Outcomes In Heart Transplant Patients Research Articles

(840) - Exercise Test and Hemodynamic Outcomes in Heart Transplant Patients Treated with Long-Term Mechanical Circulatory Support as Bridge to Transplantation

(840) - Exercise Test and Hemodynamic Outcomes in Heart Transplant Patients Treated with Long-Term Mechanical Circulatory Support as Bridge to Transplantation

Groin wound management after decannulation of veno-arterial extracorporeal membrane oxygenation in heart transplantation: Role of sartorius muscle flap.

The management of complex groin wounds following VA-ECMO after heart transplant (HT) is uncertain due to limited experience. Sartorius muscle flaps (SMF) have been used in vascular surgery for groin wound complications. However, their use in HT recipients with perioperative VA-ECMO is unclear. This study aims to describe characteristics and outcomes of HT patients with groin complications after arterial decannulation for femoral VA-ECMO. We retrospectively reviewed HT patients who underwent peri-transplant femoral VA-ECMO at our institution from April 2011 to February 2023. Patients were categorized into two groups based on the presence of cannulation-related wound complications. Among the 34 patients requiring VA-ECMO peri-transplant, 17 (50%) experienced complications at the cannulation site. Baseline characteristics including duration of VA-ECMO support were comparable in both groups. Patients with complications presented mostly with open wounds (41.1%) after a median duration of 22 days post-transplant. Concurrent groin infections were observed in 52.3% of patients, all caused by gram-negative bacteria. Wound complications were managed with 12 (70.6%) undergoing SMF treatment and 5 (31.2%) receiving conventional therapy. Four SMF recipients had preemptive procedures for wound dehiscence, while eight underwent SMF for groin infections. Among the SMF group, 11 patients had favorable outcomes without recurrent complications, except for one patient who developed a groin infection with pseudoaneurysm formation. Conventional therapy with vacuum assisted closure (VAC) and antibiotics were utilized in four patients without infection and one patient with infection. Three patients required additional surgeries with favorable healing of the wound. Complications related to femoral VA-ECMO are common in HT patients, with infection being the most frequent complication. SMFs can be a useful tool to prevent progression of infection and improve local healing.

Short-term outcomes of heart transplant patients bridged with Impella 5.5 ventricular assist device.

We sought to investigate the outcomes of heart transplant patients supported with Impella 5.5 temporary mechanical circulatory support. Patient demographics, perioperative data, hospital timeline, and haemodynamic parameters were followed during initial admission, Impella support, and post-transplant period. Vasoactive-inotropic score, primary graft failure, and complications were recorded. Between March 2020 and March 2021, 16 advanced heart failure patients underwent Impella 5.5 temporary left ventricular assist device support through axillary approach. Subsequently, all these patients had heart transplantation. All patients were either ambulatory or chair bound during their temporary mechanical circulatory support until heart transplantation. Patients were kept on Impella support median of 19days (3-31) with the median lactate dehydrogenase level of 220 (149-430). All Impella devices were removed during heart transplantation. During Impella support, patients had improved renal function with median creatinine serum level of 1.55mg/dL decreased to 1.25 (P=0.007), pulmonary artery pulsatility index scores increased from 2.56 (0.86-10) to 4.2 (1.3-10) (P=0.048), and right ventricular function improved (P=0.003). Patients maintained improved renal function and favourable haemodynamics after their heart transplantation as well. All patients survived without any significant morbidity after their heart transplantation. Impella 5.5 temporary left ventricular assist device optimizes care of heart transplant recipients providing superior haemodynamic support, mobility, improved renal function, pulmonary haemodynamics, and right ventricular function. Utilizing Impella 5.5 as a direct bridging strategy to heart transplantation resulted in excellent outcomes.

(575) The Outcome of Heart Transplant Patients with Severe Rejection Requiring ECMO Support: Is it Futile

(575) The Outcome of Heart Transplant Patients with Severe Rejection Requiring ECMO Support: Is it Futile

Better Than Ice: Advancing the Technology of Donor Heart Storage With the Paragonix SherpaPak.

Better Than Ice: Advancing the Technology of Donor Heart Storage With the Paragonix SherpaPak.

Post-transplant outcomes in heart transplant patients after implantation of CentriMag™ ventricular assist device

Post-transplant outcomes in heart transplant patients after implantation of CentriMag™ ventricular assist device

Impact of diastolic pulmonary gradient and pulmonary artery pulse index on outcomes in heart transplant patients-Results from the Eurotransplant database.

Predicting complications associated with pulmonary hypertension (PH) after cardiac transplantation is an important factor when considering cardiac transplantation. The transpulmonary gradient (TPG) is recommended to quantify PH in transplant candidates. Nonetheless, PH remains a common driver of mortality. The diastolic pressure gradient (DPG) and pulmonary vascular resistance (PVR) can differentiate post- from combined pre- and post-capillary PH and may improve estimation of PH-associated risks. We used a large European cohort of transplant candidates to assess whether the pulmonary pulsatility index (PAPi), improves prediction of graft failure and mortality compared to DPG and PVR. Out of all patients undergoing heart transplantation between 2009 and 2019 in Eurotransplant member states (n = 10,465), we analyzed the impact of PH (mPAP > 25 mmHg) and right heart catheter hemodynamic data on graft failure and mortality within 1-5 years. In 1,407 heart transplant patients with PH (79% male, median age 54 years, IQR 39-69 years), the median PVR was 2.5 WU (IQR 1.6 WU) with a median mPAP (pulmonary arterial pressure) of 32 mmHg (IQR 9 mmHg). Patients with low (< 3 mmHg) DPG had a better 5 year survival than those with higher DPG (log rank p = 0.023). TPG, mPAP, PAPi, and PVR did not improve prediction of survival. Low PAPi (OR = 2.24, p < 0.001) and high PVR (OR = 2.12, p = 0.005) were associated with graft failure. PAPI and PVR are associated with graft failure in patients with PH undergoing cardiac transplantation. DPG is associated with survival in this cohort.

Abstract 14755: Left Ventricular Three-Dimensional Speckle Tracking Echocardiography Predicts Adverse Clinical Outcomes in Heart Transplant Patients

Background: The prognostic value of 3D-GLS in HT recipients has not been evaluated. This study explored the long-term prognostic significance of 3D-GLS in HT recipients. Methods: The study comprised 296 consecutive patients who underwent HT between January 2015 and December 2019 at Union Hospital in Wuhan, China. All subjects underwent comprehensive transthoracic two-dimensional (2D) and 3D echocardiographic examinations. Patients were followed until January 1st, 2022. Major adverse cardiac events (MACE) were defined as a composite of heart failure hospitalization, re-transplantation and death. Results: After a median follow-up of 3.3 years, 53 HT patients experienced MACE. Patients with MACE displayed significantly impaired 2D-GLS and 3D-GLS compared with those without MACE. Kaplan-Meier analysis showed that the risk of MACE increased significantly with worsening tertiles of 2DGLS and 3DGLS (both log-rank p &lt; 0.001). Area under the curve for 3D-GLS was larger than that in 2D-GLS for MACE prediction. On multivariate Cox proportional hazards regression, 2D-GLS and 3D-GLS were independently associated with the MACE after adjustment for diabetes, history of rejection, hemoglobin, brain natriuretic peptide (BNP), and LV ejection fraction. In addition, 3D-GLS provided incremental prognostic value over 2D-GLS. Continuous net reclassification improvement analysis showed an improvement of + 23.3% was noted in the accuracy of classification between 3D-GLS and 2D-GLS. Conclusion: In heart transplant recipients, 3D-GLS is an independently predictor of MACE. These findings support the potential of 3D-GLS to identify higher risk HT patients.

CARC18: Towards Equitable Care: Exploring The Association Between Geographic Household Median Income And Clinical Outcomes Following Left Ventricular Assist Device Implantation

Purpose: Socioeconomic status (SES) is hypothesized to be an important predictor of clinical outcomes following left ventricular assist device (LVAD) implantation due to high costs of care. We investigated whether median income of a patient’s residing neighborhood predicts mortality or rate of readmission in LVAD therapy. Methods: 210 patients implanted with an LVAD between January 2010 and April 2020 at a single tertiary care center in the United States were retrospectively enrolled in this study. Patients were classified into tertiles based on published neighborhood median income data and compared for survival and freedom from readmission. Results: The study cohort comprised 135 unique ZIP codes, with 34 (25.2%) above and 101 (74.8%) below the national median income level. The low, middle, and high income groups had a total survivorship of 92.8%, 95.5%, and 92.5% at 1 year and 85.5%, 89.4%, and 85.1% at 3 years, respectively. Low median income was not significantly associated with worse outcomes at 1-year (P=0.400) and 3-years (P=0.689) following LVAD implantation. There was similarly no significant difference in freedom from readmissions at 3 years. Conclusion: LVAD recipients with a lower geographic median income were not more likely to experience worse outcomes after LVAD implantation. These findings were contrary to prior published reports showing worse clinical outcomes in heart transplant patients with lower SES patients. Factors such as institution-specific and system-wide patient assistance programs and risk factor modification measures may have mitigated the impact of reduced SES on patient care and helped eliminate the effect of income disparity on long-term clinical outcome post LVAD implantation. Further research to study such potential association is warranted.

Packing the donor heart: Is SherpaPak cold preservation technique safer compared to ice cold storage.

The present study aimed to compare the clinical outcomes of heart transplant patients whose donor hearts were preserved with the SherpaPak controlled cold organ system versus the conventional ice storage technique. All patients undergoing heart transplantation at our center between January 2019 and April 2021 were divided into two groups according to the technique used during donor heart preservation and transport. The first group consisted of 34 SherpaPak controlled temperature preservation patients, and the second group consisted of 47 patients where the conventional three bags and ice technique was utilized during organ transportation. The two groups were compared based on demographics, operative details, and postoperative outcomes. There were no significant differences between the groups regarding Vasoactive Inotropic Score (VIS), Primary Graft Dysfunction (PGD), and the need for a transient pacer. However, the VIS, PGD, and pacing trends were lower in the SherpaPak patients even though the total ischemic and cardiopulmonary bypass times were significantly longer. Furthermore, SherpaPak patients exhibited a shorter stay in the ICU with no severe PGD and mortality. The SherpaPak donor heart preservation provides safe outcomes in heart transplant patients. Further research is needed to utilize this method for longer durations of ischemic time and expand travel distances for organ transportation.

Immune Response in Heart Transplant Patients Following COVID-19 Vaccination

PurposePrevious studies have described poor outcomes in heart transplant patients who develop COVID-19 infection. Therefore, we sought to characterize a single center's experience with heart transplant patient outcomes during the COVID-19 pandemic and the recent role of vaccination in mitigating the risk of mortality.MethodsFrom a single center, we identified all orthotopic heart transplant patients alive at the beginning of the COVID-19 pandemic in March 2020. All patients were followed from the start of the pandemic until their most recent follow up or death. Baseline comorbidities and immediate outcomes data were obtained from the Society for Thoracic Surgery (STS) Adult Cardiac Surgery Database (ACSD). Multiple logistic regression analyzed the association between vaccination status, baseline covariates, and other standard STS outcome measures. Non-parametric tests were used to compare different subgroups.ResultsWe included 153 patients, of which 20.9% developed COVID-19 infection (32/153) with 40.6% (13/32) requiring hospitalization and 15.6% of those patients (5/32) dying as a direct result of COVID-19 pneumonia. Kaplan-Meier survival analysis revealed that unvaccinated patients had a significantly higher rate of all-cause mortality as compared to those patients that were fully vaccinated despite similar baseline characteristics (p < 0.001). Patients with previous COVID-19 infection in addition to vaccination had significantly higher IgG titers as compared to those only vaccinated (6568.50 AU/mL vs. 58.05 AU/mL, p = 0.002).ConclusionImmunization against COVID-19 is associated with a significant reduction in the mortality of heart transplant patients. IgG titers were variable among heart transplant patients who received the vaccine with the highest titers seen in those patients with a personal history of COVID-19. The implications of IgG levels are still unknown.

Heart failure in COVID-19 patients: Critical care experience.

Patients with heart failure (HF) may be at a higher risk of coronavirus disease 2019 (COVID-19) infection and may have a worse outcome due to their comorbid conditions and advanced age. In this narrative review, we aim to study the interaction between COVID-19 and HF from a critical care perspective. We performed a systematic search for studies that reported HF and critical care-related outcomes in COVID-19 patients in the PubMed and Medline databases. From a total of 1050 papers, we identified 26 that satisfied the eligibility criteria for our review. Data such as patient demographics, HF, intensive care unit (ICU) admission, management, and outcome were extracted from these studies and analyzed. We reported outcomes in heart-transplant patients with COVID-19 separately. In hospitalized patients with COVID-19, the prevalence of HF varied between 4% and 21%. The requirement for ICU admission was between 8% and 33%. HF patients with COVID-19 had an overall mortality rate between 20% and 40%. We identified that HF is an independent predictor of mortality in hospitalized COVID-19 patients, and patients with HF were more likely to require ventilation, ICU admission and develop complications. Patients with HF with reduced ejection fraction did worse than those with HF with midrange ejection fraction, and HF with preserved ejection fraction. COVID-19 patients with HF should be identified early and managed aggressively in an attempt to improve outcomes in this cohort of patients.

Controlled temperatures in cold preservation provides safe heart transplantation results.

We aimed to investigate the short-term outcomes of heart transplant patients who underwent SherpaPak™ donor organ preservation. We prospectively collected the data of patients who underwent heart transplantation using SherpaPak™ system for donor organ transportation from February 2020 to March 2021. Donor and recipient demographic data, preoperative and postoperative echocardiographic and hemodynamic parameters, total ischemic time and SherpaPak temperatures, vasoactive inotropic scores (VIS), primary graft dysfunction (PGD) status, intensive care unit stay, complications, and mortality during follow-up were assessed. A total of 39 consecutive heart transplant patients with SherpaPak system were included in the study. The mean donor age was 32.2 ± 6.7 (range: 16-46). The mean recipient age was 57.5 ± 12 (range: 19-73). The mean preoperative ejection fraction (EF) was 23.7 ± 15.4 (range: 5-75). All recipients underwent a standard bicaval technique for orthotopic heart implantation. The mean total ischemic time was 230.1 ± 41 (range: 149-342) min. The mean Sherpa temperature was 5.6 ± 0.8°C (range: 3.7-7.5). The mean VIS was 10.2 ± 6.5 (range: 2-32). The number of mild PGD was 5 (14.7%), and moderate PGD was 4 (11.8%). There was no severe PGD. The postoperative EF was 64.3 ± 5.5 (range: 50-78). Mean intubation time was 47.4 ± 64 (range: 8-312, median: 22) h. The mean time of intensive care unit stay was 6.3 ± 5 (range: 2-31, median: 5) days. Two patients required chest revision (5.8%), two patients had lung infection (5.8%). Two patients had a stroke (5.8%). There was no mortality. Using the SherpaPak system during heart transplantation is safe and not associated with significant recipient morbidity. None of the recipients experienced significant PGD and mortality.

Abstract 10324: Characterization and Impact of Covid-19 on Heart Transplant Recipients

Introduction: Heart transplant recipients who subsequently acquire COVID-19 may be at an increased risk of severe disease and adverse outcomes, particularly in light of several comorbidities and chronic states of immunosuppression. Methods: In this retrospective case-control analysis, we compared the outcomes of heart transplant patients with confirmed COVID-19 to matched, COVID-19 positive, non-transplant patients at the Cleveland Clinic. The transplant group included adult patients who were hospitalized with COVID-19 between March 2020 and March 2021. The controls were matched 2:1 (24 heart transplant, 48 non-heart transplant) on different baseline characteristics. The primary outcome was in-hospital mortality and secondary outcomes were the length of hospital stay (LOS), need for mechanical ventilation, ICU admission, pressor requirements (norepinephrine, epinephrine, vasopressin), dialysis requirement, pneumonia incidence, and 30- day readmission within the COVID-19 diagnosis window. All tests had a 2-sided significance level of 0.05. Results: Of 11,505 patients with COVID-19 infection, 72 post-match were included in the final analysis. The mean age of hospitalized heart transplant recipients was 62 ±18, 70% were Caucasian, 87.5% were male, 47% had a smoking history, 17% had COPD, and 8% had asthma. Primary outcome of in-hospital mortality in the heart transplant COVID group vs. non-transplant COVID group was 12.5% and 14.6%, respectively (OR: 0.84; 95% CI 0.2-3.57). There was no statistically significant difference in median LOS (more than 7 days; 45.8% vs. 52.1%; OR: 0.78; 95% CI 0.29-2.08), need for mechanical ventilation (16.7% vs. 14.5%; OR: 1.17; 95% CI 0.31-4.47), ICU admissions (33.3% vs. 35.4%; OR: 0.91; 95% CI 0.32-2.57) pressor requirements (8.3% vs. 8.3%; OR: 1; 95% CI 0.17-5.89), dialysis needs (4.1% vs. 6.2%; OR: 0.65; 95% CI 0.06-6.63), pneumonia (4.2% vs. 8.5%; OR 0.48: 95% CI 0.05-4.53), or 30-day readmission (17.4% vs. 8.5%; OR: 2.26; 95% CI 0.51-10.02). Conclusion: Our study suggests that heart transplant recipients who acquire and are hospitalized for COVID-19 do not show worse in-hospital outcomes compared to those of their matched non-transplant cohorts. However, the study results are limited due to sample size.

Peripheral microvascular dysfunction is associated with plaque progression and adverse long-term outcomes in heart transplant patients.

AimsCardiac allograft vasculopathy (CAV) is the major cause of increased morbidity and mortality after heart transplantation. Peripheral endothelial dysfunction (PED) is associated with early atherosclerosis and future risk of major adverse cardiovascular events (MACE) in non‐heart transplant population. We aimed to investigate the association of PED with future MACE, and plaque progression assessed by intravascular ultrasound (IVUS) after heart transplantation.Methods and resultsWe included 66 transplant patients who underwent serial IVUS surveillance for CAV and baseline assessment of peripheral endothelial function using reactive hyperaemia peripheral arterial tonometry. PED was defined as reactive hyperaemia index < 2. The primary endpoint of the study was to investigate the association of PED with CAV progression assessed by intravascular ultrasound (IVUS). CAV progression was assessed as the change (Δ) in plaque volume divided by segment length, and Δ plaque index (plaque volume/vessel volume), adjusted for the time between IVUS measurements (median 3.0 [2.2, 3.1] years). The secondary endpoint was to investigate the association between PED and future MACE, which was defined as any incident of revascularization, heart failure hospitalization, stroke, myocardial infarction, re‐transplantation, and death. Patients with PED (n = 27) had more yearly plaque progression (0.50 ± 0.66 vs. 0.15 ± 0.50 mm3/mm/year, P = 0.02) and a higher Δ plaque index (2.41 ± 2.53% vs. 0.69 ± 2.22%, P = 0.01). Patients with PED were more likely to experience MACE during a median follow‐up of 8.2 years (interquartile range [7.6, 8.4]), after adjustment for potential cofounders such as age, high‐density lipoprotein cholesterol levels, total rejection score, baseline International Society for Heart & Lung Transplantation CAV grade, and indication of transplantation. (hazard ratio 2.15, 95% confidence interval [1.09, 4.23], P = 0.03).ConclusionsPeripheral endothelial dysfunction is associated with increased plaque progression and adverse long‐term cardiovascular outcomes in transplant patients. PED assessment might be a useful clinical tool for risk stratification after heart transplantation.

Impact of preoperative renal replacement therapy on the clinical outcome of heart transplant patients

Renal dysfunction is considered as a relative contraindication for heart transplantation (HTx). However, in the real world setting, many patients with advanced heart failure (HF) experience worsening of renal function and some even require renal replacement therapy (RRT) by the time they undergo HTx. We aimed to investigate the prognosis and clinical outcomes of HTx patients who required RRT during the perioperative period. The Korean Organ Transplant Registry (KOTRY) is a nationwide organ transplant registry in Korea. A total of 501 HTx patients had been prospectively enrolled in the KOTRY registry during 2014–2018. Among the 501 patients, 13 underwent combined heart and kidney transplantation (HKTx). The 488 patients who underwent isolated HTx were grouped according to their pre- and postoperative RRT status. The primary outcome was progression to dialysis-dependent end-stage renal disease (ESRD) after HTx. The secondary outcome was all-cause mortality after HTx. The median follow-up was 22 months (9–39 months). Patients who needed preoperative RRT but were free from postoperative RRT showed comparable overall survival and renal outcome to patients who were free from both pre- and postoperative RRT. In multivariable analysis, preoperative RRT was not associated with progression to ESRD or all-cause mortality after HTx; however, postoperative RRT was a significant predictor for both progression to ESRD and all-cause mortality after HTx. Preoperative creatinine or estimated glomerular filtration rate (eGFR) were not predictive of progression to ESRD after HTx. The present analysis suggests that preoperative RRT requirement does not indicate irreversible renal dysfunction in patients waiting for HTx. However, postoperative RRT was associated with progression to ESRD and mortality after HTx.

Circulating progenitor cells are associated with plaque progression and long-term outcomes in heart transplant patients.

Circulating progenitor cells (CPCs) play a role in vascular repair and plaque stability, while osteocalcin (OC) expressing CPCs have been linked to unstable plaque and adverse cardiovascular outcomes. However, their role in cardiac allograft vasculopathy (CAV) has not been elucidated. This cohort study aimed to investigate the contribution of CPCs on CAV progression and cardiovascular events after heart transplantation. A total of 80 heart transplant patients (mean age 55 ± 14 years, 72% male) undergoing annual intravascular ultrasound (IVUS) had fresh CPCs marked by CD34, CD133, and OC counted in peripheral blood using flow cytometry, on the same day as baseline IVUS. CAV progression was assessed by IVUS as the change (Δ) in plaque volume divided by segment length (PV/SL), adjusted for the time between IVUS measurements [median 3.0, interquartile range (2.8-3.1) years] and was defined as ΔPV/SL that is above the median ΔPV/SL of study population. Major adverse cardiac events (MACEs) were defined as any incident of revascularization, myocardial infarction, heart failure admission, re-transplantation, stroke, and death. Patients with higher CD34+CD133+ CPCs had a decreased risk of CAV progression [odds ratio 0.58, 95% confidence interval (CI) (0.37-0.92), P = 0.01] and MACE [hazard ratio (HR) 0.79, 95% CI (0.66-0.99), P = 0.05] during a median (interquartile range) follow-up of 8.0 years (7.2-8.3). Contrarily, higher OC+ cell counts were associated with an increased risk of MACE [HR 1.26, 95% CI (1.03-1.57), P = 0.02]. Lower levels of CD34+CD133+ CPCs are associated with plaque progression and adverse long-term outcomes in patients who underwent allograft heart transplantation. In contrast, higher circulating OC+ levels are associated with adverse long-term outcomes. Thus, CPCs might play a role in amelioration of transplant vasculopathy, while OC expression by these cells might play a role in progression.

Clinical course and outcomes of heart transplant patients with COVID infection

Objective: The objective is to assess the clinical course and outcomes of heart transplant (HTx) recipients affected by COVID-19 disease in a tertiary care health care institution. Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) is a contagious illness with alarming morbidity and mortality. The HTx recipients are chronically immunosuppressed and thus COVID-19 infection in them may result in an unpredictable clinical course. Materials and Methods: HTx recipients in a tertiary care transplant center in North India were retrospectively reviewed from January 2020 to January 2021. Case records of 28 patients of HTx were reviewed, and four (14%) were found to have developed Covid-19 infection. Clinical parameters and outcomes of these four HTx recipients with confirmed SARS-CoV-2 infection are described. Results: Fourteen percent of our HTx patients (4 out of 28 patients under follow-up) developed COVID-19 in the first infection wave. The study population consisted of 3 males and 1 female patient with a median age of 28 years (range 15–39). The most common presenting symptoms were fever (100%), myalgia (100%) and cough (75%). There was no mortality observed in this study. None required intensive care admission or mechanical ventilatory support. Three were managed with hospital admission while one was subjected to home isolation. The mean hospital stay was 13.5 days (12–17 days). Immunosuppressants were modified by reducing tacrolimus and mycophenolate, however, corticosteroids were continued. Conclusion: The dose modification rather than discontinuation of immunomodulatory agents should be established as standard of care for transplant recipients. Steroids may provide added benefit and should be continued. The morbidity and mortality in such cases may be lower than anticipated; however, this needs to be substantiated with larger multicentric studies.

Survival Outcomes in Heart Transplant Patients; Specific Focus on ACHD Patients and Their Outcomes as Compared to Dilated and Ischemic Cardiomyopathy Patients

Purpose Congenital heart disease (CHD) is associated with high early post-transplant mortality but improved long-term survival in comparison to the overall heart transplant population. We aimed to evaluate survival outcomes of ACHD in adult transplant recipient patients as specifically compared to ischemic (ICM) and dilated cardiomyopathy (DCM) groups. This was a retrospective analysis of the ISHLT Registry data. Methods Adult heart transplant recipients between 2004 and 2014 were identified from the ISHLT registry. We used Kaplan-Meier analysis test to evaluate overall survival, 1-year survival and 1-year conditional survival among etiology groups and multivariable Cox proportional hazard (PH) model to assess the association between etiology of cardiomyopathy and 1-year, 1-year conditional all-cause mortality and cause-specific mortality. Results We included 30,130 heart transplant recipients: 1,839 (6.1%) CHD, 16,044 (53.2%) DCM and 12,247 (40.6%) ICM patients. By multivariable analysis CHD or ICM patients were at significantly higher mortality risk than DCM during the first year post-transplant. One-year survival was 78.3% in CHD, 84.3% in ICM and 86.2 in DCM patients. One-year conditional post-transplant survival was similar in CHD and DCM (HR 0.97, 95% CI 0.83-1.13) while ICM patients had higher long-term mortality risk than DCM patients (HR 1.17, 95% CI 1.09-1.26). Cause-specific mortality analyses showed that CHD patients were at higher risk for infection and graft failure related mortality than DCM patients within the first year post-transplant. Conclusion Patients with CHD or ICM are at significantly higher early all-cause mortality than DCM patients. CHD and DCM patients had comparable long-term survival and significantly improved long-term survival compared to ICM patients. This has implications for CHD patient selection for transplant and perioperative management.

Sternal wound complications in patients undergoing orthotopic heart transplantation.

The incidence and management of sternal wound complications in patients undergoing orthotopic heart transplantation (OHT) is not well studied. We report outcomes in heart transplant patients who developed sternal infections requiring reoperations. From 2004 to 2013, 437 patients underwent OHT at a single institution. In a retrospective review, patients who developed sternal infections (Infection group, n = 27) were compared with those without (Control group, n = 410). Sternal infection rate was 6.2% (n = 27). Demographics were similar (Table 1). Infection group had higher rates of COPD 25% vs 13%, P = 0.03, and previous cardiac surgery via median sternotomy 28% vs 15%, P = 0.03. Infection group had a greater incidence of prolonged ventilation, 44% vs 31%, P = 0.2, renal failure 56% vs 24%, P = 0.001, dialysis requirement 30% vs 10%, P = 0.006, permanent stroke 11% vs 2%, P = 0.02, perioperative myocardial infarction 4% vs 0.2%, P = 0.09. The infection group had a longer ICU stay (524 + 410 vs 187 + 355 hours, P = 0.001) and hospitalization (59 + 28 vs 0.29 + 43 days, P = 0.001). In-hospital/30-day mortality was 30% vs 19%, P = 0.2. The mean time for sternal reoperation at 44 + 50 days. Deep wound infection (41%) and sternal dehiscence (22%) were common presentations. Causative organisms were Enterobacter (22%), Klebsiella (15%), and Pseudomonas (15%). Vancomycin (44%), 4th generation cephalosporin (37%), and fluoroquinolones (30%) were the most commonly used antibiotics. Surgical treatment included sternal debridement with pectoralis muscle flap (52%), primary closure (18%), and omental flap (11%). Sternal wound infections impart a significant burden on patients with OHT. Causative organisms are predominantly virulent gram-negative bacteria. Therefore, a high index of suspicion must be maintained for early detection and treatment.