CI] 1.01 to 1.43, p = 0.041) and cumulative mortality (hazard ratio [HR] = 1.14, 95% CI 1.07 to 1.22, p < 0.001). In non-obese recipients, IWM was associated with increased 30-day mortality (OR = 1.89, 95% CI 1.48 to 2.41, p < 0.001) as well as cumulative mortality (HR = 1.27, 95% CI 1.15 to 1.41, p < 0.001), whereas, for obese recipients, IWM was not associated with 30-day or cumulative mortality. Male recipients of female allografts (HR = 1.08, 95% CI 1.04 to 1.12, p < 0.001) as well as female recipients of male allografts (HR = 1.07, 95% CI 1.02 to 1.13, p = 0.003) had increased cumulative mortality compared with gender-matched transplants. There was no interaction between IWM and gender mismatch. Our results indicate that donor weight <70% of recipient weight increases mortality in non-obese heart transplant recipients, but not in obese transplant recipients. Gender mismatch increases mortality independently of weight match.

The Registry of the International Society for Heart and Lung Transplantation: Nineteenth Pediatric Heart Transplantation Report—2016; Focus Theme: Primary Diagnostic Indications for Transplant

The Registry of the International Society for Heart and Lung Transplantation: Nineteenth Pediatric Heart Transplantation Report—2016; Focus Theme: Primary Diagnostic Indications for Transplant

Age-related survival disparity associated with lung transplantation in cystic fibrosis: An analysis of the registry of the International Society for Heart and Lung Transplantation

A survival advantage has been demonstrated for lung transplantation (LTx) in the cystic fibrosis (CF) population, but children may be at higher risk of post-transplant mortality than adults. The registry of the International Society for Heart and Lung Transplantation (ISHLT) was queried for lung transplants performed during the period 1998 to 2014 in patients with CF. Period differences were assessed by dividing the sample into LTxs performed between 2006 and 2014 and those performed between 1998 and 2005. Age ≥18 years distinguished adult from pediatric recipients. Supplemental analyses of United States of America (USA) LTx recipients with CF utilized 1998 to 2014 data from the United Network for Organ Sharing (UNOS) registry. A total of 7,245 patients from the ISHLT registry were selected for analysis. Kaplan-Meier curves confirmed a survival disadvantage of children as compared to adults with CF in 2006 to 2014 (p<0.001), and in the earlier era of 1998 to 2005 (p = 0.002). Univariate Cox proportional hazards regression revealed that age <18 years at transplantation [hazard ratio (HR) = 1.367; 95% confidence interval (CI) 1.225 to 1.526; p < 0.001] and LTxs performed in 1998 to 2005 (HR = 1.131; 95% CI 1.042 to 1.227; p = 0.003) were associated with greater mortality hazard. Multivariable Cox regression adjusting for potential confounders and interacting LTx era with recipient age group confirmed the persistence of age-related survival disparities after LTx in CF in the contemporary era. Analysis of UNOS data demonstrated survival disparities between children and adult CF patients receiving LTx in majority-adult programs. An age-related survival disparity after LTx has persisted in the international CF population. Data from the USA suggest this disparity is not fully explained by differences in center volume between adult and pediatric programs in the contemporary era.

Outcome, incidence and risk factors for stroke after pediatric heart transplantation: An analysis of the International Society for Heart and Lung Transplantation Registry

In the registry of the International Society for Heart and Lung Transplantation (ISHLT), cerebrovascular accidents are the fifth most common cause for mortality after pediatric heart transplantation (PHTx), but details are lacking in the literature. The purpose of this analysis of the ISHLT registry was to determine the prevalence, risk factors and outcomes of stroke after PHTx. Data from the ISHLT registry (1998 to 2010) were used to identify all patients whose primary transplantation was performed at <18 years of age. Of the 10,441 transplants reviewed, 9,837 primary transplants and 604 retransplants were analyzed. Three hundred thirty-three (3%) patients had a stroke after PHTx; 54% were male, median age at PHTx was 6 years (0 to 17 years), and 44% had a diagnosis of congenital heart disease (CHD). Freedom from stroke was 99% at 1 month, 97% at 5 years, 95% at 10 years and 91% at 20 years post-PHTx. After a stroke, survival at 1 month, 1 year and 5 years was 83%, 69% and 55%, respectively. Multivariable independent risk factors for stroke included a primary diagnosis of congenital heart disease [hazard ratio (HR) 1.4 (1.1 to 1.7), p = 0.01], previous stroke [HR 4.5 (3.2 to 6.2), p < 0.001], history of aborted sudden death [HR 1.5 (1.1 to 2), p = 0.01], ventricular assist device [HR 1.5 (1.1 to 2.2), p = 0.03] or extracorporeal membrane oxygenation [HR 1.7 (1.2 to 2.2), p = 0.01], post-operative dialysis [HR 3.3 (2.3 to 4.7), p < 0.001], infection requiring antibiotics before discharge [HR 1.9 (1.4 to 2.5), p < 0.001], pacemaker implantation [HR 1.6 (1 to 2.5), p = 0.04] or drug-treated hypertension [HR 1.4 (1.1 to 1.8), p = 0.003] during follow-up. Stroke after pediatric heart transplantation is associated with increased mortality. Congenital heart disease and mechanical support both portend greater risk, in addition to markers of increased pre- and post-transplant medical acuity.

The Registry of the International Society for Heart and Lung Transplantation: Eighteenth Official Pediatric Heart Transplantation Report—2015; Focus Theme: Early Graft Failure

The Registry of the International Society for Heart and Lung Transplantation: Eighteenth Official Pediatric Heart Transplantation Report—2015; Focus Theme: Early Graft Failure

Heart Transplantation

Heart failure is a major public health problem with significant associated morbidity and mortality. Heart transplantation remains the standard of care for highly selected patients with end-stage heart failure and absence of contraindications to transplantation. This chapter discusses indications and contraindications for transplantation; recipient evaluation, selection, and management; donor selection; timing of the procedure and surgical technique; medical management, including immunosuppression, prevention and treatment of infections, and other standard or preventive therapy; late complications; and functional status and long-term survival. Tables describe patient referral to a specialized center for heart transplantations; guidelines of indications for cardiac transplantation; organ dysfunction; pretransplantation evaluation; waiting lists; therapeutic options for patients with advanced or refractory heart failure; treating highly sensitized patients; suggested vaccinations; guidelines for donor hearts with severe infection; high-risk donor behavior; hemodynamic effect of commonly used parenteral agents; frequency of follow-up evaluations; revised International Society for Heart and Lung Transplantation (ISHLT) formulation for diagnosis of cardiac allograft rejection and suggested treatment; function of immunosuppressive agents; administration, dosing, monitoring, and adverse effects of commonly used immunosuppressants; common agents that interfere with tacrolimus and cyclosporine; cytomegalovirus prophylaxis and valganciclovir based on estimated renal function; cumulative morbidity rates in adult heart transplant survivors; and therapies to prevent and treat osteoporosis posttransplantation. Figures depict the progression of heart failure; change in functional status over time in patients with chronic heart failure; US heart transplantations in 2012; percentage of US adult wait-listed patients who received a donor heart transplant within a year and donation rates by state; bicaval surgical technique; endomyocardial biopsies; timeline of infection following solid-organ transplantation; cardiac allograft vasculopathy; and squamous cell carcinomas in a heart transplant patient. Graphs show adult worldwide heart transplantation volume from 1982 to 2010; changing characteristics of US adult heart transplant recipients; relative risk of death and development of cardiac allograft vasculopathy; posttransplantation immunosuppression at 1 and 5 years in the ISHLT Registry; older donor age and risk of developing cardiac allograft vasculopathy; freedom from malignancy in the ISHLT Registry; employment status of adult heart transplant recipients; adult heart transplant survival; and patient survival among US heart transplant recipients by gender and race. This review contains 18 highly rendered figures, 20 tables, and 109 references.

Barriers to Optimal Palliative Care of Lung Transplant Candidates

The provision of effective palliative care is of great importance to patients awaiting lung transplantation. Although the prospect of lung transplantation provides hope to patients and their families, these patients are usually very symptomatic from their underlying disease. An e-mail questionnaire was sent to members of the American College of Chest Physicians' Transplant NetWork and the Pulmonary Council of the International Society for Heart and Lung Transplantation (ISHLT). The survey included questions about barriers to providing palliative care, the availability of palliative care services, and recommended strategies to improve palliative care for lung transplant candidates. The 158 respondents represented approximately 65% of transplant programs in the ISHLT registry. Respondents were in practice a mean of 11.3 (± 9) years, 70% were pulmonologists, 17% were surgeons, and 13% were other care providers. Barriers were classified into domains including patient factors, family factors, physician factors, and institutional/transplant program/lung allocation system factors. Significant patient/family barriers included unrealistic patient/family expectations about survival, unwillingness to plan end-of-life care, concerns about abandonment or inappropriate care after enrollment in a palliative care program, and family disagreements about care goals. For institutional/program/allocation system barriers, only the requirement for weight loss or gain to meet program-specific BMI requirements was identified. Significant physician barriers included competing time demands and the seemingly contradictory goals of transplant vs palliative care. Strategies recommended to improve palliative care included routine advance care planning for patients awaiting transplantation, access to palliative care specialists, training of transplant physicians in symptom management, and regular meetings among transplant physicians, nurses, patients, and families. Physicians providing care to lung transplant candidates reported considerable barriers to the delivery and acceptance of palliative care and identified specific strategies to improve palliative care for lung transplant candidates.

First-Year Clinical Outcomes in Gender-Mismatched Heart Transplant Recipients

Research indicates that gender mismatch of organ donor and recipient may adversely affect outcomes in heart transplant (HT) patients. However, there is a paucity of literature on gender-mismatched outcomes in patients receiving an HT, and only a few outcomes have been investigated. Objectives were to (1) determine if gender-mismatched HT recipients experienced decreased survival, more posttransplantation complications, and more days of hospitalization during the first postoperative year as compared with gender-matched recipients and (2) identify risk factors for decreased survival. Patients were 347 HT recipients; 21.3% (74) received a heart from the opposite gender. Three groups were compared: group 1: same gender donor-recipient (273 [78.7%]: 36 women, 237 men); group 2: female donor-male recipient (40 [11.5%]); group 3: male donor-female recipient (34 [9.8%]). Ten outcomes were compared with Kaplan-Meier survival analysis, logistic regression, and multivariate analysis of covariance, using a Bonferroni-adjusted P ≤ .005. Risk factors for decreased survival were examined with Cox regression. Gender-mismatched HT patients with a male donor and a female recipient (group 3) had more treated acute rejections and were rehospitalized for more days after HT discharge during the first postoperative year as compared with gender-matched patients. No significant differences were found in 8 other first-year outcomes: number of deaths, survival time, hospital length of stay for HT surgery, cardiac allograft vasculopathy, severe renal dysfunction, new-onset steroid-induced diabetes, nonskin cancers, or the number of infections treated with an intravenous antibiotic. Risk factors for decreased year 1 survival were higher year 1 cholesterol, earlier intravenous-treated infection, severe renal dysfunction, earlier treated rejection, and diabetes (both preexisting and new-onset steroid-induced diabetes). Gender-mismatched HT recipients had more complications due to rejection and higher resource utilization due to more rehospitalization during the first postoperative year as compared with gender-matched recipients. Therefore, these problem areas may provide targets for possible interventions.

The Registry of the International Society for Heart and Lung Transplantation: Fifteenth Pediatric Lung and Heart-Lung Transplantation Report—2012

This section of the International Society for Heart and Lung Transplantation (ISHLT) Registry Report covers the pediatric lung and heart-lung transplantation experience from January 1986 through June 2011. During this time, 1,770 pediatric lung transplant and 660 pediatric heart-lung transplant procedures were reported to the Registry. In 2010, the last complete year included in this 15th official Pediatric Lung and Heart-Lung Transplantation Report, 126 pediatric lung transplant procedures were reported, compared with 97 procedures in 2005. The figures, however, contain only the pediatric lung transplant procedures that were reported to the ISHLT Registry and, thus, may not reflect numbers of pediatric lung procedures undertaken worldwide. This year’s Registry report incorporates a summary of data analyses performed by the Registry this year that is supplemented by further analyses and additional figures that are available on the ISHLT Registry’s Web site (www.ishlt.org/registries). The 2012 Registry Report does not include detailed analyses and figures of pediatric lung retransplantation because those data were presented in last year’s report and the annually performed number of pediatric lung retransplant procedures is low. Data on pediatric heart-lung transplantation are presented in this year’s ISHLT Registry Report as these data were not displayed in the 2011 Registry Report.

The Registry of the International Society for Heart and Lung Transplantation: Fifteenth Pediatric Heart Transplantation Report—2012

The Registry of the International Society for Heart and Lung Transplantation: Fifteenth Pediatric Heart Transplantation Report—2012