Mortality In Heart Transplantation Research Articles

A new heart transplant resource: DBD donor with out-of-hospital cardiac arrest

Abstract The aim of the present study is to analyze the differences in terms of cardiac transplant survival in organ recipients from a DBD (donor with brain death) donor characterized by out-of-hospital cardiac arrest (OHCA) and from a DBD donor not characterized by OHCA, in order to find new strategies to expand the donor pool. We analyzed the differences in mortality 30 days and 120 days after transplantation between the two groups of recipients, the length of stay in the ICU, the length of post-operative stay in the hospital, mechanical ventilation, the use of ECMO, the use of CVVH and the possible occurrence of ischemic and/or haemorrhagic stroke. 78 patients were compared: 13 recipients from a donor with OHCA with an average age of 55.18 (44.35 - 63.1) and 65 recipients from a donor without OHCA with an average age of 57.74 (50.9 - 66). The populations under study presented almost the same characteristics in terms of initial diagnosis, risk factors, comorbidities and list status. Comparing the results, no statistically significant differences were found between the two groups for ICU stay (p=1.000), for in-hospital stay (p=0.920) and for mechanical ventilation (p=0.95 ). No statistically significant difference was detected between the two groups even in terms of ECMO support (p=0.90), ischemic stroke (p=0.70), hemorrhagic stroke (p=0.781). From the analysis of the survival curves it can be seen that there is no statistically significant difference between the two groups either with regard to 30-day mortality (p=0.905) or 120-day mortality (p=0.957). The use of a DBD donor with OHCA represents a valid resource in the field of heart transplantation. In the present study it does not affect the recipient's survival rate. 30 days after heart transplantation mortality is conditioned by the intrinsic characteristics of the recipients.Kaplan-Meier 30 day survivalKaplan-Meier 30 day survival

Regional disparities in heart transplant mortality in the United States.

Mortality after heart transplantation can be influenced by multiple factors. This study analyzed its variation across 4 regions of the United States. Analyze the differences in mortality among patients receiving a heart transplant across 4 regions of the United States. Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) registry was analyzed for adult heart transplant recipients from 1987-2023. They were divided into 4 regions according to heart transplant recipients' residence: the Northeast, Midwest, South, and West. The endpoint was all-cause mortality. A total of 33,482 heart transplant recipients were included in the analysis. Baseline characteristics differed by region. The median survival (years) was lower in the South [Northeast 12.9 (6.1-17.9), Midwest 13.1 (6.5-18.1), South 11.6 (5.3-16.8), West 13.6 (7.0-18.6); p<0.0001]. Mortality incidence rate was greater in the South. When compared to the Northeast, in the unadjusted analysis, mortality was higher in the South [HR 1.13 (95%CI 1.07-1.19), p<0.001] and lower in the West [HR 0.89 (95%CI 0.83-0.94), p<0.001]. After adjusting for demographic and clinical variables, only the South retained significant differences [HR 1.17 (95%CI 1.10-1.24), p<0.001]. Mortality significantly increased in all regions after 2018. Mortality of heart transplant recipients varies across region of residence in the United States. A significant increase in adjusted mortality was observed in the South. These findings suggest that there are regional disparities in the mortality rates of heart transplant recipients.

Comparative Temporal Analysis of Morbidity and Early Mortality in Heart Transplantation with Extracorporeal Membrane Oxygenation Support: Exploring Trends over Time.

The direct bridge to urgent heart transplant (HT) with venoarterial extracorporeal membrane oxygenation (VA-ECMO) support has been associated with high morbidity and mortality. The objective of this study is to analyze the morbidity and mortality of patients transplanted with VA-ECMO and compare the presumed differences between various eras over a 17-year timeline. This is a prospective, observational study on consecutive patients stabilized with VA-ECMO and transplanted with VA-ECMO from July 2007 to December 2023 at a reference center (98 patients). Objective variables were mortality and morbidity from renal failure, venous thromboembolic disease (VTD), primary graft dysfunction (PGD), the need for tracheostomy, severe myopathy, reoperation, post-transplant ECMO, vascular complications, and sepsis/infection. The percentage of patients who reached transplantation without the need for mechanical ventilation has increased over the periods studied. No significant differences were found between the study periods in 30-day mortality (p = 0.822), hospital discharge (p = 0.972), one-year mortality (p = 0.706), or five-year mortality (p = 0.797). Survival rates in these periods were 84%, 75%, 64%, and 61%, respectively. Comorbidities were very frequent, with an average of 3.33 comorbidities per patient. The most frequent were vascular complications (58%), the need for post-transplant ECMO (57%), and myopathy (55%). The development of myopathy and the need for post-transplant ECMO were higher in recent periods (p = 0.004 and p = 0.0001, respectively). VA-ECMO support as a bridge to HT allows hospital discharge for 3 out of 4 transplanted patients. This survival rate has not changed over the years. The comorbidities associated with this device are frequent and significant.

Donor great vessel free arterial grafts for complex reconstruction during pediatric heart transplantation

ObjectivePrior studies suggest that prolonged donor heart warm ischemia time increases heart transplant mortality. Patients with single-ventricle heart disease requiring transplant with concomitant aortic arch or central pulmonary artery reconstruction present technical challenges that extend donor warm ischemia time using conventional techniques. Studies in larger pediatric and adult patients with single-ventricle anatomy have described the use of prosthetic material for concomitant great vessel reconstruction. We have used donor free arterial grafts to simplify concomitant great vessel reconstructions and reduce warm donor ischemia time in small patients with single-ventricle physiology undergoing heart transplant. The purpose of this study is to review our results in these patients. MethodsChildren with single-ventricle heart disease who underwent free donor arterial graft great vessel reconstruction at heart transplant were identified, divided into aortic arch and central pulmonary artery groups, and retrospectively reviewed. Warm and total ischemia times were recorded contemporaneously at transplant. ResultsFifteen pediatric patients with single-ventricle physiology underwent donor free arterial graft great vessel reconstructions (9 aortic arch, 6 pulmonary artery). Mean donor warm and total ischemia times for the entire cohort were 52.8 ± 10.7 and 341.7 ± 41.2 minutes. Two patients required postoperative extracorporeal membrane oxygenation. Hospital survival was 94% (1 death). There were no late deaths, and 2 patients had late retransplant. There were no early or late aortic or pulmonary artery obstructions, reinterventions, or complications at median follow-up of 14.2 years (interquartile range, 4.2-16.3 years). ConclusionsDonor free arterial grafts for concomitant great vessel reconstruction during heart transplant in small, single-ventricle patients reduces warm ischemia time, simplifies technical demands, and preserves growth potential.

Impact of Heart Failure Etiology on Waitlist Mortality in Heart Transplant Candidates Supported With Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) has gained traction as a bridge to heart transplantation (HT) but remains associated with increased waitlist mortality. This study explores whether this risk is modified by underlying heart failure (HF) etiology. Using the Organ Procurement and Transplantation Network registry, we conducted a retrospective review of first-time adult HT candidates from 2018 through 2022. Patients were categorized as "ECMO", if ECMO was utilized during the waitlisting period, or "No ECMO" otherwise. Patients were then stratified according to the following HF etiology: ischemic cardiomyopathy (CMP), dilated nonischemic CMP, restrictive CMP, hypertrophic CMP, and congenital heart disease (CHD). After baseline comparisons, waitlist mortality was characterized for ECMO and HF etiology using the Fine-Gray regression. A total of 16143 patients were identified of whom 7.0% (n=1063) were bridged with ECMO. Compared to No ECMO patients, ECMO patients had shorter waitlist durations (46.3 vs. 185.0 days, p<0.01) and were more likely to undergo transplantation (75.3%vs. 70.3%, p<0.01). Outcomes analysis revealed that ECMO was associated with increased mortality risk (subdistribution hazard ratio [SHR]: 3.42, p<0.01), a risk that persisted in all subgroups and was notably high in CHD (SHR: 4.83, p<0.01) and hypertrophic CMP (SHR: 9.78, p<0.01). HF etiology comparison within ECMO patients revealed increased mortality risk with CHD (SHR: 3.22, p<0.01). Within No ECMO patients, hypertrophic CMP patients had lower mortality risk (SHR: 0.64, p=0.03). The increased waitlist mortality risk with ECMO persisted after stratification by HF etiology. These findings can help decision-making surrounding candidacy for cannulation and prognostic evaluation.

Donor-derived cell-free DNA, gene expression profile, and acute rejection in donation after circulatory death (DCD) heart transplant recipients

BackgroundAcute rejection (AR) is a leading cause of early morbidity and mortality in heart transplant (HTx) recipients. There is limited data in donor after circulatory death (DCD) HTx recipients where ischemia reperfusion injury may contribute to development of AR and may be detected early with non-invasive biomarkers such as donor-derived cell-free DNA (dd-cfDNA) and gene expression profile (GEP). The goal of this study is to compare dd-cfDNA, GEP and rejection outcomes in DCD and donor after brain death (DBD) HTx recipients. MethodsThis single-center, retrospective study included DCD and DBD HTx recipients from January 2020 to September 2022. Patients were excluded from the study if dd-cfDNA and GEP were not available. The CareDx HeartCare platform was used to obtain dd-cfDNA (AlloSure-Heart) and GEP (AlloMap) with the highest values for each patient recorded at 6 and 12 months. The mean values for these non-invasive markers were compared between DCD and DBD groups. Patients were followed for clinical outcomes, including treated AR, coronary allograft vasculopathy (CAV) and death, through September 2023. ResultsA total of 156 HTx patients were included with 50 DCD and 106 DBD recipients. Baseline characteristics were similar between DCD and DBD recipients including mean age (58.5 years vs 56.9 years, p = 0.48), male sex (82% vs 76%, p = 0.56) and Caucasian race (46% vs 43%, p = 0.78). There were no significant differences in mean AlloSure-Heart at 6 and 12 months between DCD and DBD recipients. AlloMap was significantly lower at 6 months (p = 0.04), but not at 12 months between DCD and DBD recipients. With respect to clinical outcomes at 1 year, there were no significant differences in treated AR (22% vs 14%, p = 0.32), ISHLT grade ≥ 2 CAV (0 vs 4%, p = 0.44) or mortality (2% vs 0%, p = 0.69) between DCD and DBD recipients. ConclusionsIn this single center study, there were no significant differences in mean dd-cfDNA and treated AR at 1 year between DCD and DBD HTx recipients. There was a significant increase in mean GEP at 6 months, but not at 12 months in the DBD cohort. Overall, there does not appear to be clinically significant cardiac allograft injury related to DCD as measured by non-invasive markers. Further work is needed to confirm these findings.

Feasibility of Interleukin-6 Receptor Blockade in Cardiac Antibody-mediated Rejection.

Antibody-mediated rejection (AMR) remains a significant cause of heart transplant mortality with few effective therapies. This study aimed to describe initial experience of using interleukin-6 receptor blockade with tocilizumab in the treatment of acute cardiac AMR at Barnes-Jewish Hospital/Washington University Transplant Center from July 2017 to May 2021 (n = 7). Clinical, echocardiographic, and serum alloantibody data were analyzed before and after treatment. All participants demonstrated marked improvement in functional status. Echocardiographic data following 4-6 mo of tocilizumab revealed significant improvements in biventricular systolic function for all participants. Consistent reductions in donor-specific HLA or angiotensin type I receptor antibodies were not observed, suggesting that tocilizumab may act downstream of antibody production. No patient experienced drug-related complications that necessitated discontinuation of therapy. These findings provide initial insights into the safety and efficacy of interleukin-6 receptor blockade in the treatment of cardiac AMR and support the design of larger prospective studies.

Risk Factors for 1-Year Mortality After Heart Transplant in Obese Patients Bridged With an LVAD

BackgroundHeart transplantation is relatively contraindicated in morbidly obese patients because of increased morbidity and mortality. This study identified risk factors for post–heart transplantation mortality in obese patients with a left ventricular assist device (LVAD). MethodsThe United Network for Organ Sharing database was used to identify patients with a body mass index ≥35 kg/m2 who had a durable LVAD at the time of isolated heart transplantation between 2010 and 2021. The primary outcome was post–heart transplantation 1-year mortality. Multivariable Cox regression modeling was used to identify significant risk factors for 1-year mortality. Receiver-operating characteristic analyses were performed to identify optimal thresholds for continuous variables associated with the primary outcome. Patients were stratified by the number of risk factors, and Kaplan-Meier analysis was used to compare survival. ResultsA total of 1222 obese patients were bridged to heart transplantation with a durable LVAD. Six risk factors were identified as significantly associated with 1-year post–heart transplantation mortality: recipient age >62.5 years, body mass index >36.6 kg/m2, bilirubin level >0.95 mg/dL, cold ischemic time >3.7 hours, recipient-donor sex mismatch, and pretransplantation mechanical ventilation. The distribution of cumulative risk factors was as follows: 8.6% with 0, 30.6% with 1, 37.0% with 2, and 23.8% patients with ≥3 risk factors. The 1-year survival rate decreased significantly from 96.0% in those patients with 0 risk factors to 77.6% in those with 3 or more risk factors. ConclusionsThese data provide a useful guide for risk stratification and patient selection in obese LVAD candidates being considered for heart transplantation.

COVID-19 in heart transplant recipients.

Introduction: After solid organ transplantation, patients require lifelong immunosuppressive medication, increasing susceptibility to COVID-19. We evaluated the clinical outcomes of heart transplant recipients in patients with COVID-19. Methods: We enrolled twenty-two COVID-19 cases of adult heart transplantation from February 2020 to September 2021. Results: The most common symptoms in patients were fever and myalgia. The death occurred in 3 (13.6 %). Conclusion: Although heart transplantation mortality may increase in the acute rejection phase concomitant with COVID-19, immunosuppressive dose reduction may not be necessary for all heart transplant patients with COVID-19.

Abstract 12595: De Novo Lymphoproliferative Disorders in Heart Transplant Recipients: Predictors and Clinical Outcomes

Introduction: Post-transplant lymphoproliferative disorder (PTLD) is an important cause of morbidity and mortality in heart transplant (HTx) recipients. However, clinical characteristics and predictors of PTLD in the real world have not been well studied. Methods We retrospectively analyzed clinical characteristics, predictors, and outcomes of PTLD, in 28,136 recipients of heart alone transplants between January 2000 and June 2015 from the International Society for Heart and Lung Transplantation Thoracic Organ Transplant Registry. Results Ten-year incidence of PTLD after successful discharge from HTx during 2000-2007 was 3.8%. The adjusted overall risk of mortality was significantly higher in patients diagnosed with PTLD within 3 years after HTx compared to those without PTLD (HR 2.22, 95% CI 1.86-2.65, p&lt;0.001). Bimodal age peak of the PTLD incidence within the 3 years of HTx and mortality after the diagnosis of PTLD was noted. Both adjusted risk of PTLD incidence and mortality were lower in recent HTx; lower incidence and mortality in era of 2008-2015, compared to 2000-2007 (Incidence: HR 0.75, 95% CI 0.57-0.98, p=0.038) (Mortality: HR 0.86, 95% CI 0.81-0.91, p&lt;0.001). Age at transplant, male recipient, high risk Epstein-Barr virus (EBV) mismatch (donor positive and recipient negative for EBV) were independent risk factors, while primary maintenance therapy with cyclosporine (vs. tacrolimus) at initial discharge was a protective factor for PTLD within 3 years. Conclusions The incidence as well as mortality of PTLD has decreased in recent years of HTx, possibly with advances in changed pattern of immunosuppression according to patient profile. Clinical characteristics such as age, male gender, EBV status and rejection history are key factors for assessing the risk of PTLD, which can be detrimental in the course of post HTx care.

Characteristics, outcomes, and predictors of de novo malignancy after heart transplantation.

BackgroundPost-transplant malignancy (PTM) causes long-term morbidity and mortality in heart transplant (HTx) recipients. However, the detailed characteristics or predictors of PTM are not well-known. We evaluated the incidence, characteristics, long-term outcomes, and predictors of de novo PTM using a single center large-volume database.MethodsWe retrospectively analyzed the types and characteristics of de novo PTM in 989 patients who underwent HTx. Univariate and multivariate logistic regression analyses were used for the PTM prediction model.ResultsTwo hundred and six patients (20.8%) had de novo PTMs (241 cancers) during a median follow-up of 11.5 years. PTM patients were older than non-PTM patients, received immunosuppressive therapy for a longer period, and were more likely to be male and white. Skin cancers were the most frequent types of malignancy (60.6%) followed by prostate (9.5%), lung (7.1%), and breast (4.1%) cancers. Although most cancers (88.8%) were surgically resected at initial presentation, about half (47.3%) recurred or progressed. Patients with skin cancer and non-skin cancer had significantly lower overall survival (P < 0.001) than patients without cancer. Older age (P < 0.001), white race (P = 0.001), and longer time receiving immunosuppressive therapy (P < 0.001) were independent predictors for PTM.ConclusionOlder age, white race, and longer administration of immunosuppressive therapies were independent risk factors for PTM, which was associated with increased mortality. Further research is necessary for the prevention and early detection of PTM in HTx recipients.

Utility of the IMPACT score for predicting heart transplant mortality. Analysis on a contemporary cohort of the Spanish Heart Transplant Registry.

The Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score was derived and validated as a predictor of mortality after heart transplantation (HT). The primary objective of this work is to externally validate the IMPACT score in a contemporary Spanish cohort. Spanish Heart Transplant Registry data were used to identify adult (>16 years) HT patients between January 2000 and December 2015. Retransplantation, multiorgan transplantation and patients in whom at least one of the variables required to calculate the IMPACT score was missing were excluded from the analysis (N=2810). Median value of the IMPACT score was five points (IQR: 3, 8). Overall, 1-year survival rate was 79.1%. Kaplan-Meier 1-year survival rates by IMPACT score categories (0-2, 3-5, 6-9, 10-14, ≥15) were 84.4%, 81.5%, 79.3%, 77.3%, and 58.5%, respectively (Log-Rank test: p<.001). Performance analysis showed a good calibration (Hosmer-Lemeshow chi-square for 1 year was 7.56; p=.47) and poor discrimination ability (AUC-ROC .59) of the IMPACT score as a predictive model. In a contemporary Spanish cohort, the IMPACT score failed to accurately predict the risk of death after HT.

Machine learning and artificial intelligence in cardiac transplantation: A systematic review.

BackgroundThis review aims to systematically evaluate the currently available evidence investigating the use of artificial intelligence (AI) and machine learning (ML) in the field of cardiac transplantation. Furthermore, based on the challenges identified we aim to provide a series of recommendations and a knowledge base for future research in the field of ML and heart transplantation.MethodsA systematic database search was conducted of original articles that explored the use of ML and/or AI in heart transplantation in EMBASE, MEDLINE, Cochrane database, and Google Scholar, from inception to November 2021.ResultsOur search yielded 237 articles, of which 13 studies were included in this review, featuring 463 850 patients. Three main areas of application were identified: (1) ML for predictive modeling of heart transplantation mortality outcomes; (2) ML in graft failure outcomes; (3) ML to aid imaging in heart transplantation. The results of the included studies suggest that AI and ML are more accurate in predicting graft failure and mortality than traditional scoring systems and conventional regression analysis. Major predictors of graft failure and mortality identified in ML models were: length of hospital stay, immunosuppressive regimen, recipient's age, congenital heart disease, and organ ischemia time. Other potential benefits include analyzing initial lab investigations and imaging, assisting a patient with medication adherence, and creating positive behavioral changes to minimize further cardiovascular risk.ConclusionML demonstrated promising applications for improving heart transplantation outcomes and patient‐centered care, nevertheless, there remain important limitations relating to implementing AI into everyday surgical practices.

Hemodynamic Implications of Sildenafil in Candidates for Heart Transplantation with Group 2 Pulmonary Hypertension: A Single Latin-American Center Registry

<h3>Purpose</h3> Heart failure is the most common cause of Group 2 pulmonary hypertension (PH). When it becomes fixed, it increases morbidity and mortality in heart transplantation (HTx). Reversing this situation is difficult, but the use of selective pulmonary vasodilators such as sildenafil could be a simple pharmacological tool in this setting. <h3>Objectives</h3> To analyze the prevalence of PH and the effect of Sildenafil in HTx candidates and its impact on mortality. <h3>Methods</h3> Patients who had undergone HTx over a ten-year period were analyzed retrospectively. PH was defined as mean pulmonary artery pressure (PAP) ≥25mmHg and/or pulmonary vascular resistance (PVR) > 3UW. Among the P with PH those who received sildenafil (Group A) and those who did not (Group B) were compared. Quantitative variables were compared with t-test or Mann-Whitney, and nominals with Fisher's test. Survival was analyzed using the log-rank test. A p<0.05 was considered significant <h3>Results</h3> From 01/2008 to 12/2018, 294 P undergone HTx, 30 P (10%) with combined transplantation, pediatric, re-transplantation, and without data, were excluded. Of the 217 P analyzed, 153 P (70%) presented PH, of whom 77P (51%) received sildenafil. Baseline characteristics are described in Table 1a. The causes for which 76 P (49%) with PH did not receive treatment with sildenafil were: intolerance to vasodilators, treatment with vasopressors, pulmonary congestion, and a tendency to reserve selective pulmonary vasodilators for those patients under previous treatment with ACEIs, ARAII or ARNI. Table 1b describes the hemodynamic variables for both groups. Table 1a shows a decrease in MPAP, transpulmonary gradient, and PVR without changes in cardiac index in Group A. There was no difference in mortality between both groups (graphic 1) <h3>Conclusion</h3> The use of Sildenafil in P with Group 2 PH could be an effective strategy to improve the hemodynamic profile during the candidacy for HTx, without impact on survival.

Primary Graft Dysfunction After Heart Transplantation: Incidence and Current Risk Factors

<h3>Purpose</h3> Primary graft dysfunction (PGD) is a leading cause of perioperative mortality in heart transplant (HT). Yet the impact of the current increased use of high-risk recipients and donors for HT on the incidence of PGD is unknown. <h3>Methods</h3> This is a retrospective single-center study of adult patients who underwent isolated heart or heart-kidney transplant from January 2018 to March 2020 to evaluate the incidence and patient characteristics associated with PGD, as defined by the International Society for Heart and Lung Transplantation consensus guidelines. Baseline characteristics and postoperative outcomes were compared between patients with no/mild PGD versus moderate/severe PGD. Multivariate logistic regression was used to determine independent predictors of PGD. <h3>Results</h3> One-hundred seventeen patients were evaluated: 105 (89.7%) had no/mild PGD and 12 (10.3%) had moderate/severe PGD. Patients with moderate/severe PGD were less likely to be bridged to transplant with temporary mechanical circulatory support (MCS) (8.3% versus 55.2%, p=0.002) and were more likely to receive undersized hearts (donor/recipient weight ratio 0.93±0.14 versus 1.12±0.26, p=0.008). Moderate/severe PGD patients had a higher postoperative median vasoactive inotropic score (24.97 versus 6.50, p<0.001) and only one moderate/severe PGD patient required postoperative extracorporeal membrane oxygenation (ECMO). By multivariate analysis, undersized donor (odds ratio [OR] 1.055; 95% confidence interval [CI] 1.003-1.127, p<0.001) was an independent predictor of PGD and pre-transplant temporary MCS was a negative predictor of PGD (OR 0.075; 95% CI 0.003-0.580, p=0.033). <h3>Conclusion</h3> In this experience with HT in high acuity recipients, the incidence of moderate/severe PGD is low and need for post-transplant ECMO is rare. Interestingly, these data suggest that use of pre-transplant temporary MCS may be protective against moderate/severe PGD, and further investigation of this approach is indicated.

Contemporary US Trends In Heart Transplantation And LVAD Index Hospitalizations: Volumes Increase, Utilization And Cost Vary Over Time, 2015-2018

<h3>Introduction</h3> : From 2009-2014, total index hospitalizations and annual expenditures for heart transplantation (HT) and LVAD doubled, but more contemporary trends utilization and cost are not well understood. <h3>Methods and Results</h3> From 2015-2018, we identified 10,435 HT and 16,455 LVAD implantation index hospitalizations from the National Inpatient Sample. Hospitalizations for both increased over the study period, but less for LVAD (HT:2235 to 2955, LVAD: 3985 to 4045). For HT, length of stay (LOS) decreased but total costs and in-hospital mortality increased, (p≤0.005, all). For LVAD implantation, LOS and inpatient mortality increased (both p≤0.005) but total costs were stable. A higher percentage of HT admissions were discharged to home compared to those for LVAD implantation (<b>Table 1</b>). For both cohorts, admissions of Asian patients on Medicaid were the costliest (HT: median $361,068 [interquartile range (IQR) $165,938-595,240], LVAD: $459,419 [$270,332-583,858]). Those of Hispanic patients had the highest in-hospital mortality and longest LOS, all p<0.001. Women had longer median LOS for both, but lower in-hospital mortality in HT only, all p≤0.014 (<b>Table 2</b>). <h3>Conclusions</h3> : Hospitalization volume and in-hospital mortality increased for both, but LOS and totals costs varied for HT vs LVAD implantation. More work is needed to understand these disparities and post-discharge utilization and cost.

Cardiac allograft vasculopathy: A review

Heart transplantation has become the standard of care for pediatric patients with end-stage heart disease, and outcomes have consistently improved over the last few decades. CAV, however, remains a leading cause of morbidity and mortality in heart transplantation and is the leading cause of death beyond 3years post-transplantation. We sought out to provide an in-depth overview of CAV in the pediatric heart transplant population. Database searches were conducted in both Medline and Embase on the topic of cardiac vasculopathy in pediatric heart transplant recipients. The search used five broad concept terms: heart transplant; pediatric; CAV; diagnosis, prognosis, and risk factors; and guidelines and reviews. References were captured if there was at least one term in each of the concepts. The search was limited to articles in the English language. A total of 148 articles were identified via the literature search with further articles identified via review of references. Pediatric data regarding the etiology and development of CAV remain limited although knowledge about the immune and non-immune factors playing a role are increasing. CAV continues to be difficult to detect with many invasive and non-invasive methods available, yet their effectiveness in the detection of CAV remains suboptimal. There remains no proven medical intervention to treat or reverse established CAV disease, and CAV is associated with high rates of graft loss once detected. However, several medications are used in hopes of preventing, slowing progression, or modifying the outcomes. This review provides a comprehensive overview of CAV, discusses its clinical presentation, risk factors, diagnostic tools used to identify CAV in the pediatric population, and highlights the current therapeutic options and the need for ongoing research.

Validation of Coronary Angiography-Derived Vessel Fractional Flow Reserve in Heart Transplant Patients with Suspected Graft Vasculopathy.

Cardiac transplant-related vasculopathy remains a leading cause of morbidity and mortality in heart transplant (HTx) recipients. Recently, coronary angiography-derived vessel fractional flow reserve (vFFR) has emerged as a new diagnostic computational tool to functionally evaluate the severity of coronary artery disease. Although vFFR estimates have been shown to perform well against invasive FFR in atherosclerotic coronary artery disease, data on the use of vFFR in heart transplant recipients suffering from cardiac transplant-related arteriopathy are lacking. The aim of the presented study was to validate coronary angiography-derived vessel fractional flow reserve to calculate fractional flow reserve in HTx patients with and without cardiac transplant-related vasculopathy. A prospective, single center study of HTx patients referred for annual check-up, undergoing surveillance coronarography was conducted. Invasive FFR was measured using a motorized device at the speed of 1.0 mm/s in all three major coronary arteries. Angiography-derived pullback FFR was derived from the angiogram and compared with invasive FFR pullback curve. Overall, 18,059 FFR values were extracted from the FFR pullback curves from 23 HTx patients. The mean age was 59.3 ± 9.7 years, the mean time after transplantation was 5.24 years [IQR 1.20, 11.25]. A total of 39 vessels from 23 patients (24 LAD, 11 LCX, 4 RCA) were analyzed. Mean distal vFFR was 0.87 ± 0.14 whereas invasive distal FFR was 0.88 ± 0.17. An excellent correlation was found between invasive distal FFR and vFFR (r = 0.92; p < 0.001). The correlation of the pullback tracing was high, with a correlation coefficient between vFFR and invasive FFR pullback values of 0.72 (95% CI 0.71 to 0.73, p < 0.001). The mean difference between vFFR and invasive FFR pullback values was −0.01 with 0.06 of SD (limits of agreements −0.12 to 0.13). In HTx patients, coronary angiography-derived FFR correlates excellently with invasively measured wire-derived FFR. Therefore, angiography derived FFR could be used as a novel diagnostic tool to quantify the functional severity of graft vasculopathy.

Validation of Coronary Angiography-Derived Vessel Fractional Flow in Heart Transplant Patients with Suspected Graft Vasculopathy

<h3>Purpose</h3> Cardiac transplant-related arteriopathy remains a leading cause of morbidity and mortality in heart transplant (HTx) recipients. Recently, vessel fractional flow reserve (vFFR) derived from coronary angiography has emerged as a new diagnostic computational tool to functionally evaluate the severity of coronary artery disease (CAD). Although vFFR estimates have been shown to perform well against invasive FFR in atherosclerotic CAD, data on the use of vFFR in HTx recipients are lacking. The aim was to validate coronary angiogram-derived FFR to calculate FFR in HTx patients with and without cardiac transplant-related arteriopathy. <h3>Methods</h3> Prospective, single center study of HTx patients referred for annual check-up, undergoing surveillance coronarography. Invasive FFR was measured using a motorized device at the speed of 1.0 mm/sec in all three major coronary arteries. Angiography-derived pullback FFR was derived from the angiogram and compared with invasive FFR pullback curve. <h3>Results</h3> Overall, 13634 FFR values were extracted from the FFR pullback curves from 19 HTx patients. The mean age was 60.8 ± 9.10 years, the mean time after transplantation was 5.88 years [IQR 1.10, 12.0]. A total of 29 vessels (19 LAD, 6 LCX, 4 RCA) were analysed. Mean distal vFFR was 0.91 ± 0.05 whereas invasive distal FFR was 0.92 ± 0.07. A good correlation was found between invasive distal FFR and vFFR (r =0.635; p <0.001). The correlation of the pullback tracing was high with a correlation coefficient between vFFR and invasive FFR pullback values of 0.72 (95% CI 0.71 to 0.73, p <0.001) (<b>Figure A</b>). The mean difference between vFFR and invasive FFR pullback values was -0.02 with 0.03 of SD (limits of agreements -0.08 to 0.04; <b>Figure B</b>). <h3>Conclusion</h3> In HTx patients coronary angiography-derived FFR correlates well with invasively measured wire-derived FFR. Angiography-derived FFR could be used as a novel diagnostic tool to quantify the functional severity of graft vasculopathy.

Hepatorenal dysfunction assessment with the Model for End-Stage Liver Disease Excluding INR score predicts worse survival after heart transplant in pediatric Fontan patients

BackgroundFontan physiology results in multiorgan dysfunction, most notably affecting the liver and kidney. We evaluated the utility of Model for End-Stage Liver Disease Excluding INR (MELD-XI) score, a score evaluating the function of both liver and kidney to identify Fontan patients at increased risk for morbidity and mortality post–heart transplant. MethodsThe Pediatric Heart Transplant Society database was queried to identify Fontan patients listed for heart transplant between January 2005 and December 2018. MELD-XI scores were calculated at listing and heart transplant. A multivariable analysis was conducted to identify risk factors for post–heart transplant mortality. Demographic, clinical characteristics, and survival differences were evaluated and compared between the high and low MELD-XI score cohorts. The impact of changing MELD-XI scores during the waitlist period on post–heart transplant outcomes was also evaluated. ResultsOf 565 Fontan patients who underwent transplantation, 524 (93%) had calculable MELD-XI scores at the time of heart transplant: 421 calculable at listing and 392 calculable at listing and at heart transplant. On multivariable analysis, only MELD-XI score (squared) (hazard ratio, 1.007), history of protein-losing enteropathy (hazard ratio, 2.1), and ventricular assist device use at transplant (hazard ratio, 3.4) were risk factors for early phase post–heart transplant mortality. Patients with high MELD-XI scores at heart transplant had inferior survival post–heart transplant (P = .02); those in the high MELD-XI score cohort at wait listing and heart transplant tend to have the worst post–heart transplant survival; however, this was not significant (P = .42). ConclusionsThe MELD-XI, an easily calculated score, serves as a valuable aid in identifying pediatric Fontan patients at increased risk for post–heart transplant mortality.