Post-heart Transplant Survival Research Articles

(306) Regardless of Donor Cardiac Function, When Other Organs are Not Utilized, Decreased Post-Heart Transplant Survival Can Be Expected

(306) Regardless of Donor Cardiac Function, When Other Organs are Not Utilized, Decreased Post-Heart Transplant Survival Can Be Expected

Contemporary Outcomes of Heart Transplantation in Children with Heterotaxy Syndrome: Sub-Optimal Pre-Transplant Optimization Translates into Early Post-Transplant Mortality.

Patients with heterotaxy syndrome and congenital heart disease (CHD) experience inferior cardiac surgical outcomes. Heart transplantation outcomes are understudied, however, particularly compared to non-CHD patients. Data from UNOS and PHIS were used to identify 4803 children (< 18years) undergoing first-time heart transplant between 2003 and 2022 with diagnoses of heterotaxy (n = 278), other-CHD (n = 2236), and non-CHD cardiomyopathy (n = 2289). Heterotaxy patients were older (median 5yr) and heavier (median 17kg) at transplant than other-CHD (median 2yr and 12kg), and younger and lighter than cardiomyopathy (median 7yr and 24kg) (all p < 0.001). UNOS status 1A/1 at listing was not different between groups (65-67%; p = 0.683). At transplant, heterotaxy and other-CHD patients had similar rates of renal dysfunction (12 and 17%), inotropes (10% and 11%), and ventilator-dependence (19 and 18%). Compared to cardiomyopathy, heterotaxy patients had comparable renal dysfunction (9%, p = 0.058) and inotropes (46%, p = 0.097) but more hepatic dysfunction (17%, p < 0.001) and ventilator-dependence (12%, p = 0.003). Rates of ventricular assist device (VAD) were: heterotaxy-10%, other-CHD-11% (p = 0.839 vs. heterotaxy), cardiomyopathy-37% (p < 0.001 vs. heterotaxy). The 1-year incidence of acute rejection post-transplant was comparable between heterotaxy and others (p > 0.05). While overall post-transplant survival was significantly worse for heterotaxy than others (p < 0.05 vs. both), conditional 1-year survival was comparable (p > 0.3 vs. both). Children with heterotaxy syndrome experience inferior post-heart transplant survival, although early mortality appears to influence this trend, with 1-year survivors having equivalent outcomes. Given similar pre-transplant clinical status to others, heterotaxy patients are potentially under risk-stratified. Increased VAD utilization and pre-transplant end-organ function optimization may portend improved outcomes.

Impact of 2016 UNOS pediatric heart allocation policy changes on VAD utilization, waitlist, and post-transplant survival outcomes in children with CHD versus Non-CHD.

We analyzed the impact of the revised pediatric heart allocation policy on types of ventricular assist device (VAD) utilization, and waitlist (WL) and post-heart transplant (HT) survival outcomes in congenital heart disease (CHD) versus non-CHD patients before (Era-1) and after (Era-2) pediatric heart allocation policy implementation. We retrospectively reviewed the UNOS database from December 16, 2011, through March 31, 2021, for patients<18 years old and listed for primary HT. We compared the differences observed between Era-1 and Era-2. 5551 patients were listed for HT, of whom 2447(44%) were in Era-1 and 3104(56%) were in Era-2. CHD patients were listed as status 1A unchanged, but the number of patients listed as status 1B decreased in Era-2, whereas the number of non-CHD patients listed as status 1A decreased, but status 1B increased. In Era-2 compared to Era-1, both temporary (1% to 4%, p<.001) and durable VAD (13.6% to 17.8%, p<.001) utilization increased, and the transplantation rate per 100-patient years increased in both groups. The median WL period for CHD patients increased marginally from 70 to 71 days (p=.06), whereas for non-CHD patients it decreased from 61 to 54 days (p<.001). Adjusted 90-day WL survival increased from 84% to 88%, p=.016 in CHD, but there was no significant change in non-CHD patients (p=.57). There was no significant difference in 1-year post-HT survival in CHD and non-CHD patients between Era-1 and Era-2. In summary, after the revised heart allocation policy implementation, temporary and durable VAD support increased, HT rate increased, waitlist duration marginally increased in the CHD cohort and decreased in the non-CHD cohort, and 90-day WL survival probability improved in children with CHD without significant change in 1-year post-HT outcomes. Future studies are needed to identify changes to the policy that may further improve the listing criteria to improve WL duration and post-HT survival.

Impact of predicted heart mass-based size matching on survival after heart transplantation in Korea: Analysis of the Korean Organ Transplant Registry.

Previous studies regarding donor-recipient size and sex matching in heart transplantation (HTx) mainly included Caucasians with only a small portion of Asians. Even predicted heart mass (PHM) has not yet been elucidated in Asians. We evaluated the association between donor-recipient sex and size matching, including mismatching by PHM, and post-heart transplant survival in Korea. We enrolled 660 adult HTx recipients between January 2014 and December 2020 using the Korean Organ Transplant Registry data. Recipients were categorized based on donor-recipient PHM, body weight, and sex matching. The primary outcome was 1-year mortality and retransplantation after HTx and survival analyses were performed using Kaplan-Meier method and Cox proportional hazard models. Among 660 patients, 74 (11.2%), 404 (61.2%), and 182 (27.6%) received undersized (<-15%), matched (-15% to 20%), and oversized (>20%) hearts by PHM, respectively. Size mismatching by PHM was present in a large number of sex-mismatched patients with 85.1% of male donor-female recipients being classified as oversized by PHM and 62.2% of female donor-male recipients being classified as undersized by PHM. Recipients of undersized or oversized hearts by PHM showed an increased 1-year mortality compared with recipients of matched-size hearts (14.8% versus 9.7%; log-rank p=0.038). The increased mortality persisted after adjusting for other factors affecting mortality (hazard ratio=1.60, 95% confidence interval: 1.01-2.56). These associations were not shown in obese recipients (body mass index ≥25 kg/m2). Heart size mismatching by body weight (log-rank p=0.332) or sex mismatching (all, log-rank p > 0.05) did not predict 1-year mortality after HTx. Heart size matching by PHM, not by body weight or sex, was associated with increased 1-year mortality after HTx in Korea.

Palliated Hypoplastic Left Heart Syndrome Patients Experience Superior Waitlist and Comparable Post-Heart Transplant Survival to Non-Single Ventricle Congenital Heart Disease Patients

Congenital heart disease (CHD) is a well-established risk factor for inferior waitlist and post-heart transplant survival in children. Differences in outcomes between CHD subgroups are understudied. The present study compared outcomes for palliated hypoplastic left heart syndrome (HLHS) patients to other non-single ventricle CHD (non-SVCHD) and non-CHD patients. United Network for Organ Sharing was used to identify children (age < 18) listed for heart transplant in the United States between 2016 and 2021. CHD sub-diagnoses were only available for United Network for Organ Sharing status 1a after 2015, thereby defining the cohort. Waitlist outcomes were studied using competing-risk time-to-event analysis for transplantation, mortality/decompensation, and alive-on-waitlist. Multivariable Cox proportional hazards regression analyses were used to identify factors associated with inferior post-transplant survival. Patients included: palliated-HLHS (n = 477), non-SVCHD (n = 686), and non-CHD (n = 1261). At listing, Palliated-HLHS patients were older than non-SVCHD (median 2-year [IQR 0-8] vs median 0-year [0-3], respectively) and younger than non-CHD (median 7-year [0-14]) (P < 0.001 vs both), and were more likely to be white (P < 0.01 vs both). Upon time-to-event analysis, rates of waitlist mortality/decompensation rates were greater among non-SVCHD than palliated-HLHS. Post-transplant survival was comparable between palliated-HLHS and non-SVCHD (P = 0.920) but worse compared to non-CHD (P < 0.001). Both palliated-HLHS (HR 2.40 [95% CI 1.68-3.42]) and non-SVSCHD (2.04 [1.39-2.99]) were independently associated with post-transplant mortality. Palliated-HLHS patients with heart failure experience significantly worse post-transplant outcomes than non-CHD but, compared to other CHD patients, experience superior waitlist and comparable post-transplant survival. While a high-risk cohort, HLHS patients can achieve gratifying waitlist and post-transplant survival.

Infants Who Require Total Parenteral Nutrition and Paralytics at Time of Heart Transplant Experience Inferior Post-Transplant Mortality.

Background: Infants experience the worst one-year post-heart transplant (HTx) survival of any other pediatric group. Although mechanical ventilatory (MV) requirement at the time of transplant is an established predictor of post-transplant mortality, the impacts of commonly co-utilized support modalities such as total parenteral nutrition (TPN)-dependence and paralytics are understudied. Methods: All infant HTx recipients from 2003 to 2020 in both the United Network for Organ Sharing and Pediatric Health Information System databases were identified (n = 1344) and categorized depending upon support requirement at the time of transplant-none (59%), MV-only (10%), MV + Paralytics (2%), TPN-dependence-only (15%), MV + TPN (10%), and MV + Paralytics + TPN (4%). The primary study aim was to characterize the impact of TPN-dependence and paralytics on one-year post-transplant survival (PTS). Results: Compared to no-support, supported infants were generally at higher risk and more ill at transplant, with greater rates of congenital heart disease, renal and hepatic dysfunctions, and inotrope requirements. Post-transplant hospital outcomes were inferior among supported patients; all support groups experienced longer post-transplant MV, intensive care unit, and hospital lengths of stay (all P < .05 vs no-support). Upon multivariable analysis, each support modality independently predicted 1-year mortality (MV vs no-MV: 1.54 [1.10-2.14]; MV + Paralytics vs neither: 2.02 [1.25-3.27]; TPN vs no-TPN: 1.53 [1.10-2.13]; P < .01 for all), whereas no-support was protective (HR 0.66 [95% CI 0.48-0.91]). Conclusions: Infants who require paralytics and/or who are TPN-dependent at the time of HTx experience worse one-year PTS. Such knowledge can assist in risk-stratification, and the identification of patients who would benefit from pretransplant optimization.

Impact of primary diagnosis on survival after heart transplant in female recipients of childbearing age: an analysis of the International Society for Heart and Lung Transplantation (ISHLT) Registry

Abstract Background Women undergoing heart transplantation (HT) for peripartum cardiomyopathy (PPCM) have been reported to have inferior post-transplant survival. Specific data on the impact of pre-transplant diagnosis on survival in female HT recipients of childbearing age are lacking, but important for pre-conception counseling of women considering a pregnancy. Methods Retrospective data analysis was conducted using the ISHLT Registry. The primary aim was to study the impact of pre-transplant diagnosis and alloimmunisation on post-transplant survival in women aged 15–45 yrs at time of HT. Secondary outcomes included the impact of primary diagnosis on conditional survival at 5, 10 and 15-yrs post HT. Results Of 121,501 HT recipients (Jan 1992–June 2018), 30,179 (24.8%) were women. 9,229 (7.6%) were 15–45 yrs at time of HT. Peripartum cardiomyopathy (PPCM) and congenital heart diseases (CHD) was the primary diagnosis in 8.9% and 9.3%, respectively. Overall median post-transplant survival was 15.2 yrs. Female with PPCM were associated with higher alloimmunisation (Figure 1). PPCM was associated with lower survival (median survival in PPCM vs CHD vs other: 9.1 years vs 15.2 years vs 15.5 years respectively, p&amp;lt;0.05). This was not entirely explained by higher alloimmunisation in this group (Figure 2A). Five-year conditional survival of recipients of childbearing age was significantly affected by primary diagnosis of PPCM, and by pediatric status at HT, defined as age &amp;lt;18-yrs (PPCM vs other diagnosis p&amp;lt;0.05; pediatric vs non-pediatric p 0.003), whilst 10- and 15-year conditional survival was not. The difference in 5-year conditional outcome between PPCM and other diagnosis, was not significant however when female recipients were grouped according to their level of alloimmunisation (Figure 2B). Conclusion PPCM as the primary indication for HT is associated with a worse post HT survival. Our data suggest that this is not entirely explained by alloimmunisation. The impact of previous PPCM appears to be greatest in the first 5 yrs post HT. Further research is needed to fully elucidate the mechanisms associated with worse survival in this group and help inform pre-conception counseling in those HT recipients considering a subsequent pregnancy. Funding Acknowledgement Type of funding sources: None.

Impact of left ventricular assist device complications on heart transplant outcomes under the 2018 heart transplant allocation policy

ObjectiveThe study objective was to determine the impact of left ventricular assist device complications on post–heart transplant survival before and after the 2018 US heart transplant allocation policy change. MethodsAdult patients (age >18 years) supported by left ventricular assist devices at the time of listing or transplantation in the United Network for Organ Sharing between October 18, 2015, and December 31, 2021, were included. Left ventricular assist device complications were defined by status at transplant (nonelective 1A in the prior era or new era status 2 or 3). Post-transplant survival (primary analysis) and baseline characteristics were compared among those with and without left ventricular assist device complications and by allocation era using multivariable Cox regression analyses. ResultsThe primary analysis included 4160 patients with left ventricular assist devices who underwent heart transplant (prior era n = 2458, new era n = 1702). Patients who underwent heart transplant with left ventricular assist device complications were on left ventricular assist device support longer under the new era (498 days vs 423 days P < .001). Post-transplant survival was highest in the prior era among those without left ventricular assist device complications. Patients who underwent transplantation in the prior era with a complication and in the new era without complications were not statistically different. Left ventricular assist device complications in the new era were associated with the highest post-transplant mortality (status 2 adjusted hazard ratio, 1.87, 95% confidence interval, 1.31-2.67, P < .001, status 3 adjusted hazard ratio, 1.50, 95% confidence interval, 1.11-2.04, P = .009). ConclusionsLeft ventricular assist device complications in the new era are associated with increased post-transplant mortality. As a heart allocation score is being considered, modeling time on left ventricular assist device support to promote heart transplant before development of left ventricular assist device–related complications may improve outcomes for patients with left ventricular assist devices.

The importance of mechanical circulatory support on pediatric waitlist and post heart transplant survival: a narrative review

Background and Objective: While heart transplantation for children with end-stage heart failure has been available for more than 50 years, outcomes on the waitlist and as well as post-transplant outcomes have not always been favorable. Post-transplant survival initially showed marked improvement with better and better immunosuppression regimens. However, waitlist outcomes (as well as those deemed too sick to list) remained unfortunately low. With the introduction of mechanical circulatory support (MCS) in the 1970s, a new hope for the those with end-stage heart failure emerged. This paper will review the past, present and what is on the horizon for MCS as a bridge to heart transplantation in pediatric patients.

EBV-seronegative Status In Recipients Worsens Post Heart Transplant Survival

<h3>Background</h3> Although the incidence of Post-transplant lymphoproliferative disease which is associated with Epstein-Barr virus (EBV) is relatively high and its presence is associated with severe complications, impact of EBV serostatus on post heart transplantation (HT) survival is not clear. We sought to determine the impact of donor and recipient EBV serostatus on post HT survival. <h3>Methods</h3> We identified adult patients who underwent HT between 2000 and 2018 in the Scientific Registry of Transplant Recipients. These patients were categorized as per recipient and donor EBV serological status. We compared survival with the Kaplan-Meier method. We constructed Cox proportional hazards regression models to determine the risk-adjusted influence of EBV serostatus on post HT survival. <h3>Results</h3> Out of 20, 533 HT identified, 16,222 were +/+, 1081 were +/-, 2544 were -/+ and 186 were -/- EBV serological statuses. Compared to positive donor to negative recipient EBV serostatus, other donor and recipient EBV serostatuses were associated with decreased mortality (Figure and Table). <h3>Conclusion</h3> A primary EBV infection in EBV-seronegative patients receiving an EBV-seropositive donor organ or a reactivation in those who are already latently infected pre-transplantation can lead to uninhibited growth of EBV-infected B cells which can impact post HT survival. In the absence of effective preventive strategies, such as vaccines and antiviral agents the role of EBV viral load monitoring and immunosuppression regimen modulation needs investigation.

Does Post-Heart Transplantation Placement of Permanent Pacemakers Affect Survival?

<h3>Purpose</h3> Permanent pacemaker implantation (PPI) is required in about 2%-24% of patients after a heart transplant (HTX) due to conduction abnormalities. We sought to investigate the short- and long-term survival outcomes of permanent pacemaker implantation in patients following HTX. <h3>Methods</h3> United Network for Organ Sharing (UNOS) registry was queried for all adult HTX from 1999 to 2018 for PPI. Recipients were grouped based on PPI. Kaplan-Meier(KM) survival analysis and Cox regression modelling were used in our analysis for confounding variables including age, gender, status of HF and ethnicity in addition to logistic regression for data analysis. <h3>Results</h3> Of 34,997 HTR, 1159 (3%) had PPI following HTX. KM survival analysis showed PPI had no difference on post-heart transplant survival (Fig). Similar results were obtained on adjusting for confounding variables including diabetes mellitus, age, sex, gender, and ethnicity. In our logistic regression model, 33,222 HTR were included and 11,396 (34%) deaths among these on adjusting for similar confounders as the Cox regression model. Increasing donor age and increase in number of rejection episodes resulted in a higher percentage of pacemaker implantations (data not shown). Hence, our observations indicate that permanent pacemaker does not impact both short-term and long-term survival. <h3>Conclusion</h3> In conclusion, permanent pacemaker implantation has no influence on survival. However, additional analysis of the surgical technique used in transplantation, types of conduction abnormalities and other factors which can influence outcomes need to be evaluated further.

Education and Its Impact on Post-Heart Transplant Survival?

<h3>Purpose</h3> The purpose of this study was to evaluate the effect of education on survival after orthotopic heart transplantation. Few studies have explored the impact of education from quality of life and adherence to medication and follow-up, thus a paucity of literature exists in understanding education and its impact on survival. <h3>Methods</h3> We evaluated the United Network for Organ Sharing (UNOS) registry for all adult heart transplant recipients (HTR) from 1999 to 2018. Recipients were grouped based upon their education level. We had two groups in our analysis: group 1 = education level > high school and group 2 = education level < high school. Kaplan-Meier survival analysis and Cox regression modelling were used in our analysis for confounders like age, gender, status of HF, ethnicity, etc. <h3>Results</h3> We had a total of 30,999 heart transplant recipients (HTR) in our analysis, of which 1,122 HTR with less than high school education and 29,877 with education above high school. Kaplan-Meier survival analysis of the patient survival time showed a higher survival in HTRs with education level above high school (Figure 1). Education level < high school had 17% increased risk of death (p=0.0024). On adjusting for confounders like age, gender, status of HF, ethnicity, etc., education still had a positive impact on survival. Lower episodes of rejection and better follow-up were also seen in HTR with an education level higher than high school. (data not shown) <h3>Conclusion</h3> Higher level of education has a positive impact on survival. This relationship can be explained by the notion that HTRs with higher education status may be better informed, more adherent to medication, and more likely to follow-up. All of these factors contribute to earlier identification of complications and fewer rejection episodes, ultimately leading to greater outcomes of survival. Further studies are required to further understand this complex relationship.

Fontan-associated liver disease.

Fontan-associated liver disease.

Sex and Heart Failure Treatment Prescription and Adherence

Heart disease is the leading cause of death in both men and women in developed countries. Heart failure (HF) contributes to significant morbidity and mortality and continues to remain on the rise. While advances in pharmacological therapies have improved its prognosis, there remain a number of unanswered questions regarding the impact of these therapies in women. Current HF guidelines recommend up-titration of neurohormonal blockade, to the same target doses in both men and women but several factors may impair achieving this goal in women: more adverse drug reactions, reduced adherence and even lack of evidence on the optimal drug dose. Systematic under-representation of women in cardiovascular drug trials hinders the identification of sex differences in the efficacy and safety of cardiovascular medications. Women are also under-represented in device therapy trials and are 30% less likely to receive a device in clinical practice. Despite presenting with fewer ventricular arrythmias and having an increased risk of implant complications, women show better response to resynchronization therapy, with lower mortality and HF hospitalizations. Fewer women receive advanced HF therapies. They have a better post-heart transplant survival compared to men, but an increased immunological risk needs to be acknowledged. Technological advances in mechanical circulatory support, with smaller and more hemocompatible devices, will likely increase their implantation in women. This review outlines current evidence regarding sex-related differences in prescription, adherence, adverse events, and prognostic impact of the main management strategies for HF.

Impact of Donor and Recipient Age on 5-year Survival Following Heart Transplantation: A 24-year National Analysis from the United Kingdom

<h3>Purpose</h3> The impact of donor and recipient age on outcomes following heart transplantation remains controversial. The aim of this study was to evaluate the impact of donor and recipient age on 5-year survival following heart transplantation in the UK <h3>Methods</h3> Data were extracted from the UK Transplant Registry held by NHS Blood and Transplant on 3192 adult (≥18) DBD heart transplants in the UK between 1995 and 2018 inclusive. Donors and recipients were divided into 3 age groups (18-40, 41-50, 51+ years) for analysis. Kaplan-Meier survival curves and Cox-proportional hazards models (adjusted for donor cause of death, donor BMI, recipient BMI, creatinine, VAD status, primary disease, sex mismatch, ischemia time, and OCS use) were used to estimate the effect of recipient and donor age on 5-year patient survival and survival conditional on 90-days <h3>Results</h3> The overall median recipient and donor age was 50 years and 38 years, respectively, with donor age increasing over time Un-adjusted analysis showed a significant difference in 5-year survival for both donor and recipient age groups, p<0.001 and p=0.005, respectively. After excluding patients who died within 90-days of surgery there was no longer a difference in outcome (Fig 1) Donor age, but not recipient age, was a predictor of inferior 5-year survival once added to a risk-adjusted model (p=0.008). A recipient receiving a heart from a donor aged 51+ had a 1.2 times higher risk of death than a recipient receiving an organ from a donor aged <40. After removing patients that had died within 90-days of transplant from the model, there was no longer a significant difference, indicating that the effect of donor age is only important short-term <h3>Conclusion</h3> We have demonstrated that donor age is a statistically significant variable in modelling post heart transplant survival at 5 years. However, once a patient has survived the first three months post-transplant, donor age no longer significantly impacts on longer-term outcomes

Comparison of Post-Heart Transplant Survival between Status 1A versus Status 1-3 Recipients before and after the UNOS Allocation Policy Change

Purpose The October 2018 UNOS heart allocation policy change was implemented in an effort to better prioritize heart transplants for the most critically ill patients. We compare six-month post-transplant survival of HT patients listed at status 1A one year before (PRE) vs. status 1-3 one year after (POST) the allocation policy change. Methods We identified patients (N = 2926) listed at the highest status levels (status 1A vs. status 1-3) that underwent HT between 10/18/2017 to 10/17/2019. There were 1242 status 1A patients in the PRE group and 1684 status 1-3 patients in the POST group. Baseline clinical characteristics were compared using Mann-Whitney U test and Chi-Square test as appropriate. Survival analysis was performed using Kaplan-Meier analysis. Univariate and Multivariate Cox Proportional Hazards (PH) regression analysis was adjusted for policy change, recipient age, donor age, bilirubin, creatinine, dialysis use, ischemic time, ventilator use, and ECMO use. Results There was no significant change in six-month survival in the POST vs. PRE groups (92% vs 93%, p=0.13). Furthermore, the policy change was not a significant predictor of mortality on both univariate Cox PH (HR: 1.24 [0.94-1.63, p=0.13]) and multivariate (HR: 1.13 [0.85-1.50, p=0.40]) analyses. Ischemic time (median and interquartile range: 3.5h [2.9, 4.1] vs. 3.1h [2.4, 3.7], p Conclusion Among patients in the highest acuity status groups, there was no difference in six-month post-HT survival following implementation of the policy change. This outcome was seen despite longer ischemic times, greater distance from donor recipient hospitals, and shorter total waitlist times. Further investigation is warranted to assess longer term outcomes.

Comparison of Six-Month Post-Heart Transplant Survival between Status 1B/2 and Status 4-6 Recipients before and after the UNOS Allocation System Change

Purpose The UNOS heart allocation policy change in 2018 emphasized heart transplantation (HT) for patients based on medical urgency by prioritizing the sickest patients. The impact of the policy change on less critically ill patients is unclear, and to date no analysis on these patients has been performed. We compare the characteristics and outcomes of status 1B/2 recipients with status 4-6 recipients. Methods In the UNOS database, patients registered as status 1B/2 transplanted within 1 year prior to policy change (PRE, N=499) and patients listed as status 4-6 transplanted within 1 year after policy change (POST, N=351) were identified. Baseline characteristics were compared using the Mann Whitney U test and Chi square test as appropriate. 6-month survival was compared using Kaplan-Meier survival analysis. Univariate cox regression was performed as well as multivariate Cox proportional hazard regression analysis which adjusted for recipient age, donor age, creatinine, bilirubin, dialysis requirement, and ischemic time. Results There was no significant difference in 6-month post-transplant survival in the PRE vs. POST group (95% vs 93%, p=0.27). Additionally, on univariate (HR: 1.38 [0.78, 2.47]) and multivariate analysis (HR: 1.33 [0.73, 2.42]), the policy change was not a significant predictor of 6-month post-transplant survival. Median ischemic time (2.9 hrs vs 3.0 hrs, p=0.025) and distance from donor to recipient hospitals (74.0 nmi vs. 106.0 nmi, p=0.001) was increased in the POST group while there was no difference in median waitlist time (48 days vs 44 days, p=0.72). Dialysis after listing was more common in the POST group (0.4% vs 2.8%, p=0.007). In the POST group, there was also an increase in female recipients (37.3% vs 46.2%, p=0.012) and female donors (38.9% vs 52.4%, p=0.001) with no difference in gender mismatch (13.0% vs 14.2%, p=0.682). Conclusion Though there was a significant increase in ischemic time and geographical distribution, the heart allocation policy change did not affect six-month post-transplant survival for lower acuity patients. The median waitlist time was unchanged.

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.

Abstract 15953: Impact of Citizenship on Heart Transplantation Outcomes in the United States

Background: Non-citizens of the United States face complex social and economic issues, which may impact their post-transplant outcomes compared to US citizens. To this end, we utilized the United Network for Organ Sharing (UNOS) database to examine post-heart transplant (OHT) outcomes, stratified by citizenship status. Methods: UNOS was queried to identify OHT recipients from 03/01/12 (start of new schema for citizenship categorization) through 10/18/18 (start of new heart allocation algorithm). Groups for analysis, were as follows: US Citizen, Non-US Citizen/Resident (NC-R) and Non-US Citizen/Non-US Resident (NC-NR). Post-transplant survival and rate of post-transplant rejection were assessed via Kaplan-Meier analysis and tests of proportions. Results: Of the 16,211 OHT recipients identified, 15,677 (96.7%) were US citizens and 534 (3.3%) were Non-Citizens. Among Non-Citizens, 430 were NC-R and 104 were NC-NR, representing 2.7% and 0.6% of the total transplants. Notably, NC-NR were younger than either Citizens or NC-R, and had the shortest median time from listing to transplant (NC-R 80 days vs. Citizens 107 days vs. NC-NR 76 days, p=0.001). The proportion of transplants received by non-citizens varied widely by region, ranging from 0.59% in region 8 (6/1018) to 8.31% (84/1011) in region 9. There was no significant difference in post-transplant survival estimates in citizens vs. non-citizens (logrank p = 0.542), nor in the proportion of patients treated for rejection by one year (15.0% vs. 16.1%, p= 0.504) Conclusion: Non-US Citizens receive three percent of heart transplants performed in the US each year. Post-heart transplant survival and rate of rejection are similar in US citizens and non-citizens. These data may be relevant in the context of evolving UNOS policies. Additional studies are needed are to further inform organ allocation policy.

Artificial Intelligence-related Literature in Transplantation: A Practical Guide.

Artificial Intelligence-related Literature in Transplantation: A Practical Guide.