Long-term Post-transplant Survival Research Articles

Heart Transplant Survival and the Use of Donors with Intracranial Bleeding: UNOS Registry Propensity Matched Analysis

ObjectiveThe transplantation of hearts from donors who suffered intracranial bleeding (ICB) has been associated with inferior long-term survival in both single-center analyses and, more recently, with the UNOS registry. The purpose of this study was to further explore this relationship through propensity matching in recipients receiving donor hearts from ICB and non-ICB donors in a large national registry. MethodsWe performed a retrospective cohort analysis of the UNOS Registry OPTN between 2006 and 2018 for adult candidates wait-listed for isolated heart transplantation. Recipients were stratified into two groups, ICB and non-ICB donors. Propensity score matching was performed to estimate causal effects by using observational data. Kaplan-Meier analysis was used to estimate survival posttransplant. Cox proportional hazards modeling was used to evaluate the independent effect of ICB as a cause of death. Results25,315 candidates met inclusion criteria. ICB heart donors (N=5,529) were older (median age, 42 versus 27 years; P<0.001), less likely men (54.5% versus 75.2% ; P<0.001), and more often had a history of smoking (20.1% versus 11.7% ; P<0.001), and hypertension (34.2% versus 9.5% ; P<0.001). Prior to matching there was a significant difference in long-term posttransplant survival e.g., the non-ICB (60.7% [59.5%,.61.9%] versus 56.8% [54.7%, 59.0%]; P<0.0001). However, when analyzing the propensity-matched groups for outcomes, no difference was found between the cohorts both in terms of long-term survival as well as in rates of rejection. ConclusionIn the largest propensity matching analysis of heart transplants from donors who had experienced ICB, we found similar survival and rejection rates in heart transplant recipients.

Long-term posttransplant survival outcome following bridging locoregional therapy in hepatocellular carcinoma patients: A systematic review and meta-analysis.

Liver transplantation (LT) is essential due to its curative efficacy, but liver-graft shortages have limited its widespread application. Bridging locoregional therapy (LRT) before LT has been performed to prevent tumor progression, and a recent literature review revealed that it is associated with a nonsignificant trend toward better survival outcomes. However, much more information on bridging therapy has become available since then. This meta-analysis aimed to compare the posttransplant survival and HCC recurrence between patients with and without pretransplant bridging LRT. Studies were identified in MEDLINE, SCOPUS, and the Cochrane Library. Two independent researchers screened titles and full articles, extracted relevant data, and conducted a parametric survival analysis. Out of 4794 studies, 18 cohort studies were eligible. The 1-, 3-, and 5-year overall survival (OS) rates were 93.1%, 85.0%, and 79.1% for those in the bridging LRT group, while they were 91.8%, 81.1%, and 75.5% for those who did not receive LRT, respectively. There were no differences in overall survival between these groups (HR 0.90; 0.78-1.05, P = 0.17). Interestingly, we discovered that bridging therapy helped prolong survival significantly in a high-risk population with a long waiting time (HR 0.76; 0.60-0.96, P = 0.02). Unfortunately, bridging LRT did not improve disease-free survival (HR 0.98; 0.86-1.11, P = 0.70). The results indicate that bridging LRT does not generally change post-LT outcomes. However, bridging LRT can significantly improve survival in patients with a long waiting time for LT.

Propensity matched post-transplant survival in durable CF-axial pump BTT patients with and without diabetes: A UNOS database analysis.

Diabetes and post-transplant survival have been linked. However, the impact on post-transplant survival of patients supported on Continuous Flow (CF) axial left ventricular assist devices (LVAD) as a bridge to transplant (BTT) with diabetes has not been widely studied. This study attempts to assess the impact of diabetes type II (DM type II) as a comorbidity influencing survival patterns in the post-cardiac transplant population supported on LVADs and to test if the presence of a pre- transplant durable LVAD acts as an independent risk factor in long-term post-transplant survival. The UNOS database population from 2004 to 2015 was used to construct the cohorts. A total of 21,032 were transplanted during this period. The transplant data were further queried to extract CF-axial flow pumps BTT (HMII-BTT) patients and patients who did not have VAD support before the transplant. A total of 4224 transplant recipients had HMII at the time of transplant, and 13,131 did not have VAD support. Propensity analysis was performed, and 4107 recipients of similar patient characteristics to those in the BTT group were selected for comparison. The patients with a VAD had significantly reduced survival at 2 years post-transplant (p = 0.00514) but this trend did not persist at 5 years (p = 0.0617) and 10 years post-transplant (p = 0.183). Patients with diabetes and a VAD significantly decreased survival at 2 years (p = 0.00204), 5 years (p = 0.00029), and 10 years (p = 0.00193). The presence of a durable LVAD is not an independent risk factor for long-term survival. Diabetes has a longstanding effect on the posttransplant survival of BTT patients.

Complex karyotype but not other cytogenetic abnormalities is associated with worse posttransplant survival of patients with nucleophosmin 1-mutated acute myeloid leukemia: A study from the European Society for Blood and Marrow Transplantation Acute Leukemia Working Party.

In the 2022 European LeukemiaNet classification, patients with nucleophosmin 1 (NPM1)-mutated acute myeloid leukemia (AML) were classified in the adverse-risk category in the presence of high-risk cytogenetics (CG). Nonetheless, the impact of various CG aberrations on posttransplant outcomes remains to be unraveled. This registry study analyzed adult patients with NPM1-mutated de novo AML who underwent their first allogeneic hematopoietic cell transplantation in the first complete remission from 2005 to 2021. A total of 3275 patients were identified, 2782 had normal karyotype, 493 had chromosomal aberrations including 160 with adverse-risk CG, 72 patients had complex karyotype (CK), and 66 monosomal karyotype (MK). Overall, 2377 (73%) patients had FLT3-ITD. On univariate analysis, only FLT3-ITD, minimal/measurable residual disease (MRD) positivity and CK, but not abnormal CG, affected posttransplant outcomes. On multivariable analysis, CK was associated with lower overall survival (OS) (hazard ratio [HR] 1.72, p = .009). In the subgroup of 493 patients with aberrant CG, the 2-year leukemia-free survival (LFS) and OS were around 61% and 68%, respectively. On multivariable analysis for this subgroup, CK and MRD positivity were associated with increased risk of relapse (HR 1.7, p = .025; and 1.99, p = .003 respectively) and worse LFS (HR 1.62, p = .018; and 1.64, p = .011 respectively) while FLT3-ITD, MK, or other CG abnormalities had no significant effect. Importantly, CK negatively affected OS (HR 1.91, p = .002). In the first complete remission transplant setting, CK was found as the only cytogenetic risk factor for worse outcomes in NPM1-mutated AML. Nevertheless, even for this subgroup, a significant proportion of patients can achieve long-term posttransplant survival.

SimKAP: simulation framework for the kidney allocation process with decision making model

Organ shortage is a major barrier in transplantation and rules guarding organ allocation decisions should be robust, transparent, ethical and fair. Whilst numerous allocation strategies have been proposed, it is often unrealistic to evaluate all of them in real-life settings. Hence, the capability of conducting simulations prior to deployment is important. Here, we developed a kidney allocation simulation framework (simKAP) that aims to evaluate the allocation process and the complex clinical decision-making process of organ acceptance in kidney transplantation. Our findings have shown that incorporation of both the clinical decision-making and a dynamic wait-listing process resulted in the best agreement between the actual and simulated data in almost all scenarios. Additionally, several hypothetical risk-based allocation strategies were generated, and we found that these strategies improved recipients’ long-term post-transplant patient survival and reduced wait time for transplantation. The importance of simKAP lies in its ability for policymakers in any transplant community to evaluate any proposed allocation algorithm using in-silico simulation.

Early Cardiopulmonary Fitness after Heart Transplantation as a Determinant of Post-Transplant Survival.

Decreased peak oxygen consumption during exercise (peak Vo2) is a well-established prognostic marker for mortality in ambulatory heart failure. After heart transplantation, the utility of peak Vo2 as a marker of post-transplant survival is not well established. We performed a retrospective analysis of adult heart transplant recipients at the Hospital of the University of Pennsylvania who underwent cardiopulmonary exercise testing within a year of transplant between the years 2000 to 2011. Using time-to-event models, we analyzed the hazard of mortality over nearly two decades of follow-up as a function of post-transplant percent predicted peak Vo2 (%Vo2). A total of 235 patients met inclusion criteria. The median post-transplant %Vo2 was 49% (IQR 42 to 60). Each standard deviation (±14%) increase in %Vo2 was associated with a 32% decrease in mortality in adjusted models (HR 0.68, 95% CI 0.53 to 0.87, p = 0.002). A %Vo2 below 29%, 64% and 88% predicted less than 80% survival at 5, 10, and 15 years, respectively. Post-transplant peak Vo2 is a highly significant prognostic marker for long-term post-transplant survival. It remains to be seen whether decreased peak Vo2 post-transplant is modifiable as a target to improve post-transplant longevity.

Liver transplantation is beneficial regardless of cirrhosis stage or acute-on-chronic liver failure grade: A single-center experience

Liver transplantation for the most critically ill remains controversial; however, it is currently the only curative treatment option. To assess immediate posttransplant outcomes and compare the short (1 year) and long-term (6 years) posttransplant survival among cirrhotic patients stratified by disease severity. We included cirrhotic patients undergoing liver transplantation between 2015 and 2019 and categorized them into compensated cirrhosis (CC), decompensated cirrhosis (DC), and acute-on-chronic liver failure (ACLF). ACLF was further divided into severity grades. Our primary outcomes of interest were total days of intensive care unit (ICU) and hospital stay, development of complications and posttransplant survival at 1 and 6 years. 235 patients underwent liver transplantation (CC = 11, DC = 129 and ACLF = 95). Patients with ACLF had a significantly longer hospital stay [8.0 (6.0-13.0) vs CC, 6.0 (3.0-7.0), and DC 7.0 (4.5-10.0); P = 0.01] and developed more infection-related complications [47 (49.5%), vs CC, 1 (9.1%) and DC, 38 (29.5%); P < 0.01]. Posttransplant survival at 1- and 6-years was similar among groups (P = 0.60 and P = 0.90, respectively). ACLF patients stratified according to ACLF grade [ACLF-1 n = 40 (42.1%), ACLF-2 n = 33 (34.7%) and ACLF-3 n = 22 (23.2%)], had similar ICU and hospital stay length (P = 0.68, P = 0.54), as well as comparable frequencies of overall and infectious post-transplant complications (P = 0.58, P = 0.80). There was no survival difference between ACLF grades at 1 year and 6 years (P = 0.40 and P = 0.15). Patients may benefit from liver transplantation regardless of the cirrhosis stage. ACLF patients have a longer hospital stay and frequency of infectious complications; however, excellent, and comparable 1 and 6-year survival rates support their enlisting and transplantation including those with ACLF-3.

Long-term survival of renal transplantation in patients with lupus nephritis: experience from a single university centre.

Lupus nephritis (LN) is a severe complication of systemic lupus erythematosus (SLE). Unfortunately, 10-20% of patients with LN develop end-stage renal disease (ESRD), and renal transplantation may be a therapeutic option. However, concerns about LN recurrence after transplant have been reported. We aimed to assess long-term post-transplant graft and patient survival in LN compared to patients with non-autoimmune nephropathy (polycystic kidney disease - PCKD). We carried out a single-centre retrospective study of all patients who underwent renal transplantation due to LN in a referral unit between 1980 and 2018. This cohort was compared with a group of PCKD patients. The main outcome variables were graft and patient survival for up to 20 years, and the time-course of serum creatinine and proteinuria in the first 5 years after transplantation. Cumulative survival rates were estimated by the Kaplan-Meier method and compared using the log-rank test. We included 53 patients: LN group (n=21) and PCKD group (n=32). Baseline clinical characteristics were similar in both groups, except age at transplantation (39.8±11.3 years in the LN group and 46.6±5.0 years in the PCKD group; p=0.004). No significant differences were found regarding graft (p=0.59) or patient survival (p=0.087) at 20 years of follow-up. Despite concerns about LN recurrence after renal transplantation, this study shows that this procedure might be a safe alternative therapy for ESRD related to SLE and may provide long-term survival.

The influence of equitable access policies and socioeconomic factors on post-liver transplant survival

BackgroundSurvival following liver transplant (LT) is influenced by a variety of factors, including donor risk factors and recipient disease burden and co-morbidities. It is difficult to separate these effects from those of socioeconomic factors, such as income or insurance. The United Network for Organ Sharing (UNOS) created equitable access policies, such as Share 35, to ensure that organs are distributed to individuals with greatest medical need; however, the effect of Share 35 on disparities in post-LT survival is not clear. This study aimed to (1) characterize associations between post-transplant survival and race and ethnicity, income, insurance, and citizenship status, when adjusted for other clinical and demographic factors that may influence survival, and (2) determine if the direction of associations changed after Share 35.MethodsA retrospective, cohort study of adult LT recipients (n = 83,254) from the UNOS database from 2005 to 2019 was conducted. Kaplan-Meier survival graphs and stepwise multivariate cox-regression analyses were performed to characterize the effects of socioeconomic status on post-LT survival, adjusted for recipient and donor characteristics, across the time period and after Share 35.FindingsMale sex (HR: 0.93 (95% CI: 0.90–0.96)), private insurance (0.91 (0.88–0.94)), income (0.82 (0.79–0.85)), U.S. citizenship, and Asian (0.81 (0.75–0.88)) or Hispanic (0.82 (0.79–0.86)) race and ethnicity were associated with higher post-transplant survival, after adjustment for clinical and demographic factors (Table 3). These associations were found across the entire time period studied and many persisted after the implementation of Share 35 in 2013 (Table 3; male sex (0.84 (0.79–0.90)), private insurance (0.94 (0.89–1.00)), income (0.82 (0.77–0.89)), and Asian (0.87 (0.73–1.02)) or Hispanic (0.88 (0.81–0.96)) race and ethnicity).InterpretationRecipients’ socioeconomic factors at time of transplant may impact long-term post-transplant survival, and a single policy may not significantly alter these structural health inequalities.FundingNone

Racial disparities and outcomes of left ventricular assist device implantation as a bridge to heart transplantation.

AimsThis study investigated outcomes after continuous flow left ventricular assist device (CF‐LVAD) implantation as bridge to heart transplantation (BTT) in advanced heart failure patients stratified by race.Methods and resultsDe‐identified data from the United Network for Organ Sharing database was obtained for all patients who had a CF‐LVAD as BTT from 2008 to 2018. Patients were stratified into four groups on the basis of ethnicity [Caucasian, African American (AA), Hispanic, and others (Asian, Pacific Islanders, and American Indian)]. Outcomes investigated were waitlist mortality or delisting and post‐transplant 5 year survival. Cox proportional hazards modelling was used to identify independent predictors of waitlist mortality or delisting and post‐transplant survival. We used Kaplan–Meier survival curves and the log‐rank test to estimate and compare survival among groups. A total of 14 234 patients who had CF‐LVADs as BTT were identified. Of these, 64% (n = 9058) were Caucasians, 26% (n = 3677) were AA, 7% (n = 997) were Hispanic, and 3% (n = 502) had a different race. Compared with Caucasian, AA, and Hispanic patients had higher body mass indexes and a lower level of education and are more likely to be public health insurance beneficiaries. There was a significantly lower incidence of transplantation in AAs compared with Caucasians, Hispanics, and others at 12, 24, and 60 months, respectively (Gray's test, P < 0.001). The AA race was a significant predictor of waitlist mortality or delisting owing to worsening clinical status [hazard ratio, 95% confidence interval: 1.10 (1.01 to 1.16; P < 0.001)]. Among those who were successfully BTT, risk‐adjusted post‐transplant survival was similar among the four groups (log‐rank test: P = 0.589).ConclusionsDisparities exist among different races that receive a CF‐LVAD as a BTT. These disparities translate into increased waitlist morbidity and mortality but not long‐term post‐transplant survival among those who successfully reach transplant.

Can Pre-Transplant Renal Function Predict Short-Term and Long-Term Post-Transplant Survival?

Impaired post-transplant renal function (PRFT) is a well-described fact for survival in heart transplants. However, the effect of pre-transplant renal function and its impact on survival is poorly studied. We seek to investigate the relationship between PRFT on post HTX survival. United Network for Organ Sharing (UNOS) registry was queried for all adult heart transplant recipients (HTR) from 1999 to 2018. Serum Creatinine levels were used as a marker for renal function. We stratified the HTR based on serum creatinine values (mg/dl) at time of transplant into five groups: Group 1: 0-1mg/dl, Group 2: 1.1-1.5mg/dl, Group 3: 1.6-2mg/dl, Group 4: 2.1-3mg/dl, and Group 5: 3-4 mg/dl. A creatinine level >4mg/dl was excluded from the analysis. Kaplan-Meier survival analysis (KM), Cox regression modelling and logistic regression were used in our analysis. 34,968 patient records were analyzed and stratified into the various groups (Table). KM survival analysis showed increased survival with lower creatinine levels (p<0.0001) (Fig). On adjusting for confounding variables including diabetes, age, gender and ethnicity it was observed that creatinine had an impact on survival (p<0.0001). Logistic regression analysis of serum creatinine levels on patient graft status in 33,216 patients demonstrated that there were 11,362 deaths in total. Adjusting for similar confounders as in our previous analysis also showed that creatinine level has an impact on graft status . PRFT has a positive impact on both short-term and long-term post-transplant survival. With many patients being predisposed to a spectrum of metabolic disorders, it is apparent that PRFT is an integral part of evaluation and prediction of survival following HTX. The patho-physiological synergy between the cardiac and renal systems evidently justifies that pre-transplant optimization of renal function leads to an increased short-term and long-term post-transplant survival.

Heart Transplantation in Muscular Dystrophy Patients: Is it a Viable Option?

Cardiomyopathy is a common complication among muscular dystrophy (MD) patients and often results in advanced heart failure and premature death. In spite of this, there is hesitancy to consider heart transplantation (HTx). This study describes the HTx outcomes in patients with MD in the United States. All HTx in the United Network for Organ Sharing database from October 1, 1987, to March 31, 2016, were identified. Two patient groups were created: MD cohort (n=81), and a cohort of all other cardiomyopathies, called cardiomyopathy-unmatched (n=41 317). Propensity score matching (ratio 1:2) was performed on transplant age, gender transplant year, renal function, and inotropic support at transplant to form a cardiomyopathy-matched cohort (n=162). Patient characteristics and posttransplant outcomes were compared. In the 81 patients with MD, Becker was the most common type (42%-52%). All the analyzed preoperative characteristics did not statistically differ between the MD and cardiomyopathy-matched cohorts except ventricular assist device use (16% versus 30%; P=0.017), ventilator support (0% versus 6%; P=0.031), and donor race mismatch (30% versus 55%; P<0.001). Median time on waitlist was not statistically different between the 2 groups (52 versus 59 days; P=0.12). Posttransplant survival of MD cohort was not statistically different compared with cardiomyopathy-matched cohort (P=0.18; hazard ratio [95% CI], 0.71 [0.42-1.18]) and was better than the cardiomyopathy-unmatched cohort (P=0.004; hazard ratio [95% CI], 0.53 [0.34-0.82]). Among the types of MD, no statistical difference was observed in posttransplant survival of Becker MD versus non-Becker MD (P=0.12; hazard ratio [95% CI], 2.17 [0.79-6.01]). Patients with MD undergoing HTx had similar long-term posttransplant survival compared with matched cardiomyopathy-related HTx recipients. HTx appears to be an effective treatment for a select group of muscular dystrophy patients with end-stage heart failure.

Highlights From the Circulation Family of Journals.

Highlights From the Circulation Family of Journals.

An approach to diagnosing and managing diffuse lung disease presenting in the newborn period

Although rare, diffuse lung disease is increasingly recognised as a cause of respiratory distress in newborns. However, many cases remain undiagnosed as not all clinicians are aware that these diseases may present during the newborn period. An increased index of suspicion is required in newborns not responding to conventional management, those with rapid deterioration of respiratory function and those with a family history of lung disorders. A structured diagnostic approach including radiography, genetic testing and lung histology should be followed, whereby a multidisciplinary team (neonatologist, pulmonologist, geneticist, radiologist and histopathologist) is involved. The mainstay of management is mostly supportive, and may include ventilation, infection prevention and control and nutritional support. Pharmacological therapy is based on anecdotal evidence. Although lung transplantation may be considered in some facilities, long-term post-transplant survival is poor.

Donation after Circulatory Death (DCD): A 10-Year Experience in Bilateral Lung Allograft Survival at a Single Australian Center

Purpose Early and intermediate lung transplant outcomes for DCD are equivalent to donation-after-brainstem-death. Our aim is to describe long-term graft survival for lung transplant recipients since the implementation of DCD. Methods A retrospective cohort analysis was conducted of all bilateral lung transplant patients at a single center between Nov-2007 and Sep-2018. The method of donation was collected for all recipients in additional to baseline surgical co-variates. The mechanism of death in DCD donation were categorised into cerebrovascular event, hypoxic injury and trauma. Graft survival was defined as the time to death or retransplantation. For survival analysis, Kaplan-Meier curves were generated for the donation type and compared using the Log Rank test. Results 485 patients underwent bilateral lung transplant during the study period. 98 patients received a DCD donor and 387 patients received a DBD donor. There were no significant differences between the groups in recipient age, donor age, pre-explantation donor PaO2, % CMV mismatch, recipient BMI or length of hospital stay for transplant admission. There were no significant differences in the proportions of native lung disease, except for a greater number of patients with pulmonary hypertension in the DCD group (9.2 vs 1.6%, p Conclusion There was no significant difference in the long-term graft survival benefit gained from bilateral lung transplantation depending on the mode of donation (DCD vs DBD). Our experience confirms that DCD donation is a viable mode of donation which serves to increase recipient access to transplantation with no apparent decrease in long-term post-transplant survival.

Center Variation in Hospital Costs for Pediatric Heart Transplantation: The Relationship Between Cost and Outcomes.

There are limited published data addressing the costs associated with pediatric heart transplantation and no studies evaluating the variation in costs across centers. We aimed to describe center variation in pediatric heart transplant costs and assess the association of transplant hospitalization costs with patient outcomes. Using a linkage between the Pediatric Health Information System and Scientific Registry of Transplant Recipients databases, hospital costs were assessed for patients (< 18yearsof age) undergoing heart transplantation (2007-2016). Severity-adjusted patient costs were calculated using generalized linear mixed-effects models with a random hospital intercept. Center variation in hospital cost was described after adjusting for the predicted risk of in-hospital mortality. Post-transplant survival was compared between low- and high-cost centers using Cox proportional hazard models. A total of 2156 patients were included from 24 centers. There was 3.7-fold variation in transplant hospitalization costs across centers, ranging from $329,477 to $1,226,507. Patients transplanted at high-cost centers have a higher predicted risk of in-hospital mortality (8.1% vs. 6.1%, p < 0.001). Both early (p = 0.008) and long-term (p = 0.003) post-transplant survival were better in patients transplanted at low-cost centers. Transplant at low-cost centers was associated with improved post-transplant survival, independent of patient-specific risk (adjusted hazard ratio 0.72; 95%CI 0.57-0.92, p = 0.008). There is wide variation in cost for pediatric heart transplant inpatient care among U.S. centers with low-cost centers demonstrating the best patient survival. Differences in patient populations likely contribute to these findings, but cannot account for all the variation seen. This suggests that variability in the delivery of care across centers may influence post-transplant survival.

Nonalcoholic Fatty Liver Disease: Epidemiology, Liver Transplantation Trends and Outcomes, and Risk of Recurrent Disease in the Graft.

In parallel with the rising prevalence of metabolic syndrome globally, nonalcoholic fatty liver (NAFL) disease is the most common chronic liver disease in Western countries and nonalcoholic steatohepatitis (NASH) has become increasingly associated with hepatocellular carcinoma. Recent studies have identified NASH as the most rapidly growing indication for liver transplantation (LT). As a hepatic manifestation of the metabolic syndrome, NAFL disease can be histologically divided into NAFL and NASH. NAFL is considered a benign condition, with histological changes of hepatocyte steatosis but without evidence of hepatocellular injury or fibrosis. This is distinct from NASH, which is characterized by hepatocyte ballooning and inflammation, and which can progress to fibrosis and cirrhosis, hepatocellular carcinoma, and liver failure. As for any other end-stage liver disease, LT is a curative option for NASH after the onset of decompensated cirrhosis or hepatocellular carcinoma. Although some studies have suggested increased rates of sepsis and cardiovascular complications in the immediate postoperative period, the long-term posttransplant survival of NASH cases is similar to other indications for LT. Recurrence of NAFL following LT is common and can be challenging, although recurrence rates of NASH are lower. The persistence or progression of metabolic syndrome components after LT are likely responsible for NASH recurrence in transplanted liver. Therefore, while maintaining access to LT is important, concerted effort to address the modifiable risk factors and develop effective screening strategies to identify early stages of disease are paramount to effectively tackle this growing epidemic.

The Development of Pulmonary Hypertension Results in Decreased Post-Transplant Survival.

The effects of pulmonary hypertension (PAH) on survival after heart transplantation are debated, especially for patients with left ventricular assist devices (LVAD). The United Network of Organ Sharing database was retrospectively queried from January 2005 to June 2015 to identify adult patients who underwent heart transplantation. Four groups were defined: patients without PAH, persistent PAH, resolved PAH, and developed PAH between listing and transplant. A total of 15,914 patients underwent heart transplant of which 4,662 (29%) were implanted with an LVAD. Of the total population, 10,872 (68%) had PAH at time of listing and 9,661 (61%) had PAH at time of transplant. Long-term survival was significantly worse for patients with an LVAD than for those without who had PAH at time of transplant (p = 0.010). Kaplan-Meier analysis showed a trend of worse long-term survival for patients with an LVAD who developed PAH by the time of transplant but improved survival for patients with resolved PAH while on LVAD therapy (p = 0.052). PAH at time of transplant results in worse long-term survival for patients with an LVAD. Furthermore, the development of PAH while on LVAD therapy may negatively impact long-term post-transplant survival, while resolution of PAH improves long-term survival.

Long-term heart transplant outcomes after lowering fixed pulmonary hypertension using left ventricular assist devices.

Fixed pulmonary hypertension (fPH) is a contraindication for heart transplantation (HTX). Left ventricular assist device (LVAD) implantation as a bridge to candidacy can reverse fPH in patients with terminal heart failure by chronic left ventricular unloading. We report our institutional experience with terminal heart failure patients and fPH that were successfully bridged to candidacy and underwent subsequent HTX. We retrospectively reviewed the data of 79 patients with terminal heart failure and fPH who were successfully bridged to candidacy for HTX with 6 different LVAD devices at our centre from October 1998 to September 2016 (Novacor n = 4, MicroMed DeBakey n = 29, DuraHeart n = 2, HeartMate II n = 14, HVAD n = 29 and MVAD n = 1). Median duration of LVAD support was 288 days (range 45-2279 days). Within the same timeframe, a control group of 48 patients underwent HTX after bridge-to-transplant LVAD therapy for reasons other than PH. Study end points were (i) development of fPH after LVAD implantation, (ii) post-transplant outcomes and (iii) incidence of severe adverse events. Pulmonary vascular resistance, assessed by vasodynamic catheterization, was 4.3 ± 1.8 WU before LVAD implantation. After a median support period of 89 days (interquartile range 4-156 days), pulmonary vascular resistance decreased to 2.0 ± 0.9 WU (P ≤ 0.001), and patients were listed for HTX. Median duration of LVAD support in the study group was 288 days (45-2279 days). We observed 2 patients (2.5%) with acute right heart failure who required extracorporeal mechanical support after HTX in the study group. Long-term post-transplant survival between the study group (3 years: 83.5%, 5 years: 81.0%) and the control group (3 years: 87.5%, 5 years: 85.4%) was comparable (log-rank: P = 0.585). LVAD implantation as a bridge to candidacy reverses fPH in patients with terminal heart failure. Post-HTX survival is excellent and comparable to results obtained in patients without fPH at the time of HTX listing.

Center Effect on Long-term Post-transplant Survival Among Currently Active United States Heart Transplant Centers

Center Effect on Long-term Post-transplant Survival Among Currently Active United States Heart Transplant Centers