Outcome Of Cardiac Transplantation Research Articles

(445) - Longer Time from Death Determination Using Neurologic Criteria (DNC) to Cross Clamp is Associated with Worse Cardiac Transplant Outcomes

(445) - Longer Time from Death Determination Using Neurologic Criteria (DNC) to Cross Clamp is Associated with Worse Cardiac Transplant Outcomes

Outcomes related to hospital characteristics of heart transplant centers: A National Readmission Database analysis

IntroductionThis study showcases an analysis performed using the National Readmission Database (NRD) from 2016 to 2019 to analyze the impact of ownership, location, size, and teaching status of transplant centers on cardiac transplant outcomes. MethodsDemographic variables and hospital characteristics were identified using NRD data and International Classification of Diseases,10th revision (ICD-10) codes. Comorbidities were assessed using the Elixhauser comorbidity index. Multi-variable linear and logistic regression analysis were used to assess in-hospital mortality, 30-day and 180-day readmission rates, length of stay, days from admission to procedure, transfer to a rehab center, graft rejection, graft failure, and index admission total cost. ResultsMost cardiac transplants occurred in privately owned, large metropolitan areas, large bed size, and teaching centers. No significant difference was seen in In-hospital mortality, graft rejection, or graft failure by hospital ownership, location, size, or teaching status. Patients in private hospitals were more likely to be readmitted at 180 days and less likely to be transferred to rehab center compared to government owned hospitals. Patients in private, small bed size, and teaching centers were more likely to have shorter length of stay. Additionally, days of admission to procedure was shorter in small bed size and teaching centers. Furthermore, the cost of index-hospital stay was higher in privately owned, large metropolitan areas, large bed size, and teaching centers. ConclusionWhile in hospital mortality was not significantly different, various other outcomes related to cost and efficiency seem to be impacted by hospital characteristics.

Abstract 11805: Hidden Hazards: Unraveling Risk Factors for New-Onset Acute Heart Failure in Liver Transplant Recipients

Introduction: Heart failure with reduced ejection fraction (HFrEF) following liver transplantation (LT) is associated with increased morbidity and mortality. Early identification and optimization of risk factors associated with development of heart failure in LT recipients could improve cardiac and liver transplant outcomes. Hypothesis: The study's primary objectives were to ascertain the incidence of new-onset HFrEF post-liver transplant, identify the associated risk factors and understand their clinical outcomes. We hypothesized that certain demographic and clinical factors may predispose liver transplant recipients to develop new-onset HFrEF. Methods: Our retrospective cohort study included 568 liver transplant recipients at our center. Patients were categorized based on whether or not they developed new-onset HFrEF post LT We utilized descriptive statistics, chi-square tests, and logistic regression analyses to investigate potential associations between patient demographics, clinical risk factors and the development of new HFrEF . Results: The incidence of acute heart failure post-transplant was 8% (n=43). Within this group, 51% had HFrEF (LVEF<40%), 37% HFmrEF (LVEF 40-49%),12% HF with preserved EF. LVEF was significantly lower in the new-onset HF group [40(30-45) vs 60(55-65), p<0.001]. Median time to HF onset was 25 days. Coronary artery disease (OR 2.53, 95% CI 1.01-6.35, p=0.04) and malignancy history (OR 2.35, 95% CI 1.15-4.81, p=0.02) were significant predictors of new onset HFrEF. New onset HFrEF was associated with higher 180-day mortality (14% vs 6%, OR 2.57, 95% CI 1.00-6.56, p=0.048). Conclusions: Coronary artery disease and history of malignancy were identified as risk factors for new-onset HFrEF post-LT. Additional research is needed to better understand the impact of CAD and malignancy on cardiac and liver transplant outcomes that may result in improved patient care.

Contemporary outcomes of pediatric cardiac transplantation with a positive retrospective crossmatch.

A positive crossmatch (+ XM) has traditionally been associated with adverse outcomes following pediatric heart transplantation. However, more recent studies suggest that favorable intermediate-term outcomes may be achieved despite a + XM. This study's hypothesis is that children with a + XM have similar long-term survival, but higher rate of complications such as rejection, coronary allograft vasculopathy (CAV), and infection, compared to patients with a negative (-) XM. The Pediatric Heart Transplant Society Registry (PHTS) database was queried from 2010-2021 for all patients <18 years of age with a known XM. Baseline demographics were compared between + XM and - XM groups using appropriate parametric and non-parametric group comparisons. Cox Proportional Hazards Modeling was used to identify risk factors for post-transplant graft loss, rejection, and CAV. Of 4599 pediatric heart transplants during the study period, XM results were available for 3914 (85%), of which 373 (9.5%) had a + XM. Univariate analysis showed lower 10-year survival for patients with + XM (HR = 1.3, p = .04). Multivariate analyses revealed no significant difference in 10-year survival in the 2 groups; however, time to first rejection (p = .0001) remained significantly shorter in the + XM group. Pediatric patients transplanted across a + XM experience earlier rejection; however, after multivariate adjustment, + XM is not independently associated with intermediate-term graft loss. The risk of heart transplantation against a + XM must be balanced with the ongoing risk of waitlist mortality.

WITHDRAWN: Comment on “Outcomes of Cardiac Transplantation in Western Australia: A Contemporary Single Centre Experience”

WITHDRAWN: Comment on “Outcomes of Cardiac Transplantation in Western Australia: A Contemporary Single Centre Experience”

(241) Early Metabolomics Alterations in Recipient Plasma Predict the Outcome of Cardiac Transplantation

(241) Early Metabolomics Alterations in Recipient Plasma Predict the Outcome of Cardiac Transplantation

The association with organ procurement techniques and early cardiac transplant outcomes using cardiac MRI.

Heart transplantation (HT) has historically been limited by organ availability. Use of donation after circulatory death (DCD) donors addresses this limitation by utilizing previously unused hearts through use of the Organ Care System (OCS). This study aimed to determine the impact of procurement and transportation method on allograft structure and function using early post-transplant cardiac magnetic resonance imaging (MRI). Patients who underwent HT at our institution from February 1, 2020, through April 30, 2021 who underwent cardiac MRI imaging<60 days from transplant were included. Recipient and donor characteristics, clinical outcomes, and MRI findings were compared between those who underwent DCD transplantation using the OCS device (DCD-OCS), brain dead donation (DBD) using the OCS device (DBD-OCS), and DBD transported via cold storage (DBD-cold storage) using one-way analysis of variance. A total of 85 patients underwent HT with a cardiac MRI during the study period. Thirty-one (36%) patients received a DCD organ, 16 (19%) received a DBD-OCS organ and 38 (45%) received a DBD-cold storage organ. Rates of primary graft dysfunction (PGD) were significantly higher in DCD transplants (19.5% DCD vs. .0% DBD-OCS and 5.3% DBD-cold storage; p<.050 across three groups), but with no differences in mortality or rejection. There were no differences in cardiac MRI findings between the three transplant types, including presence of gadolinium hyperenhancement after transplant (all p>.050). We observed no differences in early cardiac MRI findings between patients that received DCD and DBD-OCS heart transplants compared with those receiving DBD-cold storage transplants.

Outcomes of Cardiac Transplantation in Western Australia - A Contemporary Single Centre Experience.

Cardiac transplantation remains the gold standard therapy for select patients with end-stage heart failure and outcomes have improved significantly over the past few decades. We report the 5-year contemporary experience of cardiac transplantation in Western Australia, one of the most remote transplant centres worldwide. Patients undergoing isolated cardiac transplant at Fiona Stanley Hospital (FSH) from February 2015 until April 2021 were included. Donor details were collected using donor electronic records (Donate Life, Australia). Recipient data was collated from electronic medical records at FSH and the Australia and New Zealand Society of Cardiothoracic Surgery database. The primary outcome measure was all-cause mortality. Secondary outcome measures included postoperative intensive care and total hospital length of stay and rates of acute kidney injury, rejection, serious infections, and cardiac allograft vasculopathy. Frailty indices were also assessed. A total of 60 patients were included (mean age 53±14 yrs, 66.7% male). The commonest indication for transplant was a non-ischaemic cardiomyopathy (46.7%). Mean donor age was 35±12 years and median donor ischaemia time was 171 minutes (IQR=138-240). After median follow up of 3.7 years, there were no mortalities. Postoperative renal failure occurred in 21 (35.0%) patients, pneumonia in four (6.7%), deep sternal wound infection in three (5.1%), acute rejection in 17 (28.3%) and cardiac allograft vasculopathy (CAV) in 23 (38.3%). With recipient and donor criteria comparable to national and international standards, compounded by the challenges of geographic isolation, we report the first published data on contemporary outcomes post isolated cardiac transplantation in Western Australia.

Outcomes in Cardiac Transplantation in Patients with a History of Methamphetamine Use: A Single Center Experience

<h3>Purpose</h3> Orthotopic heart transplant(OHT) has been demonstrated to improve morbidity and mortality in patients with end-stage heart failure. Methamphetamine use is endemic in the United States and is a significant cause of heart failure. Active use of illicit and addictive substances, such as methamphetamine, is generally a contraindication to transplantation. Limited data exists regarding patients with a history of substance abuse or methamphetamine use who have undergone OHT. We hypothesized that patients with a history of methamphetamine use would have worse outcomes after OHT, including higher mortality and increased hospitalization. <h3>Methods</h3> We performed a single center, IRB-approved, retrospective review of patients who underwent OHT at a large quaternary university hospital between2/22/16 and 10/10/20 (n=255). All patients underwent psychosocial evaluation as part of their transplant workup. We identified patients with a history of methamphetamine use after review of medical history and toxicology screens. Descriptive statistics and Kaplan-Meier method were used to compare patients with and without a history of methamphetamine use. <h3>Results</h3> A total of 255consecutive patients were identified, 25 of whom had a history of methamphetamine use. No patients had used methamphetamines within 3 months of transplantation. Median time to follow up was 2.66 years. Mean age at the time of OHT was similar between the two groups (55 years). Patients with a history of methamphetamine use had a higher mean Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) score compared to those in the control group (32.3vs 18.6, p<0.001). We did not observe any deaths in patients with a history of methamphetamine use. Survival at 1 year was 100% for patients with methamphetamine use compared to 94.9% in the control group. Readmission rate within 1 year was 50% for patients in the methamphetamine group compared to56.4% in the control group (Chi² p=0.61). No statistical difference was observed in overall survival, 30-day readmission or hospitalization at 1year between the two groups. <h3>Conclusion</h3> In this single center retrospective study, a history of methamphetamine use was not associated with decreased survival or increased risk of 30-day readmission or hospitalization at 1 year following OHT. While methamphetamine use can be considered a relative contraindication to transplantation, our findings suggest that carefully selected patients can be considered for OHT.

Time Will Tell: An Updated Analysis of Brain Death and Adult Cardiac Transplantation Outcomes After a Change to the UNOS Allocation System

<h3>Purpose</h3> The process of brain death produces a series of physiological changes including shifts in catecholamines, hormones, and inflammatory mediators. Previous studies have looked at the effect of brain death on transplant outcomes. However, in October 2018, the United Network for Organ Sharing (UNOS) underwent an update to the allocation system for adult cardiac transplants. The effect of the change in allocation system on both donor variables and recipient outcomes has not yet been investigated in detail. <h3>Methods</h3> A retrospective review of all adults (≥ 18 years) in the UNOS database undergoing single organ cardiac transplantation from 2015 - 2021 was performed. The population was divided into a pre-allocation change and a post-allocation change group. Statistical analysis was performed using univariate T-test and Chi-Square tests to compare differences in patient variables between the cohorts. Our primary outcome was donor brain death time pre- and post-allocation system change. Secondary outcomes included patient and graft survival at one year, ischemic time, renal failure requiring dialysis, stroke prior to discharge, pacemaker requirement, rejection within one year, and length of stay post-transplant. <h3>Results</h3> 16,538 patients were identified in the population, 9,322 prior to the allocation change and 7,216 after. Mean brain death time was not significantly different between pre (2.45 days) and post (2.67 days) allocation change groups (p = 0.297), however mean ischemic time was much longer in the post group (3.44 hours vs 2.96 hours, p <0.001). Patient survival at one year post transplant was not significantly different in the post allocation change group (91.3%) compared to the pre (91.6%) (p = 0.616). The post group had a higher one year graft survival (48.7% vs 20.3%, p < 0.001), but also a higher rate of dialysis prior to discharge (13.4% vs 11.6%, p < 0.001). <h3>Conclusion</h3> Brain death time was found to be no different when comparing patients from before and after the UNOS allocation change. Graft survival was improved in the post allocation change group however this group also had a higher rate of dialysis after transplant. Therefore, it is unlikely but still unclear if brain death time has a significant effect on cardiac transplant outcomes. Further study is needed to investigate causes of the differences in some outcomes between groups.

The long term prognostic value of peak left atrial strain in cardiac transplant patients

Abstract Funding Acknowledgements Type of funding sources: None. Background Left atrial (LA) dysfunction is associated with poorer outcomes in many disease processes. Left atrial strain (LAS) is a novel two-dimensional (2D) quantitative analysis of LA function. Cardiac transplantation directly involves the LA during implantation of the donor heart. Traditional echocardiographic indices after transplantation have demonstrated value in correlating with acute cellular rejection (ACR), morbidity and mortality over short- and long-term follow-up. The prognostic value of LA strain has not been previously investigated in this cohort. Purpose We hypothesized that incrementally impaired LA strain in post cardiac transplant patients with varying degrees of ACR may be prognostic of poorer outcomes on long term follow-up. Methods 87 Heart transplant patients, assessed between 2009 and 2015, underwent transthoracic echocardiography and endomyocardial biopsy. 2D strain analysis on the LV and LA were performed along with traditional echocardiographic parameters. Patients were grouped according to peak LAS (PALS) tertiles and rejection burden history was assessed and grouped according to ACR burden at a median of 12 (±5.4) months post transplantation. The primary endpoint was all-cause mortality at follow-up. Results 12 patients met the primary endpoint over a median follow-up of 66 ± 51 months. The mean LA PALS was significantly different across the tertiles (lowest tertile 12.29 ± 2.5% vs middle tertile 17.89 ± 1.1% vs highest tertile 24.54 ± 4.2%; p &amp;lt;0.0001). LA strain dispersion was also significantly different between the tertiles (61.03 ± 25.8ms vs 41.8 ± 15.8ms vs 44.8 ± 18.8ms; p &amp;lt;0.001). All other clinical and echocardiographic parameters were non-significant between the tertiles however, there was a trend towards a lower PALS in the higher rejection burden group. Kaplan Meier curves demonstrated that survival over follow-up was significantly worse in the lower tertile LA PALS group compared to the highest tertiles LA PALS group (Log-rank test = p &amp;lt; 0.0001). The lowest LA PALS tertile had a significantly higher risk of reaching the primary endpoint compared with patients in the highest LA PALS tertile (hazard ratio [HR] 9.802; 95% CI 1.832-52.45; p &amp;lt;0.008). Higher LA PALS and LV GLS (LA PALS HR 0.610 95% CI 0.401-0.926; p 0.02; LV GLS HR 0.638 95% CI 0.418-0.972; p 0.037) were significantly associated with a reduction in reaching the primary endpoint in a multi-variate regression model including clinically relevant traditional and strain-based echocardiographic parameters. Conclusions Lower LA PALS is significantly associated with poorer long-term outcomes in cardiac transplant patients with ACR. Non-invasive LA PALS may be a useful predictor of long-term outcome in patients post cardiac transplantation. Abstract Figure. Survival curves for LA PALS tertiles

Outcomes of Cardiac Transplantation in Western Australia – A Contemporary Single Centre Experience

Cardiac transplantation remains the gold standard therapy for select patients with end-stage heart failure and outcomes have improved significantly over the past few decades. We report the 5-year contemporary experience of cardiac transplantation in Western Australia, one of the most remote transplant centres worldwide.

Ex Vivo Delivery of Viral Vectors by Organ Perfusion for Cardiac Transplantation Gene Therapy.

Recent advances in ex vivo perfusion have enabled an extended preservation time for solid organs prior to transplantation allowing for possible resuscitation of the donor organ during the preservation period. Opportunities to provide viral vector-mediated gene therapy to the entire cardiac graft during this extended preservation period may lead to improvements in cardiac transplantation outcomes. Here we describe how to achieve successful gene delivery using viral vectors to an entire cardiac graft by normothermic, ex vivo perfusion. This protocol has been confirmed with the most highly utilized viral vector types in gene therapy clinical studies (adenoviral [Ad] and adeno-associated viral vector [AAV]).

The Footprint of Kynurenine Pathway in Cardiovascular Diseases.

Kynurenine pathway is the main route of tryptophan metabolism and produces several metabolites with various biologic properties. It has been uncovered that several cardiovascular diseases are associated with the overactivation of kynurenine pathway and kynurenine and its metabolites have diagnostic and prognostic value in cardiovascular diseases. Furthermore, it was found that several kynurenine metabolites can differently affect cardiovascular health. For instance, preclinical studies have shown that kynurenine, xanthurenic acid and cis-WOOH decrease blood pressure; kynurenine and 3-hydroxyanthranilic acid prevent atherosclerosis; kynurenic acid supplementation and kynurenine 3-monooxygenase (KMO) inhibition improve the outcome of stroke. Indoleamine 2,3-dioxygenase (IDO) overactivity and increased kynurenine levels improve cardiac and vascular transplantation outcomes, whereas exacerbating the outcome of myocardial ischemia, post-ischemic myocardial remodeling, and abdominal aorta aneurysm. IDO inhibition and KMO inhibition are also protective against viral myocarditis. In addition, dysregulation of kynurenine pathway is observed in several conditions such as senescence, depression, diabetes, chronic kidney disease (CKD), cirrhosis, and cancer closely connected to cardiovascular dysfunction. It is worth defining the exact effect of each metabolite of kynurenine pathway on cardiovascular health. This narrative review is the first review that separately discusses the involvement of kynurenine pathway in different cardiovascular diseases and dissects the underlying molecular mechanisms.

Abstract 12292: Trends and Outcomes of Cardiac Transplantation in the Lowest Urgency Candidates

Introduction: Due to discrepancies between donor supply and recipient demand, the cardiac transplantation process aims to prioritize the most medically urgent patients. It remains unknown how recipients with the lowest medical urgency compare to others in the allocation process. Methods: We performed a retrospective analysis of the United Network for Organ Sharing database. Patients listed for cardiac transplantation between January 2011 to May 2020 were stratified according to status at time of transplantation. Baseline recipient and donor characteristics, waitlist survival, and post-transplantation outcomes were compared between lower urgency listing and higher urgency listing in the years before and after the 2018 allocation system change. Results: Lower urgency patients in the old system were older (58.5 vs. 56 years) and more likely female (54.4% vs. 23.8%) compared to the highest urgency patients, and these trends persisted in the new system for the lowest urgency patients (59 vs. 55 years; 47.0% vs. 23.9% female; p&lt;0.001, all). Donors for the lowest urgency patients were more likely older, female, or have a history of CMV, hepatitis C, or diabetes (p&lt;0.01, all). The lowest urgency patients had longer waitlist times, and under the new allocation system these patients received organs from shorter distances and with decreased ischemic times (178 vs. 269 miles, 3.1 vs 3.5 hours; p&lt;0,001, all). There was no difference in post-transplantation survival (p&lt;0.01, all). Conclusions: Cardiac transplantation for lower urgency patients has not been well characterized. Our analysis demonstrates that, over the last decade, these patients receive hearts from donors with additional comorbidities compared to higher urgency patients but that outcomes are similar at one year. Our results may support the utility of early listing and less stringent thresholds for organ acceptance to increase access to cardiac transplantation.

Trends and Outcomes of Cardiac Transplantation in the Lowest Urgency Candidates.

BackgroundBecause of discrepancies between donor supply and recipient demand, the cardiac transplantation process aims to prioritize the most medically urgent patients. It remains unknown how recipients with the lowest medical urgency compare to others in the allocation process. We aimed to examine differences in clinical characteristics, organ allocation patterns, and outcomes between cardiac transplantation candidates with the lowest and highest medical urgency.Methods and ResultsWe performed a retrospective analysis of the United Network for Organ Sharing database. Patients listed for cardiac transplantation between January 2011 and May 2020 were stratified according to status at time of transplantation. Baseline recipient and donor characteristics, waitlist survival, and posttransplantation outcomes were compared in the years before and after the 2018 allocation system change. Lower urgency patients in the old system were older (58.5 versus 56 years) and more likely female (54.4% versus 23.8%) compared with the highest urgency patients, and these trends persisted in the new system (P<0.001, all). Donors for the lowest urgency patients were more likely older, female, or have a history of cytomegalovirus, hepatitis C, or diabetes (P<0.01, all). The lowest urgency patients had longer waitlist times and under the new allocation system received organs from shorter distances with decreased ischemic times (178 miles versus 269 miles, 3.1 versus 3.5 hours; P<0.001, all). There was no difference in posttransplantation survival (P<0.01, all).ConclusionsPatients transplanted as lower urgency receive hearts from donors with additional comorbidities compared with higher urgency patients, but outcomes are similar at 1 year.

Relation of Left Ventricular Assist Device Infections With Cardiac Transplant Outcomes

Left ventricular assist device (LVAD)-specific infections (LSIs) are common in patients on LVAD support awaiting heart transplant (HT), yet their impact on post-HT outcomes is not completely understood. We hypothesized that LSIs would result in vasoplegia and negatively affect post-HT 30-day and 1-year outcomes. LSI was defined as driveline, pump, or pocket infection. The short-term outcome was a composite of acute renal failure, allograft rejection, and mortality at 30 days after HT. The long-term outcome was a composite of allograft rejection and death within 1 year after HT. We performed a retrospective analysis of 111 HT recipients bridged with durable LVAD support at our institution from May 2012 to August 2019. Of these, 63 patients had LSIs, with 94% of the infections being driveline infections. Vasoplegia was more prevalent in the LSI group but not significantly (7 vs 2 persons, p=0.3). There was no difference in the composite end point of acute renal failure, rejection, or death at 30 days (30% vs 25%, p=0.55) or 1-year end point of rejection and death (38% vs 40%, p=0.87) in patients with LSI versus those without LSI. In conclusion, LSIs were common in patients on LVAD who underwent HT in our single-center contemporary cohort. However, LSI was not associated with adverse outcomes at 30 days or at 1 year after HT.

A state-of-the-art review of the current role of cardioprotective techniques in cardiac transplantation.

The use of 'extended criteria' donor hearts and reconditioned hearts from donation after circulatory death has corresponded with an increase in primary graft dysfunction, with ischaemia-reperfusion injury being a major contributing factor in its pathogenesis. Limiting ischaemia-reperfusion injury through optimising donor heart preservation may significantly improve outcomes. We sought to review the literature to evaluate the evidence for this. A review of the published literature was performed to assess the potential impact of organ preservation optimisation on cardiac transplantation outcomes. Ischaemia-reperfusion injury is a major factor in myocardial injury during transplantation with multiple potential therapeutic targets. Innate survival pathways have been identified, which can be mimicked with pharmacological conditioning. Although incompletely understood, discoveries in this domain have yielded extremely encouraging results with one of the most exciting prospects being the synergistic effect of selected agents. Ex situ heart perfusion is an additional promising adjunct. Cardiac transplantation presents a unique opportunity to perfuse the whole heart before, or immediately after, the onset of ischaemia, thus maximising the potential for global cardioprotection while limiting possible systemic side effects. While clinical translation in the setting of myocardial infarction has often been disappointing, cardiac transplantation may afford the opportunity for cardioprotection to finally deliver on its preclinical promise.

Current opinion in pediatric heart transplantation.

Cardiac transplant remains the most effective therapy for children with end-stage heart disease. Outcomes remain better than any alternative therapy for this condition, but its use is limited by donor organ availability. As a result, waitlist times and mortality on the waiting list remain unacceptably high. Novel approaches are necessary to address this problem. Organ Procurement and Transplant Network/United Network for Organ Sharing readjusted the pediatric heart allocation system in 2016 to prioritize children at highest risk of mortality, encourage judicious listing, and improve appropriate donor organ utilization. Subsequent studies have aligned with these priorities to help risk-stratify patients at the time of listing and identify the importance that should be assigned to donor-specific factors. In addition, many authors are advocating for increased utilization of hearts donated after cardiac death. Pediatric Ventricular Assist Device (VAD) application has also been increasing to help decrease waitlist mortality. Although results have significantly improved, there remain important limitations to widespread use of VADs in the pediatric population. This has prompted novel techniques such as pulmonary artery banding to improve cardiac function and, in some cases, promote recovery. The demand for cardiac replacement continues to increase with an ageing population of patients with congenital heart disease, presenting new challenges and stressors to the system. Pediatric cardiac transplant outcomes are excellent but remain plagued by the limited supply of donor organs. Recent strategies to combat this problem have focused on judicious listing, maximal utilization of available donor organs, and safely extending the lives of patients on the waitlist. New demands on the organ supply chain will continue to stress the system, making these efforts of the highest importance.Clinical Trial Registry Number not applicable.

Cardiac transplantation outcomes in patients with amyloid cardiomyopathy

Amyloid cardiomyopathy (ACM) is a progressive and life-threatening disease caused by abnormal protein deposits within cardiac tissue. The most common forms of ACM are caused by immunoglobulin derived light chains (AL) and transthyretin (TTR). Orthotopic heart transplantation (OHT) remains the definitive treatment for patients with end stage heart failure. In this study, we perform a contemporary multicenter analysis evaluating post OHT survival in patients with ACM. We conducted a multicenter analysis of 40,044 adult OHT recipients captured in the United Network for Organ Sharing (UNOS) registry from 1987-2018. Patients were characterized as ACM or non-ACM. Baseline characteristics were obtained, and summary characteristics were calculated. Outcomes of interest included post-transplant survival, infection, treated rejection, and the ability to return to work. Racial differences in OHT survival were also analyzed. Unadjusted associations between ACM and non-ACM survival were determined using the Kaplan-Meier estimations and confounding was addressed using multivariable Cox proportional hazards models. Three hundred ninety-eight patients with a diagnosis of ACM were identified of which 313 underwent heart only OHT. ACM patients were older (61 vs 53; P < .0001) and had a higher proportion of African Americans (30.7% vs 17.6%; P < .0001). Median survival for ACM was 10.2 years vs 12.5 years in non-ACM (P = .01). After adjusting for confounding, ACM patients had a higher likelihood of death post-OHT (HR 1.39 CI: 1.14, 1.70; P = .001). African American ACM patients had a higher likelihood of survival compared to White ACM patients (HR 0.51 CI 0.31-0.85; P = .01). No difference was observed in episodes of treated rejection (OR 0.63 CI 0.23, 1.78; P = .39), hospitalizations for infections (OR 1.24 CI: 0.85, 1.81; P = .26), or likelihood of returning to work for income (OR 1.23 CI: 0.84, 1.80; P = .30). In this analysis of OHT in ACM, ACM was associated with a higher likelihood of post-OHT mortality. Racial differences in post-OHT were observed with African American patients with ACM having higher likelihood of survival compared to White patients with ACM. No differences were observed in episodes of treated rejection, hospitalization for infection, or likelihood to return to work for income.