Outcomes In Heart Transplant Recipients Research Articles

Impact of waitlist weight change on outcomes in heart transplant recipients: a UNOS database analysis.

While the effect of pre-transplant weight on patient outcomes following heart transplantation (HTx) has previously been studied, data regarding the impact of dynamic weight change prior to HTx are extremely limited. We sought to elucidate the interaction between HTx listing weight and weight change while waitlisted, and explore how that interaction impacts post-HTx survival in a continuous manner. Adult patients listed for HTx from 1987 to 2020 were identified from UNOS database. Three-dimensional restricted cubic spline analysis explored post-HTx survival relative to both changes in BMI/weight and BMI at time of HTx listing. Continuous predictor variables were analyzed with Cox proportional hazards method. 9,628 included patients underwent HTx. Median recipient age was 55 [IQR 46-62] years, and 21% were females. 53% of patients lost while 47% gained weight on the waitlist. Median BMI (27.6kg/m2 [24.3-31.3] vs. 27.4kg/m2 [24.2-30.9], paired p < 0.001) and weight (84.8kg [73.0-98.0] kg vs. 84.4kg [72.6-96.6], p < 0.001) were similar at listing and transplant. One-year survival was 89.3%. Weight loss over 3 BMI points or 10kg was associated with higher hazard of death irrespective of listing BMI. In non-obese patients, some weight gain (1-4 BMI points or 5-15kg) was associated with improved survival. In cachectic patients (BMI < 18.5), failure to gain weight was associated with worse survival. Impact of weight change varies depending on listing BMI. While a survival benefit is seen in non-obese patients who gain some weight, significant weight loss is associated with poorer survival.

TCT-963 Age-Based Cardiovascular Outcomes of Heart Transplant Recipients: National Readmission Analysis

TCT-963 Age-Based Cardiovascular Outcomes of Heart Transplant Recipients: National Readmission Analysis

Donor plasma VEGF-A as a biomarker for myocardial injury and primary graft dysfunction after heart transplantation

BackgroundVascular endothelial growth factor (VEGF)-A is an angiogenic and proinflammatory cytokine with profound effects on microvascular permeability and vasodilation. Several processes may induce VEGF-A expression in brain-dead organ donors. However, it remains unclear whether donor VEGF-A is linked to adverse outcomes after heart transplantation. MethodsWe examined plasma VEGF-A levels from 83 heart transplant donors as well as the clinical data of these donors and their respective recipients operated between 2010 and 2016. The donor plasma was analyzed using Luminex-based Multiplex and confirmed with a single-target ELISA. Based on donor VEGF-A plasma levels, the recipients were divided into three equal-sized groups (low VEGF <500 ng/L, n=28; moderate VEGF 500-3000 ng/L, n=28; and high VEGF >3000 ng/L, n=27). Biochemical and clinical parameters of myocardial injury as well as heart transplant and kidney function were followed-up for one year, while rejection episodes, development of cardiac allograft vasculopathy, and mortality were monitored for five years. ResultsBaseline parameters were comparable between the donor groups, except for age, where median ages of 40, 45, and 50 were observed for low, moderate, and high donor plasma VEGF levels groups, respectively, and therefore donor age was included as a confounding factor. High donor plasma VEGF-A levels were associated with pronounced myocardial injury (TnT and TnI), a higher inotrope score, and a higher incidence of primary graft dysfunction in the recipient after heart transplantation. Furthermore, recipients with allografts from donors with high plasma VEGF-A levels had a longer length of stay in the intensive care unit and the hospital, and an increased likelihood for prolonged renal replacement therapy. ConclusionsOur findings suggest that elevated donor plasma VEGF-A levels were associated with adverse outcomes in heart transplant recipients, particularly in terms of myocardial injury, primary graft dysfunction, and long-term renal complications. Donor VEGF-A may serve as a potential biomarker for predicting these adverse outcomes and identifying extended donor criteria.

(413) - Outcomes of Heart Transplant Recipients with Highly Elevated Donor-Derived Cell-Free DNA Values: A Single Center Experience

(413) - Outcomes of Heart Transplant Recipients with Highly Elevated Donor-Derived Cell-Free DNA Values: A Single Center Experience

(829) - The Forgotten Pump - Waitlist & Post-Transplant Outcomes of Heart Transplant Recipients Supported by Heartware HVAD Before & After Device Recall

(829) - The Forgotten Pump - Waitlist & Post-Transplant Outcomes of Heart Transplant Recipients Supported by Heartware HVAD Before & After Device Recall

(793) - Outcomes of Heart Transplant Recipients with Giant Cells or Eosinophils on Endomyocardial Biopsy

(793) - Outcomes of Heart Transplant Recipients with Giant Cells or Eosinophils on Endomyocardial Biopsy

(25) - Surviving to Safety Net? Post-Transplant Outcomes of Heart Transplant Recipients with Low EGFR

(25) - Surviving to Safety Net? Post-Transplant Outcomes of Heart Transplant Recipients with Low EGFR

Low Mean Perfusion Pressure Indexed to Body Surface Area is a Powerful Predictor of Poor Outcomes After Heart Transplantation in Patients With High Pre-Transplant Venous Pressure: A Clinical Study With Physiological Insights From Mathematical Modelling of Biventricular Heart Failure

The deleterious consequences of chronically elevated venous pressure in patients with profound right ventricular or biventricular dysfunction are well known, including renal and hepatic dysfunction, and volume overload. The only option for these patients, if they fail optimal medical treatment, is a heart transplant, as they are not candidates for left ventricular assist device therapy. Mean perfusion pressure (MPP) is important in the outcomes of critically ill patients with high venous pressure. The question arises whether MPP is important for the outcomes of heart transplants in patients with elevated pre-transplant venous pressure. Medical management of heart failure patients with reduced ejection fraction involves lowering the systemic afterload with vasodilators while awaiting a transplant. We hypothesised that when venous pressure is elevated prior to transplant, a substantial reduction in systemic arterial elastance (Ea) through vasodilation may significantly decrease MPP, resulting in compromised end-organ function and consequent unfavourable outcomes after heart transplantation. This study aims to investigate whether a low MPP serves as a risk factor for adverse outcomes in heart transplant recipients with high venous pressure. A retrospective analysis was conducted on 250 heart transplant recipients undergoing isolated heart transplantation at a single institution from October 2012 to March 2020. Right atrial pressure (RAP) of more than 15 mmHg was considered high. Additionally, Ea calculated as the ratio of end-systolic pressure to stroke volume, and MPP calculated as the difference between mean arterial pressure and RAP were considered in our analysis. The outcomes of transplantation were measured in terms of 90-day mortality and survival up to 7 years. High RAP was a significant risk factor for short-term and medium-term survival if Ea was low (<2.7 mmHg/mL, the median value). This group had 39.39% in-hospital mortality compared to 14.49% for RAP<15 mmHg (p∼0.005). When Ea was high, this difference in survival was not evident: 8% for RAP<15 mmHg vs 4.8% for RAP>15 mmHg (p∼0.550). This effect was mediated through a lower MPP, and the mortality due to lower MPP increased strikingly with higher body surface area (BSA). A negative correlation was observed between MPP indexed to BSA (MPPI) and the Model for End-Stage Liver Disease score (r∼-0.3580, p<0.0001) as well as creatinine (r∼-0.3551, p<0.0001). MPPI less than 40 mmHg/m2 was associated with poorer short-term (23.2% for MPPI<40 mmHg/m2 vs 7.1% for MPPI>40 mmHg/m2, p∼0.001) and medium-term survival. The impact of high RAP and low Ea on survival was evident even on medium-term follow-up; only 30% survival at 7 years follow-up for high RAP and low Ea vs 75% for RAP<15 mmHg (p∼0.0033). The acceptable blood pressure during vasodilator therapy in patients with high RAP needs to be higher, especially in those with higher BSA. MPPI less than 40 mmHg/m2 is a risk factor for survival, in the short and medium-term, after heart transplantation.

Outcomes in Heart Transplant Recipients by Bridge to Transplant Strategy When Using the SherpaPak Cardiac Transport System.

The last several years have seen a rise in use of mechanical circulatory support (MCS) to bridge heart transplant recipients. A controlled hypothermic organ preservation system, the SherpaPak Cardiac Transport System (SCTS), was introduced in 2018 and has grown in utilization with reports of improved posttransplant outcomes. The Global Utilization And Registry Database for Improved heArt preservatioN (GUARDIAN)-Heart registry is an international, multicenter registry assessing outcomes after transplant using the SCTS. This analysis examines outcomes in recipients bridged with various MCS devices in the GUARDIAN-Heart Registry. A total of 422 recipients with donor hearts transported using SCTS were included and identified. Durable ventricular assist devices (VADs) were used exclusively in 179 recipients, temporary VADs or intra-aortic balloon pump (IABP) in 197, and extracorporeal membrane oxygenation (ECMO) in 14 recipients. Average ischemic times were over 3.5 hours in all cohorts. Severe primary graft dysfunction (PGD) posttransplant increased across groups (4.5% VAD, 5.1% temporary support, 21.4% ECMO), whereas intensive care unit (ICU) length of stay (18.2 days) and total hospital stay (39.4 days) was longer in the ECMO cohort than the VAD and IABP groups. A comparison of outcomes of MCS bridging in SCTS versus traditional ice revealed significantly lower rates of both moderate/severe right ventricular (RV) dysfunction and severe PGD in the SCTS cohort; however, upon propensity matching only the reductions in moderate/severe RV dysfunction were statistically significant. Use of SCTS in transplant recipients with various bridging strategies results in excellent outcomes.

Heart transplantation from COVID-positive donors with 6-month follow-up: A case series.

Data on long term outcomes in heart transplant recipients from Coronavirus disease 2019 (COVID-19) positive donors are limited. We present a series of nine patients who underwent heart transplants from COVID-19 PCR-positive donors between November 2021 to August 2022 with mean follow-up of 12.12±3 months. All the recipients received two doses of COVID-19 vaccine and had at least 6 months follow-up. Eight recipients had acceptable long-term outcomes; one patient died during index admission from primary graft dysfunction. Details regarding donor and recipient characteristics, management and outcomes are provided. Two patients developed deep vein thrombosis, and one patient underwent pacemaker implantation for sinus node dysfunction. Among the surviving eight patients, none developed COVID-19 infection during follow-up period. There was no significant difference in outcome parameters when compared to patients who received hearts from donors who tested negative for COVID-19 during the same time period at our center. Keeping in mind the significant waitlist mortality in patients awaiting heart transplantation, COVID-19-positive donors should be considered for heart transplantation to help expand the donor pool and potentially reduce waitlist mortality.

Usage of older donors is associated with higher mortality after heart transplantation: A UNOS observational study

IntroductionUtilization of heart from older donors is variable across centers with uncertain outcomes of recipients. We sought to utilize a national registry to examine usage and outcomes of heart transplant recipients from older donors. We also explored the impact of current donor heart allocation scheme on outcomes of hearts from older donors. MethodsThis observational study utilized the United Network for Organ Sharing database between 2015 and 2023 with donors categorized into age < 45 years or ≥ 45 years and evaluated organ disposition and geographical variation. 30-day, 1- and 3- year mortality, and graft failure rates were compared amongst recipients as per donor age group. We also evaluated annual trends in HT for each group over the follow-up period. Results24,966 adult donors were recovered: 3,742 (15.0%) were ≥ 45 years; 3,349 (15.6%) adults received heart from such donors with significant geographical variation, and a declining utilization in the transplantation rate in current donor allocation system. Donors with age ≥ 45 years had higher comorbidities and were allotted with a significantly shorter ischemic time to recipients who were significantly less likely to receive temporary mechanical circulatory support and more likely female. Unadjusted and adjusted, 30-day mortality were similar but 1- and 3-year mortality and graft failure rates were significantly higher in recipients of such donors. spline analysis suggested a higher 1-year mortality risk at older donor age with risk increasing after age 40 years. ConclusionsOlder donor age was associated with worsened 1- and 3-year mortality and graft failure for heart transplant recipients.

Coronavirus disease 2019 outcomes in heart transplant recipients: A large Australian cohort

Heart transplant recipients have been reported to be at a significantly elevated risk of poor outcomes from coronavirus disease 2019 (COVID-19) infection owing to their underlying comorbidities and immunosuppression. We conducted a single-center retrospective cohort of all heart transplant recipients who were known to have contracted COVID-19 between January 2020 and September 2022. Electronic medical records were used to collect baseline demographics, vaccination status, COVID-19 treatment received, hospitalization data, and mortality. Our primary end point was mortality, and our secondary endpoint was hospitalization. Between January 2020 and September 2022, 132 heart transplant recipients at our single-center contracted COVID-19 infection. Our population had high rates of vaccination, with 124 patients (94%) having received at least 2 vaccines. We found significantly lower rates of mortality and hospitalization than had been previously reported earlier in the pandemic, with a mortality rate of 8/132 (6%) and hospitalization rate of 21/132 (16%).

Synchronous Donor Heart and Lung Procurement Does Not Impair Outcomes After Heart Transplant.

Donor hearts frequently originate from donors whose lungs are also recovered for transplant. Synchronous heart and lung procurement is more complex than procurement ofthe heart alone, and the effects on outcomes are debated. This study examines the effect of synchronous procurement on outcomes in heart transplant recipients. This single-center study included patients who received a heart transplant from September 2010 to June 2022. Main outcomes were overall mortality and mortality at 30 days, 3 months, 1 year, and 3 years and morbidity within the first year. We analyzed overall mortality using KaplanMeier survival analysis. Logistic regression was used for the remaining outcomes, adjusting for covariates. P < .05 was considered significant. Our study included 253 heart transplant recipients (72.3% male, mean age 55.0 years), of which 184 patients (72.7%) received hearts from donors of heart and lung, and 69 (27.3%) received hearts from donors of only hearts. Heart-and-lung donors were younger than heart-only donors (43.2 vs 47.2 years; P = .017). Transplant recipient baseline characteristics were not different between the 2 groups. Receipt of hearts from heart-and-lung donors was not associated with higher overall mortality (P = .33) or mortality at 3 months (P = .199), 1 year (P = .348), or 3 years (P = .375), and even showed better 30-day survival than receipt of hearts from heart-only donors (p=0.035). Recipients of hearts from heart-and-lung donors did not have higher rates of postoperative mechanical circulatory support, resternotomy, or pacemaker implantation within the first year. Our study confirms that synchronous heart and lung procurement for transplant is not associated with worse outcomes in heart transplant recipients and that hearts originating from heart-andlung donors may even be associated with improved outcomes.

Outcomes of COVID-19-Positive Donor Heart Transplantation in the United States.

Background Little is known regarding the impact of donor COVID-19 status on recipient outcomes after heart transplantation. In this study, we characterize outcomes of the first 110 heart transplants from organ donors positive for COVID-19 (COVID-19+) in the United States. Methods and Results Retrospective analysis of the United Network for Organ Sharing database was performed for single-organ adult heart transplants from January 2020 to March 2022. Donor COVID-19+ status was defined as a positive nucleic acid amplification, antigen, or other COVID-19 test within 7 days of transplant. Nearest-neighbor propensity score matching used to adjust for differences between recipients of COVID-19+ and nonpositive donor hearts. Overall, 7251 heart transplants were included in analysis, with 110 using COVID-19+ donor hearts. Recipients of COVID-19+ allografts were younger (54 [interquartile range, 41-61]) versus 57 [46-64] years; P=0.02) but had similar rates of female sex and non-White race compared with those receiving allografts from negative donors. Nearest-neighbor propensity score matching resulted in 100 well-matched pairs of recipients of COVID-19+ versus nonpositive donor organs. The 2 matched groups had similar median lengths of stay (15 [11-23] days versus 15 [13-23] days; P=0.40), rates of graft failure (1% versus 0%; P=0.99), 30-day death (3% versus 3%; P=0.99), and 3-month survival (88% versus 94%; P=0.23) compared with recipients of nonpositive donors. No deaths occurred due to COVID-19 infection among the 8 (7%) total deceased recipients of COVID-19+ allografts to date. Conclusions Short-term outcomes of heart transplant recipients receiving COVID-19+ donor organs are reassuring. However, continued monitoring for long-term survival and potential complications are warranted.

Outcomes of heart transplant recipients with prior left ventricular assist device associated stroke

BackgroundLeft ventricular assist devices (LVADs) improve survival in patients with end-stage heart failure but are associated with ischemic stroke and intracranial hemorrhage (ICH). The impact of LVAD-associated stroke on transplant candidacy and outcomes has not been characterized. MethodsAdult patients undergoing LVAD implantation at Cleveland Clinic between 2004 to 2021 were reviewed and patients who developed ischemic stroke or ICH were identified. Post-transplant survival analysis was performed between patients with LVAD-associated stroke vs. without. Results917 patients had an LVAD implantation of whom 244 (median age 57, 79% male) underwent subsequent transplant including 25 with prior LVAD-associated stroke. The 1- and 2-year survival after transplant in patients with LVAD-associated stroke were 100% and 95% respectively, compared with 92% and 90% in patients without stroke (p=0.156; p=0.323) Similarly, there was no difference in stroke incidence at 1- and 2 years after transplant between patients with LVAD-associated stroke (4% and 5%) and those without prior stroke (5% and 6%, p = 0.884; p=0.744). ConclusionsIn this single-center retrospective study, patients with LVAD-associated stroke were significantly less likely to undergo heart transplant, but those who underwent heart transplant had similar post-transplant outcomes as patients without history of LVAD-associated stroke. Given the similar outcomes seen in this population, history of LVAD-associated stroke should not be viewed as an absolute contraindication to subsequent heart transplant.

CARC17: Outcomes in Heart Transplant Recipients with Sex Mismatched Organs: A Subgroup Analysis of the GUARDIAN-Heart Registry

Background: Donor and recipient sex mismatch in heart transplantation is considered a risk factor for poor outcomes. The mechanisms for this are poorly understood. We sought to assess whether a male to female or female to male donor mismatch influences outcomes following transplants using donor hearts preserved with the SherpaPak Cardiac Transport System (CTS). The CTS provides controlled hypothermic heart preservation during transportation which may abate cold injury to the donor heart. Methods: The GUARDIAN-Heart registry is an international, multicenter registry assessing outcomes following heart transplantation using donor organs preserved with CTS compared to standard ice transportation (ICE). A subgroup analysis of sex-mismatched donors and recipients resulted in cohorts of 121 ICE transplants compared to 141 CTS transplants. Summary statistics were used for comparing the groups. Further analysis with ongoing enrollment will be available for presentation. Results: The baselines of the two groups were similar, including the proportion of female to male mismatches (57% (ICE) vs 56%, (CTS), p = 0.87) and the percent undersized by >15% (17.4% (ICE) vs 22.5% (CTS), p = 0.33), except there was significantly longer total ischemic time in transplants using CTS by 26 minutes (195.2 vs 221.2 minutes, p = 0.004) and distance traveled to procure the organs was 44% farther (251.6 vs 445.7 miles, p < 0.001, ICE vs CTS, respectively). Post-transplant, the incidence of severe PGD was similar (11.7% vs 7.8%, p = 0.29, ICE vs CTS, respectively), as was the total length of ICU and hospital stay. The CTS cohort demonstrated a significant improvement in both 30 day (95% vs 100%, p = 0.01) and in-hospital survival (92.6% vs 99.3%, p = 0.005, ICE vs CTS, respectively). Conclusions: Despite significantly longer ischemic times, use of the SherpaPak CTS resulted in improved early survival when compared to heart transplants using standard ice transport.

TOP1: Outcomes in Heart Transplant Recipients by Bridge-To-Transplant Strategy When Using the SherpaPak Cardiac Transport System

Background: The last several years have seen a rise in the use of mechanical circulatory support (MCS) to bridge heart transplant recipients. This may be due to expanding indications for devices such as extracorporeal membrane oxygenation (ECMO), but also to changes in the UNOS allocation policy in 2018. A controlled hypothermic organ preservation system, the SherpaPak Cardiac Transport System (CTS), was also introduced in 2018 and has grown in utilization with reports of improved post-transplant outcomes. We present here a subgroup analysis in recipients bridged with various MCS devices in the GUARDIAN-Heart Registry. Methods: The GUARDIAN-Heart registry is an international, multicenter registry assessing outcomes after transplant using CTS preservation. A retrospective review of clinical outcomes in transplant recipients with ventricular assist devices (VAD), intra-aortic balloon pumps (IABP) and ECMO prior to transplant were examined using summary statistics. Further analysis with ongoing enrollment will be available for presentation. Results: A total of 373 heart transplant recipients with donor hearts transported using the CTS system were included in this analysis. VADs were used in 171 recipients, IABP in 165, and ECMO in 37 recipients. Average ischemic times were over 3.5 hours for all cohorts. Mean IMPACT scores increased across groups (VAD = 6.8, IABP = 9.4, ECMO = 15.9), as did the rates of severe PGD post-transplant (VAD = 4.7%, IABP 7.9%, ECMO 18.9%). However, overall one-year survival was excellent (LVAD = 90.3%, IABP = 94.1%, ECMO = 93.3%). Median ICU length of stay was longer in the EMCO cohort (13.0 days) compared to the LVAD and IABP cohorts (each 7.0 days), as well as total hospital length of stay at 27.0 (ECMO) compared to 21.5 (LVAD) and 18.0 days (IABP). Conclusions: Despite average ischemic times in excess of 3.5 hours, use of the SherpaPak CTS for recipients with various bridging strategies results in excellent survival.

(445) Outcomes of Heart Transplant Recipients That Had a Percutaneous Coronary Intervention

(445) Outcomes of Heart Transplant Recipients That Had a Percutaneous Coronary Intervention

(623) Uncontrolled Cardiac Arrest of Donor Heart Before Donation Does Not Affect Heart Transplant Recipient Outcomes: Proof of Concept for DCD Long-Term Outcomes

(623) Uncontrolled Cardiac Arrest of Donor Heart Before Donation Does Not Affect Heart Transplant Recipient Outcomes: Proof of Concept for DCD Long-Term Outcomes

Outcomes of heart transplant recipients bridged with percutaneous versus durable left ventricular assist devices.

The new United Network for Organ Sharing (UNOS) heart allocation policy prioritizes temporary percutaneous over durable left ventricular assist devices (LVAD) as bridge to transplant. We sought to examine 1-year outcomes of heart transplant recipients bridged with Impella versus durable LVADs. All primary adult orthotopic heart transplant recipients registered in UNOS between January 2016 and June 2021 were analyzed. Recipients were identified as being bridged with isolated durable or percutaneous LVAD at the time of transplant. Baseline characteristics were compared and 1-year survival was examined using the Kaplan Meier method and multivariable Cox proportional hazards regression. During our study period, heart transplant recipients bridged with LVADs were divided between 5422(94%) durable and 324(6%) percutaneous options. Impella-bridged recipients were more likely to be status 1A under the old allocation system (98% vs. 70%, p<.01) and status 2 or higher under the new allocation system (99% vs. 24%, p<.01). Impella-bridged recipients were less likely to be obese (27% vs. 42%, p<.01), have ischemic cardiomyopathy (27% vs. 34%, p<.01), and were more likely to be on inotropic agents at the time of transplant (68% vs. 6%, p<.01). One-year post-transplant survival was not significantly different between the two groups on univariable (HR .87, 95% CI .56-1.37) or multivariable analysis (aHR .63, 95% CI .37-1.07). Following the UNOS allocation policy change, Impella utilization has increased with no significant difference in 1-year survival compared to bridge with durable LVADs. Impella may be a reasonable alternative to durable LVADs in select patients.