Post-heart Transplant Research Articles

Abstract 4144521: Racial disparities in heart transplantation: long term graft survival and non-mortality outcomes

Background: There is conflicting evidence on whether racial disparities still exist in heart transplant (HT) outcomes, with prior studies focusing primarily on differences in short-term mortality. We examined disparities in HT survival over a longer follow-up duration alongside a broader range of post-HT outcomes. Methods: Using the United Network for Organ Sharing (UNOS) database, we evaluated adult HT recipients between 2017 and 2022 and classified each according to race as either Black, non-Hispanic White and Other. The primary outcome was graft survival and secondary outcomes included rejection, renal dysfunction, and post-transplant diabetes. Chi-squared tests were used to compare baseline clinical factors and selected outcomes by racial group. Kaplan-Meier and Cox proportional hazards analyses were performed to compare risks of the primary outcome by race. Results: Among 15,873 recipients (63% non-Hispanic White, 23% Black, 14% Other), Black recipients were more often female, less often college educated, and more often had public (vs. private) insurance. Blacks had higher use of durable ventricular assist devices (VAD) and intra-aortic balloon pump (IABP) at the time of HT. Graft survival at one year did not differ by race (91.8% for Blacks vs. 91.1% for non-Blacks), but at three years was significantly lower for Blacks (83.4%) than non-Blacks (85.7%). Blacks had higher risk of graft failure after adjustment for baseline socioeconomic status (SES) and clinical variables (HR 1.28, CI 1.17 - 1.41). Blacks also had significantly higher prevalences of acute rejection (12.4% vs. 10.2%), diabetes (10.8% vs. 7.1%), and progression of renal dysfunction at 3-years post HT (40.9% vs. 37.1%; p < 0.05 for all). Conclusions: Racial disparities in graft survival after HT remain in the contemporary era but are only evident after longer-term follow-up. These survival disparities could be mediated by concurrent disparities in shorter term outcomes such as development of acute rejection, chronic kidney disease, and new onset diabetes.

Abstract 4144529: Cardiac Allograft Hypertrophy (CAH) at 6 Months Post Transplant Is a Prognostic Marker of Long-Term Outcomes: Are We Missing a Simple Biomarker?

Introduction: Cardiac hypertrophy is a known adverse prognostic marker in various non-transplant pathologies. In heart transplant patients, due to many confounders, it has been controversial on the relevance and timing of cardiac hypertrophy as an adverse remodeling vs acute injury pattern in an immunologically hostile environment. Previous studies have shown prognostication of hypertrophy on echocardiogram at 1-year post-heart transplant. Research Questions: Does cardiac hypertrophy within a year after transplant have long-term prognostic implications? Methods: We collected relevant clinical variables for all heart transplants using EPIC EHR’s Clarity database. Hypertrophy was defined based on LV Mass Indexed to body surface area where LV Mass = 0.8 x (1.04 x (((LVIDD + IVSd + PWd) 3 - LVIDD 3 ))) + 0.6. Relative Wall Thickness was defined as RWT = 2 x PWd / LVIDD. We used a rule-based natural language processing program validated by correlation with manual readings by trained cardiologists (r=0.96, p=0.007) to abstract echo variables. Results: Inclusion criteria were heart transplants performed from 2015 to 2023 at our center, with an echocardiogram closest to 6 months (+/- 1 month). Ten percent (n=33) showed hypertrophy on echocardiograms at 6 months (Table 1). Of these, 20 (61%) had mild, 3 (9%) severe, and 10 (30%) moderate hypertrophy. Of 33 patients, 28 (85%) had concentric, and 5 (15%) had eccentric hypertrophy. Patients with hypertrophy at 6 months had significantly worse survival at 5 years (p=0.01) and 10 years (p=0.05) compared to patients without hypertrophy (Fig 1). Survival at 5 and 10 years was not statistically different for patients with hypertrophy at 3 months (5 yrs p=0.17, 10 yrs p=0.06), 12 months (5 yrs p=0.38, 10 yrs p=0.30), and 18 months (5 yrs p=0.15, 10 yrs p=0.08) compared to those without hypertrophy. Conclusion: Cardiac hypertrophy on echocardiogram at 6 months predicts adverse long-term survival, while other time points did not.

OA06 Echoes of Hope: Navigating Pregnancy post heart transplant in the context of systemic sclerosis

OA06 Echoes of Hope: Navigating Pregnancy post heart transplant in the context of systemic sclerosis

Heart Transplant Rejection in the Setting of Glyphosate Herbicide Exposure; A Case Report

Glyphosate is a common herbicide utilized worldwide with known exposure related toxicities. Numerous adverse effects related to glyphosate exposure have been documented, specifically in non-human models, however literature is lacking on cardiotoxic effects specific to heart transplant patients. Rejection is the most common post-transplant complication and the diagnosis of such is vital in order to guide immediate and appropriate treatment. In addition to the endomyocardial biopsy, noninvasive genetic testing can aid in rejection diagnosis and distinguish between cell-mediated and antibody-mediated rejection. We describe a case of glyphosate exposure in a post orthotopic heart transplant and the subsequent heart transplant rejection, patient’s clinical course, treatment, and follow up.

Evaluation of serum levels of sCD40, sCD40L and s4-1BB in advanced heart failure and after heart transplant

Abstract Heart failure is one of the most important problems in public health. Although big advances had been reached in treatment, the prognosis of advanced heart failure is still reserved and the heart transplant is the main therapy for this stage of disease. Allograft rejection is responsible for mortality in transplantation patients and the diagnosis of this complication is made through an invasive diagnostic method – the cardiac biopsy. The inflammatory response has been described in cardiovascular disease and in allograft rejection process. The objective of this study is to evaluate levels of sCD40, sCD40L and s4-1BB (inflammatory biomarkers) in advanced heart failure and post heart transplant with allograft rejection comparing to normal individuals and post heart transplant patients with no allograft rejection. The study population comprised 38 patients undergoing heart transplant in our center. Fifteen patients had biomarkers dosed before heart transplant and twenty three patients had dosed just after procedure. In this group, six patients were enrolled in the study for clinical suspicion of rejection. Nineteen health persons composed the control group with age between 18 and 49 years. Plasma dosage of sCD40, sCD40L e s4-1BB was made by enzyme linked immunosorbentassay (ELISA). Mann-Whitney test, Wilcoxon and t test were used to analyse dates. Statistical analysis used GraphPad®Prism6 and the value p< 0,05 was considered statistical significant. Allograft rejection occurred in 6,26% of studied patients. There was no statistical difference in age, sex, comorbities as hypertension, diabetes or etiology of cardiomyopathy. Serum levels of sCD40, sCD40L e s4-1BB were higher in patients with advanced heart failure comparing to controls (p< 0,0001). There was no difference in these levels of sCD40 (p = 0,74) e sCD40L (p = 0,44) between groups with and without rejection. Levels of s4-1BB were significantly lower in patients with allograft rejection (p= 0,02). The sCD40/PCR and s4-1BB/PCR indexs were significantly higher in the group of patients with allograft rejection (p =0,02 e p= 0,0001). We concluded that sCD40, sCD40L e s4-1BB are biomarkers of severe heart failure. The serum level of s4-1BB could be a potential biomarker of allograft rejection and the association of sCD40 and s4-1BB with PCR could be a better strategy to this.

Reversibility of precapillary pulmonary hypertension and outcomes after heart transplantation bridged with left ventricular assist devices: insight from the UNOS

Abstract Background In light of the updated lowered threshold for diagnosing pulmonary hypertension (PH), the reversibility of precapillary PH with left ventricular assist device (LVAD) and the associated post heart transplantation (HT) outcomes remain unclear. Purpose and methods Using data from the United Network for Organ Sharing database, we aimed to investigate predictors of persistent precapillary PH in HT recipients bridged with LVAD, and examine the interrelated post-HT survival, using the updated pulmonary vascular resistance (PVR) cutoff of >2 WU for precapillary PH. Results Among 2169 HT recipients bridged with LVAD, 1299 had PVR>2 at baseline; 551 (42.4%) of whom normalized their PVR≤2 and 748 (57.6%) remained with elevated PVR>2 after LVAD implantation. Female sex (adjusted odds ratio [aOR] 2.22, 95% confidence interval [CI]:1.61-3.07, p<0.001) and inotropes-treatment at-listing (aOR 1.31, 95% CI: 1.03-1.66, p=0.028) were associated with persistently elevated PVR post LVAD. Conversely, longer duration of LVAD support (aOR 0.74, 95% CI: 0.65-.84, p<0.001) and use of HeartMate 2 (aOR 0.74, CI: 0.59-0. 93, p=0.011) were protective against persistently elevated PVR post-LVAD. Persistently elevated PVR >2 post-LVAD was associated with increased risk of death compared to those who normalized their PVR (adjusted hazard ratio [aHR] 1.26, 95% CI: 1.01-1.57, p=0.037). However, normalized PVR post-LVAD group had comparable survival to those with PVR≤2 at baseline (aHR 0.76, 95% CI: 0.57-1.02, p=0.07). Conclusions Many HT recipients bridged with LVAD remain with PVR>2 post-LVAD implantation, which is associated with increased risk of death post-HT compared to patients with normalized PVR post-LVAD.

Establishing normal global longitudinal strain values in heart transplant patients: a novel approach to enhancing detection of rejection and cardiac allograft vasculopathy

Abstract In the realm of heart transplantation, accurate cardiac monitoring is pivotal for patient outcomes. This study pioneers in filling a critical void by delineating the normative values of Global Longitudinal Strain (GLS), specifically tailored for heart transplant recipients, distinguishing them from the general population. We conducted a retrospective analysis on a cohort of 110 patients who underwent heart transplantation, meticulously compiling echocardiographic data over the first 18 months post-operation. Our research focused on two primary indicators of cardiac function: Ejection Fraction (EF) and Global Longitudinal Strain (GLS). The data indicated that EF values remained within the normal range and relatively stable throughout the monitoring period. In contrast, GLS values exhibited a gradual increase over time, suggesting a post-transplant myocardial adaptation process. However, these GLS values did not reach the established reference ranges for non-transplanted, healthy hearts, highlighting the distinctive physiological landscape of transplant recipients. Our study elucidates the superior sensitivity of GLS in detecting subtle myocardial changes that might precede clinically apparent dysfunction, advocating its utility as a crucial surveillance tool for this demographic. By pinpointing the modified GLS benchmarks applicable to post-heart transplant patients, our findings advocate for a recalibrated echocardiographic assessment protocol. Such a protocol can significantly enhance the surveillance for post-transplant complications, most notably graft rejection and the onset of cardiac allograft vasculopathy (CAV). The study posits that incorporating these refined GLS thresholds into routine post-transplant evaluations could facilitate early intervention, potentially mitigating adverse outcomes and improving the long-term prognosis for heart transplant recipients. Thus, our research underscores the need for updated clinical guidelines that integrate these novel echocardiographic insights, paving the way for improved patient-centric cardiac care in the transplant setting.

Facilitators and barriers to perform physical activity in patients post-heart transplantation: a qualitative study.

Most patients experience barriers for becoming physical active post-heart transplantation. Therefore, identifying barriers and facilitators can help healthcare professionals in developing physical activity programs. This study aimed to explore the physical activity experiences, perceived barriers, and facilitators to perform physical activity of patients' post-heart transplantation. A qualitative study was carried out using in-depth semi-structured interviews on 24 patients post-heart transplantation from October to December 2022. The data were analyzed using an inductive strategy for finding emerging themes. NVivo 12.0 software was used to analyze the data. The physical activity experiences included that (1) patients felt that they had to adapt to a new situation after the heart transplantation, (2) walking was a popular physical activity preferably outdoors, (3) participants preferred to perform physical activity regularly with others, and (4) they felt better since they perform physical activity. The facilitators were: (1) Desire to live; (2) Experiencing physical benefits; (3) Being physically active with others; (4) Use of mobility assistive devices resources. The barriers were: (1) Feeling not being able to perform former physical activity; (2) Complications and experiencing symptoms post-heart transplantation; (3) Unfavourable climate. Patients post-heart transplantation have various facilitators influencing their post-transplant experience to perform physical activity. Key facilitators include the desire to live, physical benefits, social activity, and external support. Yet, they also face barriers like lost abilities, post-transplant complications, and environmental challenges.

Pulmonary artery mass with PIK3CA mutation after orthotopic heart transplantation

BackgroundPatients can develop de novo malignancies following orthotopic heart transplantation. However, vascular tumors are not commonly described in this population.Case presentationWe present a 69-year-old female with a history of orthotopic heart transplantation for chemotherapy-induced cardiomyopathy who developed an incidental pulmonary artery mass six years after her transplantation. Given concerns for malignancy, the patient underwent an operative excisional biopsy through a left anterior mini-thoracotomy with femoral artery and vein cannulation for cardiopulmonary bypass. The mass was determined to be a non-malignant vascular overgrowth with PIK3CA mutation.ConclusionWe present the case of an unusual pulmonary artery mass with PIK3CA mutation found in a post heart transplant patient. We were able to spare her the morbidity of a redo-sternotomy by excising the mass via a minimally invasive left anterior thoracotomy approach.

Impact of left ventricular unloading on postheart transplantation outcomes in patients bridged with VA-ECMO

Introduction and objectives: The impact of preoperative left ventricular (LV) unloading on postoperative outcomes in patients bridged with venoarterial extracorporeal membrane oxygenation (VA-ECMO) to heart transplantation (HT) is unknown. Our aim was to compare posttransplant outcomes in patients bridged to HT with VA-ECMO, with or without the use of different mechanical strategies for LV decompression.Methods: We conducted a retrospective analysis of the postoperative outcomes of consecutive HT candidates bridged with VA-ECMO, with or without concomitant LV unloading. Patients were included from 16 Spanish centers from 2010 to 2020. The primary endpoint was 1-year post-HT survival, which was assessed using Cox regression.Results: Overall, 245 patients underwent high-emergency HT while supported with VA-ECMO. A mechanical strategy for LV unloading was used in 133 (54.3%) patients, with the intra-aortic balloon pump being the most commonly used method (n = 112; 84.2%). One-year posttransplant survival was 74.4% in the LV unloading group and 59.8% in the control group (P = .025). In multivariate analyses, preoperative LV unloading was independently associated with lower 1-year mortality (adjusted HR, 0.50; 95%CI, 0.32–0.78; P = .003). This association was observed both in patients managed with an intra-aortic balloon pump alone (adjusted HR, 0.52; 95%CI, 0.32–0.84; P = .007) and with other strategies for mechanical LV unloading (adjusted HR, 0.43; 95%CI, 0.19–0.97; P = .042). No significant differences were found between groups regarding other postoperative complications.Conclusions: Preoperative LV unloading was independently associated with increased 1-year posttransplant survival in candidates bridged with VA-ECMO.

Outcomes after SynCardia® temporary total artificial heart implantation: A 20-year single-center experience in 196patients.

The SynCardia® temporary total artificial heart (TAH) serves as a mechanical circulatory support device for patients suffering from irreversible biventricular failure. This retrospective study analyzed 196 consecutive patients who underwent TAH implantation at our center from 2001 to 2021. We assessed survival rates and all-cause mortality during TAH support, including survival post-heart transplantation. The median age of patients was 55 years, with 88% being male. The primary diagnoses included cardiomyopathy (43.9%), acute myocardial infarction (26.5%), and postcardiotomy heart failure (15.5%). At implantation, 87.2% of patients were classified as INTERMACS Profile 1. The median duration of support was 96 days (IQR: 23-227). Survival rates at 1, 6, and 12 months were 72%, 41%, and 34%, respectively. Postoperative rethoracotomy was necessary in 44.4% of patients; 39.3% experienced neurological events and 24.6% developed gastrointestinal bleeding. Overall, 64.8% of patients died while on support, primarily due to multiple organ failure (55.9%). Factors such as older age, higher bilirubin levels, postcardiotomy and specific underlying diagnoses were independent predictors of mortality during TAH support. On a positive note, 35.2% of patients underwent successful heart transplants, with 1-, 5-, and 10-year posttransplant survival rates of 65%, 58%, and 51%, respectively. While high mortality rates persist among patients with biventricular failure, the SynCardia® TAH offers a viable interim solution for critically ill patients, particularly those who can be successfully bridged to heart transplantation.

Association between pre-heart transplant kidney function and post-transplant outcomes in Black and White adults.

It remains unknown whether estimated glomerular filtration rate (eGFR) using the refit Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation without a term for race is associated with mortality and the need for kidney replacement therapy (KRT) differentially between Black and White heart transplant recipients. We studied 25,900 adults included in the Scientific Registry of Transplant Recipients. We classified recipients into six categories of eGFR (< 30, 30 to < 45, 45 to < 60, 60 to < 90, 90 to < 120, ≥ 120ml/min/1.73 m2) using the race-neutral CKD-EPI refit equation, and assessed survival with multivariable adjusted Cox proportional hazards regression. The association between pre-transplant race-neutral eGFR and mortality varied by race (Pinteraction = 0.006). Compared to White patients with an eGFR of 90-120ml/min/1.73 m2, the mortality rates were 57% (95% CI 1.25, 1.98), 29% (95% CI 1.11, 1.51), 34% (95% CI 1.19, 1.52), and 19% (95% CI 1.06, 1.33) higher in Black patients with an eGFR less than 30, 30-45, 45-60, and 60-90ml/min/1.73m2, respectively; and 53% (95% CI 1.28, 1.82), 49% (95% CI 1.33, 1.66), and 23% (95% CI 1.11, 1.35) higher among White patients with an eGFR less than 30, 30-45, and 45-60ml/min/1.73 m2, respectively. The association between pre-transplant eGFR and the need for KRT during follow-up was similar between Black and White patients (Pinteraction = 0.57). Worsening pre-transplant eGFR using the new race-neutral CKD-EPI refit equation was associated with a higher rate of post-heart transplant mortality and KRT in Black and White recipients. The racial disparity in post-heart transplant mortality was narrower in the setting of severe kidney dysfunction.

The impact of blood type and body size on successful bridging to heart transplantation using intra-aortic balloon pump or surgically implanted microaxial left ventricular assist device

ObjectiveWaitlist time for United Network for Organ Sharing Status 2 heart transplant candidates has steadily increased. We compared a bridging strategy using either the Impella 5.0/5.5 (“Impella”) or intra-aortic balloon pump with a durable left ventricular assist device in patients with blood type O stratified by body habitus. MethodsThe United Network for Organ Sharing registry was queried for adults listed for de novo heart transplantation (without dialysis) supported by the Impella, an intra-aortic balloon pump, or the HeartMate 3 left ventricular assist device. The primary outcome was 1-year postlisting survival, defined as the sum of waitlist time and post–heart transplant survival time if the candidate underwent heart transplantation. ResultsIn total, 2942 candidates were included (Impella: 214; intra-aortic balloon pump: 1326; HeartMate 3: 1402). Listing with the Impella or intra-aortic balloon pump was associated with worse postlisting survival compared with the HeartMate 3 left ventricular assist device in type O candidates (Impella: hazard ratio, 2.90 [95% CI, 1.48-5.67], P = .002; intra-aortic balloon pump: hazard ratio, 2.42 [95% CI, 1.59-3.68], P < .001) but less so in non–type O candidates. Further analysis of type O candidates demonstrated that the Impella and intra-aortic balloon pump were associated with a lower risk of postlisting mortality among those with normal height (25-75th percentile) and nonobese (body mass index <30) (Impella: hazard ratio, 1.78 [95% CI, 0.61-5.18], P = .292; intra-aortic balloon pump: hazard ratio, 1.28 [95% CI, 0.67-2.45], P = .455); among those not of normal height and nonobese, the Impella and intra-aortic balloon pump were associated with an elevated risk of postlisting mortality (Impella: hazard ratio, 3.65 [95% CI, 1.68-7.95], P = .001; intra-aortic balloon pump: hazard ratio, 3.01 [95% CI, 1.95-4.67], P < .001). ConclusionsBlood type O candidates listed with the Impella or intra-aortic balloon pump are at increased risk of postlisting mortality compared with a durable left ventricular assist device in the current organ allocation era. These effects are diminished among those with normal height and body habitus.

Clinical outcomes after a biopsy diagnosis of antibody-mediated rejection in pediatric heart transplant recipients

BackgroundExtending graft survival after heart transplant (HT) is of paramount importance to achieve survival well into adulthood for childhood recipients. Acute rejection is a significant adverse event, and biopsy remains the most specific means for diagnosing acute cellular rejection (ACR) versus antibody-mediated rejection (AMR). MethodsAll children in the Pediatric Heart Transplant Society (PHTS) Registry who underwent HT between 1/2015 and 6/2022 and had ≥1 episode of treated rejection were included. Survival after rejection was compared between those with AMR and those with ACR-only. Secondary outcomes of infection, malignancy, and cardiac allograft vasculopathy (CAV) were assessed. Risk factors for graft loss after AMR were identified using Cox proportional hazard modeling. ResultsAmong 906 children treated for rejection during follow-up through 12/2022, 697 (77%) with complete biopsy information were included. AMR was present on biopsy in 261 (37%) patients; ACR-only was present in 436 (63%) patients. Time to treated rejection was earlier in those with AMR, median time from HT to rejection 0.11 versus 0.29 years, p=0.0006. When rejection occurred within the 1st year, survival after AMR was lower than survival after ACR-only. Predictors of graft loss after AMR were younger age at HT, diagnosis of congenital heart disease, and rejection with hemodynamic compromise. There was no difference in time to CAV, infection, or malignancy after treated rejection between groups. ConclusionsThe largest analysis of pediatric HT recipients treated for rejection with biopsy data to identify AMR underscores the continued importance of AMR on survival. AMR is associated with higher graft loss versus ACR when occurring in the first-year post HT. Predictors of graft loss after AMR identify patients who may benefit from increased surveillance, more aggressive rejection treatment, or augmented maintenance immunosuppression.

Severe early graft dysfunction post-heart transplantation: Two clinical trajectories and diastolic perfusion pressure as a predictor of mechanical circulatory support

BackgroundSevere early graft dysfunction (EGD) is defined by mechanical circulatory support (MCS) <24 hours of heart transplantation (HT). We classified severe EGD based on timing of post-HT MCS: ‘Immediate’ intra-operative vs ‘Delayed’ post-operative MCS (after admission into intensive care unit (ICU) from operating theatre). We hypothesised that (i) risk factors and clinical course differ between ‘Immediate’ and ‘Delayed’ MCS; and (ii) diastolic perfusion pressure (DPP=diastolic blood pressure-central venous pressure) and Norepinephrine equivalents (NE=sum of vasopressor doses), as measures of vasoplegia are related to ‘Delayed’ MCS. MethodsTwo-centre study of 216 consecutive patients who underwent HT. Recipient, donor, vasopressor doses and hemodynamic data at T0 and T6 (on admission and 6 hours after admission into ICU) were collected. ResultsOf the 216 patients, 67 patients had severe EGD (‘Immediate’ MCS: n=43, ‘Delayed’ MCS: n=24). The likelihood of ‘immediate’ MCS but not 'delayed' MCS increased with increasing warm ischemic and cardiopulmonary bypass times on multinomial regression analysis with ‘no MCS’ as the referent group. One-year mortality was highest in ’Immediate’ MCS vs ’no MCS’ and ‘delayed’ MCS (34.9% vs 3.4% and 8% respectively, P<0.001). Of the patients who had no immediate post-transplant MCS, DPP and NE at T6 were independently associated with subsequent 'delayed' MCS’. Sensitivity and specificity of NE ≥0.2mcg/kg/min for ‘Delayed’ MCS were 71% and 81%. Sensitivity and specificity of DPP of ≥40mmHg for No MCS were 83% and 74%. The discriminatory value of systemic vascular resistance for ‘Delayed’ MCS was poor. ConclusionRisk factors and one-year survival differed significantly between ‘Immediate’ and ‘Delayed’ post-HT MCS. The latter is related to lower DPP and higher NE, which is consistent with vasoplegia as the dominant pathophysiology.

Implantation of a permanent pacemaker following orthotopic heart transplantation: a systematic review and meta-analysis.

Orthotopic heart transplant (OHT) is among the final armamentariums for end-stage heart disease. Many patients who have had OHT require a post-transplant permanent pacemaker (PPM) implantation due to an abnormal conduction system. We aimed to evaluate the risk of mortality and acute rejection in patients with OHT who had received PPM compared to patients without PPM and to determine predictors for PPM placement in this population. We comprehensively searched for studies from MEDLINE, EMBASE, and Cochrane databases from inception to September 2023. Inclusion criteria focused on patients who had undergone OHT and PPM implantation post-transplant. Data from each study were combined using a random-effects model. Results were expressed as relative risk (RR) or odd ratios (OR) with a 95% confidence interval (CI). A total of 9 studies were included in this meta-analysis incorporating a total of 54,848 patients (3.3% had PPM). The pooled all-cause mortality rate among patients with PPM post-OHT was 26% (95% CI: 19-33%, I2 = 1%). There were no differences between post-heart transplant patients with PPM and those without PPM in risk of all-cause mortality (RR 0.76, 95% CI: 0.43-1.34; I2 = 45%) and acute rejection (RR 1.22, 95% CI: 0.74-2.00, I2 = 59%). Bi-atrial anastomosis was associated with an increased risk of PPM implantation post-OHT (OR 7.74, 95% CI: 3.55-16.91, I2 = 0%), while pre-OHT mechanical circulatory support (MCS) was associated with a decreased risk of PPM implantation post-OHT (OR 0.45, 95% CI 0.27-0.76, I2 = 0%). There were no significant differences in all-cause mortality or acute rejection between post-OHT recipients who required PPM compared to those who did not receive PPM. Further, bi-atrial anastomosis portended the need for PPM implantation, while MCS was associated with a decreased occurrence of PPM.

Update on Nutritional Advice Post-Heart Transplant: A Cross-Sectional Study across French-Speaking European Centers.

Heart transplantation is the standard treatment for severe heart failure. Graft preservation and infectious risk secondary to immunosuppressive drugs lead healthcare teams to offer nutritional advice to patients upon discharge from the hospital. However, no consensus or recommendation is available. We conducted a study to review the practices in all 26 centers providing heart transplantation in French-speaking Europe. We requested and analyzed the written documents these centers provided to their patients. The same two dieticians categorized the highlighted pieces of advice into distinct, autonomous categories. We identified 116 pieces of advice, categorized into three areas: dietary restrictions for immunosuppressant/food interaction; environmental and food preparation guidelines and prevention of foodborne infections; and healthy and active lifestyle recommendations. Except for advice on immunosuppressant/food interaction, over one-third of the centers suggest discontinuing advice within 2 years post-transplant. General dietary advice covers lipids, carbohydrates, protein, calcium, sodium, and fiber but offers limited guidance on fatty acids despite their importance in cardiovascular risk prevention. This study represents a pioneering exploration of the nutritional advice provided to patients following cardiac transplantation. It underscores the critical necessity of establishing consensus-based clinical guidelines in this domain.

Application of donor predicted heart mass in heart transplant recipients with left ventricular assist device

IntroductionAn association between predicted heart mass (PHM) and post heart transplantation outcomes has been well established; however, there is limited data on the effect of donor PHM on recipients bridged with a durable left ventricular assist device (LVAD). This retrospective observational study seeks to challenge the theoretical benefit of oversizing donor hearts for recipients bridged with LVADs. MethodsAnalysis of the United Network for Organ Sharing (UNOS) database revealed 10,806 adult patients with one of three durable LVADs (HeartMate 2, HeartMate 3 [HM3], HeartWare [HVAD]) between January 1, 2015 and December 31, 2021. Baseline characteristics were compared between seven equally sized groups based on donor-to-recipient PHM. Univariable and multivariable Cox regression analyses were constructed to evaluate the effect of PHM size-matching on the primary outcome of 1-year post-transplant survival. Further analyses were performed specifically on HM3 patients and with PHM as a continuous variable. ResultsMultivariable analysis revealed that severely undersized donor hearts (PHM ratio < 0.86) resulted in worse outcomes with respect to 1-year mortality (HR 1.30; CI 1.03-1.64, p=0.03). There was no significant benefit to oversizing donor hearts. Similar results were found in patients bridged to transplant with HM3. ConclusionSimilar to prior studies on heart transplant recipients, recipients bridged with durable LVAD had worse outcomes when using severely undersized donor hearts. Oversized donor hearts did not significantly improve 1-year mortality, compared to size-matched references. These results were consistent in a subgroup analysis of patients bridged only with HM3 LVADs.

Reversible cerebral vasoconstriction syndrome post-cardiac transplantation: a therapeutic dilemma: case report

BackgroundReversible cerebral vasoconstriction syndrome (RCVS) is characterized by diffuse, multifocal segmental narrowing of cerebral arteries and can result in ischaemic stroke. Causal factors, identified in 60% of cases, include immunosuppressant pharmacotherapy. The few reports following heart transplantation are almost all in Asian recipients. We report on a Caucasian Australian patient with immunotherapy induced RCVS post heart transplantation to highlight the state of knowledge of the condition and the treatment dilemma it poses.Case presentationA 51-year-old female underwent orthotopic heart transplantation at our institution. Induction immunotherapy comprised basiliximab, mycophenolate mofetil and methylprednisolone. On day 6 post-transplantation the patient was transitioned to oral prednisolone and tacrolimus. On day 7 the patient began to experience bilateral, severe, transient occipital and temporal headaches. On day 9 tacrolimus dose was up-titrated. A non-contrast computed tomography brain (CTB) was normal. Endomyocardial biopsy on day 12 demonstrated moderate Acute Cellular Rejection (ACR), which was treated with intravenous methylprednisolone. That evening the patient experienced a 15-minute episode of expressive dysphasia. The following morning she became confused, aphasic, and demonstrated right sided neglect and right hemianopia. A CT cerebral perfusion scan demonstrated hypoperfusion in the left middle cerebral artery (MCA) territory and cerebral angiography revealed widespread, focal multi-segmental narrowing of the anterior and posterior circulations. A diagnosis of RCVS was made, and nimodipine was commenced. As both steroids and tacrolimus are potential triggers of RCVS, cyclosporin replaced tacrolimus and methylprednisolone dose was reduced. A further CTB demonstrated a large left MCA territory infarct with left M2 MCA occlusion. The patient made steady neurological improvement. She was discharged 34 days post-transplantation with mild residual right lower limb weakness and persistent visual field defect on verapamil, cyclosporine, everolimus, mycophenolate mofetil and prednisolone.ConclusionReversible cerebral vasoconstriction syndrome is rare after orthotopic heart transplantation. Until now, RCVS has been almost exclusively described in Asian recipients, and is typically caused by immunotherapy. The condition may lead to permanent neurological deficits, and in the absence of definitive treatments, early recognition and imaging based diagnosis is essential to provide the opportunity to remove the causal agent(s). Co-existent ACR, can pose unique treatment difficulties.

Redefining CAV surveillance strategies: Benefits of CCTA vs. ICA

BackgroundCardiac allograft vasculopathy (CAV) assessment post-heart transplantation (HT) typically relies on invasive coronary angiography (ICA). However, cardiac computed tomography angiography (CCTA) is emerging as a promising alternative due to its potential benefits in economic, safety, and logistical aspects. This study aimed to evaluate the impact of a CCTA program on these aspects in CAV surveillance post-HT. MethodsA retrospective single-center study was conducted between March 2021 and February 2023, involving HT patients who underwent either CCTA or ICA. ResultsAmong 260 patients undergoing CAV surveillance, 115 (44.2%) patients underwent CCTA, and 145 (55.8%) patients underwent ICA. The CCTA group showed incurred lower overall costs (p ​< ​0.0001) and shorter hospitalization times (p ​< ​0.0001) compared to the ICA group. In terms of safety, CCTA surveillance required significantly lower contrast volumes (p ​< ​0.0001) and lower effective doses (p ​= ​0.03). ConclusionCCTA emerges as a safe and cost-effective non-invasive alternative for CAV surveillance post-HT, outperforming ICA in terms of safety, logistical aspects, and economic burden.