Isolated Heart Transplantation Research Articles

Severely Reduced Kidney Function Assessed by a Single eGFR Determination at the Time of an Isolated Heart Transplant Does Not Predict Inevitable Posttransplant ESKD.

Consensus guidelines advise simultaneous heart kidney transplantation (SHK) in heart candidates with an estimated glomerular filtration rate (eGFR) of <30 mL/min/1.73 m 2 . We hypothesize that a significant fraction of such patients would not need an SHK, even though a graded increase in mortality and end-stage kidney disease (ESKD) would be seen with decrements in eGFR. United Network of Organ Sharing data for isolated heart transplants between 2000 and 2020 were divided into two groups based on eGFR at transplant (≤20 mL/min/1.73 m 2 and 21-29 mL/min/1.73 m 2 ). The primary outcome was mortality and secondary outcome was ESKD posttransplant. Cox regression and cumulative incidence competing risk methods were used to compare risk of mortality and ESKD. There was no difference in mortality (adjusted hazard ratio [aHR] 0.82 [95% confidence interval, CI: 0.60-1.11, P = 0.21]) or ESKD (aHR 1.01 [95% CI: 0.49-2.09, P = 0.96]) between the two groups (≤20 versus 21-29). The overall incidence of ESKD for the entire cohort at 1, 5, and 10 y were 1.5%, 9.5%, and 20%. Although risk of ESKD is highest in heart candidates with an eGFR <30 mL/min/1.73 m 2 , <10% of patients reach ESKD within 5 y' and most will recover significant renal function posttransplant. More refined selection criteria are required to identify candidates for SHK.

Pre-operative Machine Learning for Heart Transplant Patients Bridged with Temporary Mechanical Circulatory Support

Background: Existing prediction models for post-transplant mortality in patients bridged to heart transplantation with temporary mechanical circulatory support (tMCS) perform poorly. A more reliable model would allow clinicians to provide better pre-operative risk assessment and develop more targeted therapies for high-risk patients. Methods: We identified adult patients in the United Network for Organ Sharing database undergoing isolated heart transplantation between 01/2009 and 12/2017 who were supported with tMCS at the time of transplant. We constructed a machine learning model using extreme gradient boosting (XGBoost) with a 70:30 train:test split to predict 1-year post-operative mortality. All pre-transplant variables available in the UNOS database were included to train the model. Shapley Additive Explanations was used to identify and interpret the most important features for XGBoost predictions. Results: A total of 1584 patients were included, with a median age of 56 (interquartile range: 46–62) and 74% male. Actual 1-year mortality was 12.1%. Out of 498 available variables, 43 were selected for the final model. The area under the receiver operator characteristics curve (AUC) for the XGBoost model was 0.71 (95% CI: 0.62–0.78). The most important variables predictive of 1-year mortality included recipient functional status, age, pulmonary capillary wedge pressure (PCWP), cardiac output, ECMO usage, and serum creatinine. Conclusions: An interpretable machine learning model trained on a large clinical database demonstrated good performance in predicting 1-year mortality for patients bridged to heart transplantation with tMCS. Machine learning may be used to enhance clinician judgement in the care of markedly high-risk transplant recipients.

Racial Disparities in Coronavirus Disease 2019 Mortality Are Present in Heart Transplant Recipients

BackgroundStudies have demonstrated the devastating effects of coronavirus disease 2019 (COVID-19) on vulnerable populations. Although they receive close follow-up, heart transplant recipients represent a particularly vulnerable population, given long-term immunosuppression and comorbid conditions. We sought to investigate the association between race/ethnicity and the probability of death due to COVID-19 in adult heart transplant recipients in the United States. MethodsAdult isolated heart transplant recipients were identified using the Organ Procurement and Transplantation Network database. Recipients who were described as deceased or lost to follow-up before January 2020 were excluded. Recipients were stratified into 4 cohorts by race/ethnicity. The primary outcome of interest was death due to COVID-19. ResultsA total of 22 157 adult recipients were identified. During the course of follow-up, 153 recipients had COVID-19 reported as the primary cause of death. COVID-19 mortality was significantly different between race/ethnicity cohorts (Black, n = 34 [0.79%]; Hispanic, n = 23 [1.33%]; White, n = 92 [0.60%]; other, n = 4 [0.44%]; P = .007). COVID-19 was listed as a contributing cause of mortality in 0.12% of Black, 0.23% of Hispanic, 0.04% of White, and 0.33% of other recipients (P = .002). No significant difference in non-COVID mortality or all-cause mortality was observed. After multivariable adjustment, Black (hazard ratio, 2.78 [1.40-5.52]; P = .003) and Hispanic (hazard ratio, 3.92 [1.88-8.16]; P < .001) recipients were at higher risk of death due to COVID-19 compared with White recipients. ConclusionsCompared with White recipients, Black and Hispanic recipients experienced higher rates of COVID-19 mortality after transplantation. These findings suggest that racial/ethnic disparities of COVID-19 mortality in the general population persist in adult heart transplant recipients.

Improvement in hepatic and renal function following isolated heart transplant in adults with congenital heart disease

BackgroundThere are limited data about postoperative changes in hepatic and renal function in adults with congenital heart disease (CHD) undergoing isolated heart transplant. The purpose of this study was to assess postoperative changes in hepatic and renal function in this population. MethodsRetrospective cohort study of adults with CHD undergoing isolated heart transplant at Mayo Clinic (2003–2019). Global hepatic function was assessed using the model for end-stage liver disease excluding international normalized ratio [MELD-XI]) score; hepatic fibrosis was assessed using the fibrosis-4 (FIB-4) score and aspartate/platelet ratio index (APRI); and renal function was assessed using estimated glomerular filtration rate (GFR). All indices were measured preoperatively and postoperatively (at 6 months, 1 year, 2 years). ResultsOf 40 patients (age 41 ± 8 years) in the study, 35 had complete preoperative and postoperative data. There was a temporal improvement in hepatic and renal indices from preop (MELD-XI 14 ± 5, APRI 0.60 ± 0.23, FIB-4 1.44 ± 0.38, GFR 59 [44–83]) to 6 months postop (MELD-XI 12 ± 6, APRI 0.49 ± 0.17, FIB-4 1.29 ± 0.33, GFR 68 [54–96]) and 1-year postop (MELD-XI 9 ± 3, APRI 0.41 ± 0.16, FIB-4 1.12 ± 0.29, GFR 82 [69–108]), p < 0.05 for all comparisons. ConclusionsCHD patients undergoing isolated heart transplant had significant improvement in hepatic and renal function. These data suggests that selected CHD patients may do well with isolated heart transplant despite reduced hepatic and renal function, and hepatic fibrosis preoperatively. More rigorous prospective studies are required to determine the relative outcomes of isolated versus combined heart-liver transplant in this population.

Outcomes of heart transplantation in cardiac amyloidosis: an updated systematic review.

Cardiac amyloidosis is one of the most common infiltrative cardiomyopathies that is characterized by the extracellular deposition of misfolded fibrillar protein. Several studies have previously found that patients with amyloid in the past have performed poorly after heart transplantation. Recent advancements in treatments have been made that have significantly improved outcomes in these patients. The study aimed to evaluate the outcomes of heart transplantation in cardiac amyloidosis. We systematically searched EMBASE, PubMed/MEDLINE, and Cochrane Library databases on 30 December 2021 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We identified 22 studies that examined 42,951 patients with cardiac amyloidosis of which only 1,329 patients underwent isolated heart transplantation. Seven studies reported individual patient data. The results of 123 patients have been pooled for analysis. There were 70 male patients, 45 female patients, and eight patients who did not report their gender. Among the types of amyloids, 63 (51%) patients were found to have light chain amyloidosis (AL) and 33 (27%) patients had transthyretin amyloidosis (ATTR). Only 41 patients (33.3%) reported a monoclonal component. There were 30 patients with AL that underwent autologous hematopoietic stem cell transplant (ASCT). The mean survival of 24 out of 30 patients was 4.33years. In addition, the reported data include 13 patients requiring intra-aortic balloon pump (IABP), six with cardiac resynchronization therapy (CRT), and four with implantable cardioverter defibrillator (ICD). With the current advancements in treatments in combination with a multidisciplinary approach and careful patient selection, patients undergoing heart transplantation for amyloidosis may have encouraging results in the current era. Further studies will be needed to evaluate the outcomes of heart transplantation in amyloidosis patients now that several advances have been made in the field.

Outcomes of extracorporeal membrane oxygenation following the 2018 adult heart allocation policy.

BackgroundThe purpose of the study was to characterize changes in waitlist and post-transplant outcomes of extracorporeal membrane oxygenation (ECMO) patients bridged to heart transplantation under the 2018 adult heart allocation policy.MethodsAll adult patients listed for isolated heart transplantation from August 2016 to December 2020 were identified using the United Network for Organ Sharing database. Patients were stratified into Eras (Era 1 and Era 2) centered around the policy change on October 18, 2018. Competing risk regression was used to evaluate waitlist death or deterioration across Eras. Cox proportional hazards models were used to determine associations between use of ECMO and 1-year post-transplant mortality within each Era.ResultsOf 8,902 heart transplants included in analysis, 339 (3.8%) were bridged with ECMO (Era 2: 6.1% vs Era 1: 1.2%, P<0.001). Patients bridged with ECMO in Era 2 were less frequently female (26.0% vs 42.0%, P = 0.02) and experienced shorter waitlist times (5 vs 11 days, P<0.001) along with a lower likelihood of waitlist death or deterioration (subdistribution hazard ratio, 0.45, 95% confidence interval, CI, 0.30–0.68, P<0.001) compared to those in Era 1. Use of ECMO was associated with increased post-transplant mortality at 1-year compared to all other transplants in Era 1 (hazard ratio 3.78, 95% CI 1.88–7.61, P < 0.001) but not Era 2.ConclusionsPatients bridged with ECMO in Era 2 experience improved waitlist and post-transplant outcomes compared to Era 1, giving credence to the increased use of ECMO under the new allocation policy.

Temporary Left Ventricular Support Device as a Bridge to Heart-Liver or Heart-Kidney Transplant: Pushing the Boundaries of Temporary Support.

In patients with severe cardiogenic shock, temporary mechanical circulatory support has become a viable strategy to bridge patients to heart transplantation. However, end-stage heart failure is often associated with progressive organ dysfunction of the liver or kidney. This can require a dual organ transplant for definitive management (combined heart-liver [HL] or heart-kidney [HK] transplantation). We evaluated temporary mechanical support to bridge patients to HL or HK transplant at a single, high-volume center. All patients who underwent Impella 5.0 placement from January 2014 to October 2018 were identified. From this dataset, patients who underwent placement as a bridge to dual organ transplant were selected, as were those who underwent Impella as a bridge to isolated heart transplant. Over the 5 years of evaluation, 104 patients underwent Impella 5.0 placement. Of these, 14.3% (n = 15) were identified as potential dual organ recipients (11 HK, 4 HL). In total, 80% (12/15) successfully underwent dual organ transplant (8 HK, 4 HL), with a 1-year survival of 100% in both transplanted groups. Among patients undergoing Impella 5.0 placement as a bridge to isolated heart transplant (n = 33), 78.8% (26) were successfully bridged, and 1-year survival was 92% after transplantation. Impella 5.0 is a viable bridge to dual organ transplantation and should be considered as a management strategy in these complex patients at experienced institutions.

Two Cases of BK Polyoma Virus Nephropathy in Patients with Isolated Heart Transplantation: Clinical Usefulness of Urinary Cytology

<h3>Introduction</h3> BK polyoma virus (BKpV) nephropathy (BKpVN) has been often reported in patients with kidney transplantation, whereas reports regarding BKpVN in patients with heart transplantation (HTx) is still sparse. <h3>Case Report</h3> We recently encountered two patients who developed BKpVN after HTx. Both patients (Case 1 and 2) coincidentally received HTx at the age of 56. A standard triple-drug regimen consisting of tacrolimus, mycophenolate mofetil (MMF), and a corticosteroid was started after surgery and the regimen was converted to everolimus (EVL) with reduced tacrolimus within 6 months after HTx because of donor transmitted atherosclerosis in both patients. Case 1 further underwent percutaneous coronary intervention 3.5 years after HTx. Despite renal-sparing immunosuppresion, values of creatinine begun to increase after HTx in both patients and they were diagnosed with BKpVN through high viral DNA copy number in the urine and blood. Regarding case 1, pathological analysis of kidney biopsy specimens disclosed interstitial infiltrate with lymphocytes associated with tubular injury which also lead to the diagnosis of BKpVN. Retrospectively, both patients were positive for decoy cell within 1 year after HTx therefore, these patients should have been recognized as high risk for BKpVN. After the diagnosis of BKpVN, immunosuppressive regimen of them was further changed to minimum dose of EVL (a trough concentration of 6-7 ng/ml) and MMF (500 mg daily) respectively under the guidance of myocardial biopsy and they have been uneventful for over a year after the diagnosis of BKpVN despite severe chronic kidney disease. <h3>Summary</h3> We presented two rare cases of BKpVN after HTx. In our institution, urinary cytology is regularly examined if there are decoy cells which we think are the sign of over immunosuppression. However, decoy cells detected by urinary cytology also suggest that there is subclinical BKpV infection. Urinary cytology, a noninvasive and cost-effective examination, should be routinely performed for the risk assessment of BKpVN even in HTx patients, since detecting decoy cell would be helpful for the early diagnosis of BKpVN.

Repeat Pediatric Heart Transplantation in the United States: United Network for Organ Sharing Database Analysis

<h3>Purpose</h3> National data on the efficacy of re-transplantation in children, in whom waitlist mortality approaches 20%, is scarce. <h3>Methods</h3> The United Network for Organ Sharing (UNOS) Database was used to identify 6,244 patients aged <18 years undergoing isolated heart transplant from 2004-2021, including 5,913 (94.7%) primary transplants and 331 (5.3%) re-transplants. The primary outcome was all-cause mortality. Multivariable cox regression was used to assess the impact of re-transplantation on survival, adjusting for patient, donor and hospital characteristics. Median follow-up was 4.5 (range 0.0-16.2) years. <h3>Results</h3> Re-transplant patients were older (median age 12 vs 4 years; p<0.01), more likely to be female (54.1%, n=179 vs 44.1%, n=2609; p<0.01), and less likely to be in UNOS status 1A (67.7%, n=224 vs 83.4% n=4932; p<0.01) than those undergoing primary transplants. The main indication for re-transplantation was allograft vasculopathy (60.7% n=201), followed by chronic rejection (10.6%, n=35) and primary failure (8.8%, n=29). The overall 90-day survival was 94.8% (95% confidence interval (CI) 94.2-95.3), this was similar between the groups (p=0.28). The unadjusted 10-year survival was 48.4% (95% CI 41.2-55.7%) among re-transplants and 71.6% (95% CI 70.0-73.2%) among primary transplants (p<0.01) (Figure 1). Re-transplantation was an independent predictor of long-term mortality in multivariable analysis (hazard ratio (HR) 1.8, 95% CI 1.4-2.2), other predictors included earlier transplant year (HR 0.9, 95% CI 0.8-0.9 per 5-years). <h3>Conclusion</h3> Despite advancements in overall outcomes, late survival following pediatric heart re-transplantation is significantly worse than primary transplantation. Increased awareness, prevention, diagnosis and management of coronary disease in pediatric heart transplant patients may improve patient outcomes and organ stewardship.

Indexed Donor Cardiac Output for Improved Size Matching in Heart Transplantation

<h3>Purpose</h3> Implantation of an appropriately sized donor heart is critical for optimal outcomes after heart transplantation. While predicted heart mass (PHM) has recently gained consideration, there remains a need for improved granularity in size matching, particularly among small donor hearts. We hypothesized that indexed donor cardiac output (CO) would be a sensitive metric to assess adequacy of a donor heart for a given recipient. <h3>Methods</h3> Isolated heart transplant recipients from the UNOS database were included if donor CO was reported (<i>N</i>=3,619). Donor CO was divided by recipient BSA to compute cardiac index (dCI) and PHM ratio (PHMr) was computed as donor/recipient PHM. The primary outcome was mortality <1 year after transplant, adjusting for age, gender, donor inotropes, and recipient hospitalization status. <h3>Results</h3> Among transplanted recipients, donor CO was 7.3 (5.8-9.0) LPM and dCI was 3.7 (3.0-4.6) LPM/m². PHMr was 1.01 (0.91-1.13). dCI moderately correlated with recipient weight (<i>r_s</i>=-0.18, <i>P</i><0.001), BSA (<i>r_s</i>=-0.18, <i>P</i><0.001), and PHMr (<i>r_s</i>=0.29, <i>P</i><0.001). In univariate analyses, higher dCI was associated with lower 1 year mortality risk (OR=0.89, <i>P</i>=0.042), but not strongly associated with stroke (<i>P</i>=0.176) or dialysis (<i>P</i>=0.161). Those in the highest dCI quartile (>4.4 LPM/m²) had a lower risk of death compared to those in the lowest quartile (<3.0 LPM/m²; <i>P</i>=0.027). After multivariable adjustment, higher dCI continued to be associated with lower 1 year mortality risk (OR=0.89, <i>P</i>=0.042; Figure). Recipients with PHMr<0.80 (<i>n</i>=227) had lower median dCI than those with PHMr≥0.80 (3.3 vs 3.7, <i>P</i><0.001). Among those with PHMr<0.80, higher dCI decreased the odds of 1 year mortality (OR=0.63, <i>P</i>=0.083). <h3>Conclusion</h3> Higher dCI was associated with a lower probability of 1 year mortality among patients undergoing heart transplantation and served to stratify mortality risk among those with a PHMr<0.80. dCI appears to be an effective tool for size matching and may serve as an adjunctive strategy among small donor hearts with a low PHMr.

Trends, Risk Factors And Mortality Of Unplanned 30-day Readmission After Heart Transplantation: An Analysis Of The National Readmission Database 2012-2018

<h3>Background</h3> Outcomes after heart transplantation have improved, but the burden of readmissions is understudied.Objective: We sought to examine the incidence, risk factors, and associated mortality of unplanned 30-day readmissions following heart transplantation. <h3>Methods</h3> This cohort study examined patient data from the United States population-based Nationwide Readmissions Database. All adults (age≥18 years) who underwent isolated heart transplantation in US hospitals between January to November of 2012 to 2018 were included. The primary outcomes were 30-day readmission rates and readmission mortality. <h3>Results</h3> The median time from discharge to readmission was 9 days, and approximately 70% of the readmissions occurred within 15 days. (Figure) After multivariable analysis, only CKD (Hazard ratio (HR): 1.11 95% CI 1.00-1.23) and length of stay (HR: 1.002; 95% CI 1.001-1.003; p <0.001) were associated with increased 30-day post-heart transplantation readmission. Readmissions diagnoses were heart transplantation complications, heart transplant rejection, postoperative infection, acute kidney injury, heart failure, pulmonary embolism, pneumonia, and pericardial effusion. (Table)The overall incidence of infection as a cause of readmission was 24.9%, with an associated mortality of 2.6% and a Median LOS of 7 days (4-14). The overall incidence of rejection was 38.0%, with a mortality of 1.2 % and a median LOS of 5 days (3-8). <h3>Conclusions</h3> Approximately 1 in 5 patients will be readmitted within 30 days after heart transplantation, and most of those readmissions will occur during the first two weeks after discharge. Readmissions were associated with a low mortality rate.

Survival After Heart Transplant is Poor with High Venous Pressures and Low Arterial Elastance

<h3>Purpose</h3> High venous pressure is a risk factor for renal dysfunction and mortality in decompensated heart failure. Medical management involves lowering arterial elastance (Ea) with vasodilators. We hypothesized that high venous pressures and a low Ea may have a poor prognosis after heart transplantation due to impaired organ perfusion. <h3>Methods</h3> We retrospectively studied the effect of high venous pressures more than 15 mm hg on survival of 250 isolated heart transplants. Arterial elastance was calculated as E_sys / SV End systolic pressure E_sys = (2* systolic blood pressure + diastolic pressure) / 3 Organ perfusion pressure index (OPPI) was calculated as (Mean arterial pressure- RAP) / BSA <h3>Results</h3> Higher RAP was a significant risk factor for 90 day mortality (p = 0.007) . This risk decreased with increasing Ea (p = 0.000). Lower OPPI (p ∼0.000) had a significant effect on 90 day mortality. The impact of high RAP and low arterial elastance persisted at medium term follow up. Kaplan Meier estimates for survival at 5 years was significantly worse if RAP was more than 15 mm hg (p ∼ 0.0059) This effect of RAP on 5 year survival was absent if Ea was > 2.7.Survival at 5 years was significantly worse if OPPI was < 40. (p ∼ 0.0124).This effect was absent if RAP was < 15 mm hg. <h3>Conclusion</h3> Elevated venous pressure> 15 mm hg with low Ea has poor outcomes of transplantation . The effect seems to be mediated through a decrease in OPPI. A value of OPPI less than 40 mm hg is associated with poor outcomes.

Impact of Pretransplant Renal Replacement Therapy on Clinical Outcome After Isolated Heart Transplantation.

End stage renal disease (ESRD) is a contraindication to isolated heart transplantation (HT). However, heart candidates with cardiogenic shock may experience acute kidney injury and require renal replacement therapy (RRT) and isolated HT as a life-saving operation. The outcomes, including survival and renal function, are rarely reported. We enrolled 569 patients undergoing isolated HT from 1989 to 2018. Among them, 66 patients required RRT before HT (34 transient and 32 persistent). The survival was worse in patients with RRT than those without (65.2% vs 84.7%; 27.3% vs 51.1% at 1- and 10-year, p < 0.001 and p = 0.012, respectively). Multivariate Cox analysis identified pre-transplant hyperbilirubinemia (Hazard ratio (HR) 2.534, 95% confidence interval (CI) 1.098–5.853, p = 0.029), post-transplant RRT (HR 5.551, 95%CI 1.280–24.068, p = 0.022) and post-transplant early bloodstream infection (HR 3.014, 95%CI 1.270–7.152, p = 0.012) as independent risk factors of 1-year mortality. The majority of operative survivors (98%) displayed renal recovery after HT. Although patients with persistent or transient RRT before HT had a similar long-term survival, patients with persistent RRT developed a high incidence (49.2%) of dialysis-dependent ESRD at 10 years. In transplant candidates with pretransplant RRT, hyperbilirubinemia should be carefully re-evaluated for the eligibility of HT whereas prevention and management of bloodstream infection after HT improve survival.

Fontan-associated liver disease.

Fontan-associated liver disease.

Assessing donor-recipient size metrics for heart transplant outcomes: UNOS database analysis.

There is no widely accepted donor to recipient size-match metric to predict outcomes in cardiac transplant. The predictive ability of size-match metrics has not been studied when recipients are stratified by heart failure etiology. We sought to assess the performance of commonly used size metrics to predict survival after heart transplant, accounting for restrictive versus non-restrictive pathology. The UNOS registry was queried from 2000 to 2017 for all primary isolated heart transplants. Donor-recipient ratios were calculated for commonly used size metrics and their association with survival was assessed using continuous, nonlinear analysis. 29817 patients were identified. Height (P<.001), predicted heart mass (PHM) (P=.003), ideal body weight (IBW) (P<.001) and body mass index (BMI) (P=.003) ratios were significantly associated with survival, while weight and body surface area (BSA) ratios were not. When stratified, only BMI ratio retained significance for both restrictive (P=.051) and non-restrictive (P=.003) subsets. Recipients with restrictive etiology had increased risk of mortality with both a lower and higher BMI ratio. While many metrics show association with survival in the non-restrictive subset, BMI is the only metric that retains significance in the restrictive subset. Recipients with restrictive and non-restrictive etiologies of heart failure tolerate size mismatch differently.

Heart Transplantation for Peripartum Cardiomyopathy: Outcomes Over 3 Decades

BackgroundThis study evaluated trends and outcomes of patients undergoing heart transplantation for peripartum cardiomyopathy (PPCM) over the past 3 decades. MethodsThe United Network for Organ Sharing registry was used to identify patients undergoing isolated heart transplantation between 1987 and 2020. Patients were stratified by the decade of transplantation. Overall survival was compared using Kaplan-Meier analysis, and risk-adjustment was performed using Cox proportional hazards modeling. ResultsA total of 76 009 heart transplantations occurred in the study period, including 20 352 female patients and 809 female patients with PPCM. The frequency of transplantation for PPCM increased over the study period (P = .015). Among female patients, PPCM was significantly associated with 1-year mortality compared with nonischemic cardiomyopathy (hazard ratio, 1.38; 95% CI, 1.11-1.69; P = .004). Among patients with PPCM, Black and Hispanic heart transplant recipients had increased 1-year posttransplant mortality risk compared with White recipients. On Kaplan-Meier survival analysis, early and midterm survival was significantly worse in patients with PPCM compared with other female patients. The 5-, 10-, and 15-year survivals in patients with PPCM were 66.5%, 49.0%, and 40.2% compared with 74.3%, 56.0%, and 37.5% in female heart transplant recipients with other heart failure diagnoses, respectively (P < .001). Survival improved significantly in patients who underwent heart transplantation for PPCM in the latest decade from 2010 to 2020 compared with earlier decades (P < .001), and this improvement was most marked for Black recipients. ConclusionsPatients who underwent heart transplantation for PPCM have a significantly elevated risk for 1-year mortality compared with other female transplant recipients. However, survival among these patients has improved in the last decade, particularly for Black transplant recipients.

Right and left ventricular assist devices are an option for bridge to heart transplant

BackgroundPatients with a left ventricular assist device with right ventricular failure are prioritized on the heart transplant waitlist; however, their post-transplant survival is less well characterized. We aimed to determine whether pretransplant right ventricular failure affects postoperative survival in patients with a left ventricular assist device as a bridge to transplant. MethodsWe performed a retrospective review of the 2005-2018 Organ Procurement and Transplantation Network/United Network for Organ Sharing registry for candidates aged 18 years or more waitlisted for first-time isolated heart transplantation after left ventricular assist device implantation. Candidates were stratified on the basis of having right ventricular failure, defined as the need for right ventricular assist device or intravenous inotropes. Baseline demographic and clinical characteristics were compared among the 3 groups, and post-transplant survival was assessed. ResultsOur cohort included 5605 candidates who met inclusion criteria, including 450 patients with right ventricular failure, 344 patients with a left ventricular assist device and intravenous inotropes as a bridge to transplant, 106 patients with a left ventricular assist device and right ventricular assist device, and 5155 patients with a left ventricular assist device as a bridge to transplant without the need for right side support. Compared with patients without right ventricular failure, patients with a left ventricular assist device as a bridge to transplant with right ventricular failure were younger (median age 51 years, 55 vs 56 years, P < .001) and waited less time for organs (median 51 days, 93.5 vs 125 days, P < .001). These patients also had longer post-transplant length of stay (median 18 days, 20 vs 16 days, P < .001). Right ventricular failure was not associated with decreased post-transplant long-term survival on unadjusted Kaplan–Meier analysis (P = .18). Neither preoperative right ventricular assist device nor intravenous inotropes independently predicted worse survival on multivariate Cox proportional hazards analysis. However, pretransplant liver dysfunction (total bilirubin >2) was an independent predictor of worse survival (hazard ratio, 1.74; 95% confidence interval, 1.39-2.17; P < .001), specifically in the left ventricular assist device group and not in the left ventricular assist device + right ventricular assist device/intravenous inotropes group. ConclusionsPatients with biventricular failure are prioritized on the waiting list, because their critical pretransplant condition has limited impact on their post-transplant survival (short-term effect only); thus, surgeons should be confident to perform transplantation in these severely ill patients. Because liver dysfunction (a surrogate marker of right ventricular failure) was found to affect long-term survival in patients with a left ventricular assist device, surgeons should be encouraged to perform transplantation in these severely ill patients after a recipient's optimization by inotropes or a right ventricular assist device because even when the bilirubin level is elevated in these patients (treated with right ventricular assist device/inotropes), their long-term survival is not affected. Future studies should assess recipients' optimization before organ acceptance to improve long-term survival.

Abstract 10672: Long-Term Need for Heart Transplantation and Post-Transplantation Survival After Fontan Palliation

Introduction: Fontan palliation for single ventricle frequently leads to heart failure and need for transplant; timing and factors associated with post-Fontan transplant, as well as post-transplant outcomes are not well understood. Methods: This is a retrospective cohort study of patients undergoing Fontan in the Pediatric Cardiac Care Consortium (PCCC), a large US-based registry of pediatric cardiac interventions. Deaths and transplants were captured in the PCCC and by linkage with the National Death Index and the Organ Procurement Transplant Network through 2019. Results: Between 1982 and 2003, 2,071 patients were enrolled in the PCCC and had their Fontan between 1988 and 2011. During Fontan hospitalization 151 deaths and 6 transplant listings occurred; 201 additional deaths and 148 listings occurred after discharge (Figure A). Cumulative incidence of transplant listing was 7.1% (95% CI 6.0-8.3) with the median time post Fontan being 11.1 years (IQR 5.3 - 13.8). After adjustment for risk factors, systemic right ventricle (HR 2.69; 95% CI 1.87 - 3.88) and &gt;30-day length of stay after Fontan (HR 2.29; 95% 1.51 - 3.48) were associated with transplant listing. Among listed patients, 112 (73%) underwent isolated heart transplant, 2 (1%) underwent heart-liver transplant, 20 (13%) died on the waitlist, and 20 (13%) are alive without transplant. One-year post-transplant survival was 70% for transplants before 2010 and 95% after 2010 (Figure B). Graft failure was associated with transplant before 2010 (HR 6.34; 95% CI 2.21-18.2), diagnosis of hypoplastic left heart syndrome (HR 3.71; 95% CI 1.38 - 9.92), and bilirubin &gt;2mg/dl at time of transplant (HR 2.79; 95% CI 1.03 - 7.58). Conclusion: Need for heart transplant is frequent post Fontan, but many die without listing. With significant improvements in post-transplant outcomes in recent years, timely transplant evaluation before significant end-organ dysfunction may improve survival for patients with single ventricle.

Fate of the liver in the survivors of adult heart transplant for a failing Fontan circulation

The Fontan circulation has inherent long-term vulnerabilities such that adult Fontan patients now comprise the largest, most rapidly growing subgroup of adult congenital heart disease referred for transplant assessment. Almost all have Fontan Associated Liver Disease (FALD). There is an absence of mid to late hepatic outcome data after heart transplant alone. Therefore, we analyzed outcomes of survivors of heart only transplant in patients with failing Fontan circulation. Including all 10 of our adult Fontan patients surviving >1 year after isolated heart transplant, we report evolution of their clinical features, bloodwork, hemodynamic data, and liver ultrasound findings over a median of 4.7 years. Nonprogression of FALD, resolution of ascites and freedom from hepatocellular carcinoma in the mid-term highlight the outcomes in this selected group once normal cardiac output and venous pressures are established by heart transplant.

Trends, risk factors and mortality of unplanned 30-day readmission after heart transplantation

Abstract Introduction Outcomes after heart transplantation have improved, but the burden of readmissions is understudied. We sought to examine the incidence, risk factors, and associated mortality of unplanned 30-day readmissions following heart transplantation. Methods This cohort study examined patient data from the United States population-based Nationwide Readmissions Database. All adults (age ≥18 years) who underwent isolated heart transplantation in US hospitals between January to November of 2012 to 2018 were included. The primary outcomes were 30-day readmission rates and readmission mortality. Results A total of 14,784 patients who underwent heart transplantation from 2012 to 2018 were included in our analysis. A total of 3299 (22.3%) patients were readmitted within 30 days after discharge. The median time from discharge to readmission was 9 days, and approximately 70% of the readmissions occurred within 15 days. After multivariable analysis, only CKD (Hazard ratio (HR): 1.11 95% CI 1.00–1.23) and length of stay (HR: 1.002; 95% CI 1.001–1.003; p&amp;lt;0.001) were associated with increased 30-day post-heart transplantation readmission. Readmissions diagnoses were heart transplantation complications, heart transplant rejection, postoperative infection, acute kidney injury, heart failure, pulmonary embolism, pneumonia, and pericardial effusion. The overall incidence of infection as a cause of readmission was 24.9%, with an associated mortality of 2.6% and a Median LOS of 7 days (4–14). The overall incidence of rejection was 38.0%, with a mortality of 1.2% and a median LOS of 5 days (3–8). Conclusion Approximately 1 in 5 patients will be readmitted within 30 days after heart transplantation, and most of those readmissions will occur during the first two weeks after discharge. Readmissions were associated with a low mortality rate. Funding Acknowledgement Type of funding sources: None.