Background: This study investigated the impact of transplanting center donor acceptance patterns on usage of extended-criteria donors (ECDs) and posttransplant outcomes following orthotopic heart transplantation (OHT). Methods: The Scientific Registry of Transplant Recipients was queried to identify heart donor offers and adult, isolated OHT recipients in the United States from 1/1/2013-10/17/2018. Centers were stratified into 3 equal-size terciles based on donor heart acceptance rates (<13.7%, 13.7%-20.2%, >20.2%). Overall survival was compared between recipients of ECDs (≥40 years, left ventricular ejection fraction <60%, distance ≥500 miles, hepatitis B, hepatitis C or human immunodeficiency virus, or ≥50 offers) and recipients of traditional-criteria donors, and among transplanting terciles. Results: A total of 85,505 donor heart offers were made to 133 centers with 15,264 (17.9%) accepted for OHT. High-acceptance programs (>20.2%) more frequently accepted donors with LVEF <60%, HIV, HCV, and/or HBV, ≥50 offers, or distance >500 miles from the transplanting center (each p<0.001). Posttransplant survival was comparable across all three terciles (p=0.11). One- and five-year survival were also similar across terciles when examining recipients of all five ECD factors. Acceptance tier and increasing acceptance rate were not found to have any impact on mortality in multivariable modeling. Of ECD factors, only age ≥40 years was found to have increased hazards for mortality (HR 1.33, 95% CI 1.22-1.46, p<0.001). Conclusions: Of recipients of ECD hearts, outcomes are similar across center-acceptance terciles. Educating less aggressive programs to increase donor acceptance and ECD utilization may yield higher national rates of OHT without major impact on outcomes.

Background: The purpose of this study was to investigate the incidence, predictors, and long-term impact of gastrointestinal (GI) complications following adult cardiac surgery. Methods: Index Society of Thoracic Surgeons (STS) adult cardiac operations performed between January 2010 and February 2018 at a single institution were included. Patients were stratified by the occurrence of postoperative GI complications. Outcomes included early and late survival as well as other associated major postoperative complications. A sub-analysis of propensity score matched patients was also performed. Results: 10,285 patients were included, and the overall rate of GI complications was 2.4% (n=246). Predictors of GI complications included dialysis dependency, intra-aortic balloon pump, congestive heart failure, chronic obstructive pulmonary disease, and longer aortic cross-clamp times. Thirty-day (2.6% vs 24.8%), one- (6.3% vs 41.9%), and three-year (11.1% vs 48.4%) mortality were substantially higher in patients who experienced GI complications (all P<0.001). GI complication was associated with a three-fold increased hazard for mortality (HR 3.1, 95% CI 2.6-3.7) after risk adjustment, and there was an association between the occurrence of GI complications and increased rates of renal failure (39.4% vs 2.5%), new dialysis dependency (31.3% vs 1.5%), multisystem organ failure (21.5% vs 1.0%), and deep sternal wound infections (2.6% vs 0.2%)(all P<0.001). These results persisted in propensity-matched analysis. Conclusions: GI complications are infrequent but have a profound impact on early and late survival, and often occur in association with other major complications. Risk factor modification, heightened awareness, and early detection and management of GI complications appears warranted.

Background: This study evaluated 20-year survival following adult orthotopic heart transplantation (OHT). Methods: The United Network of Organ Sharing Registry database was queried to study adult OHT recipients between 1987-1998 with over 20-year posttransplant follow-up. The primary and secondary outcomes were 20-year survival and cause of death following OHT, respectively. Multivariable logistic regression was used to identify significant independent predictors of long-term survival, and long-term survival was compared among cohorts stratified by number of predictors using Kaplan Meier survival analysis. Results: 20,658 patients undergoing OHT were included, with median follow-up of 9.0 (IQR 3.2-15.4) years. Kaplan-Meier estimates of 10-, 15-, and 20-year survival were 50.2%, 30.1%, and 17.2%, respectively. Median survival was 10.1 (IQR 3.9-16.9) years. Increasing recipient age (>65 years), increasing donor age (>40 years), increasing recipient BMI (>30), black race, ischemic cardiomyopathy, and longer cold ischemic time (>4 hours) were adversely associated with 20-year survival. Of these 6 negative predictors, presence of 0 risk factors had the greatest 10-year (59.7%) and 20-year survival (26.2%), with decreasing survival with additional negative predictors. The most common cause of death in 20-year survivors was renal, liver, and/or multisystem organ failure whereas graft failure more greatly impacted earlier mortality. Conclusions: This study identifies six negative preoperative predictors of 20-year survival with 20-year survival rates exceeding 25% in the absence of these factors. These data highlight the potential for very long-term survival following OHT in patients with end-stage heart failure and may be useful for patient selection and prognostication.

Background: The predictive value of preoperative pulmonary function testing (PFT) in left ventricular assist device (LVAD) patients remains unknown. This study evaluates the relationship between abnormal PFTs and postimplant outcomes in LVAD patients. Methods: LVAD implants from January 2004 to December 2018 at a single institution were included. Patients were stratified based on presence of abnormal preoperative PFTs, and the primary outcome was respiratory adverse events (AE). Secondary outcomes included one-year overall postimplant survival, and complications including bleeding, renal failure, thromboembolism, and device malfunction. Results: 333 patients underwent LVAD implant, 46.5% (n=155) with normal PFTs and 53.5% (n=178) with abnormal PFTs. Patients with abnormal PFTs were noted to have higher rates of respiratory AEs (25.9% vs 15.1%, p=0.049). In multivariable analysis, the impact of PFTs was most significant when FEV1/FVC ratio was <0.5 (HR 16.32, 95% CI 1.70, 156.78). The rates of other AEs including bleeding, renal failure, right heart failure, and device malfunction were similar. One-year overall postimplant survival was comparable between the groups (56.8% vs 68.8%, p=0.3183), though patients in the lowest strata of FEV1 (<60% predicted) and FEV1/FVC (<0.5) had elevated risk-adjusted hazards for mortality (HR 2.63 95% CI 1.51, 4.60 and HR 18.92, 95% CI 2.10, 170.40, respectively). Conclusions: The presence of abnormal preoperative PFTs is not prohibitory for LVAD implantation although it can be used for risk stratification for respiratory AEs and mortality, particularly in patients with severely reduced metrics. The importance of careful patient selection should be underscored in this higher risk patient subset.

Background: Institutional factors have been shown to impact outcomes following orthotopic heart transplantation (OHT). This study evaluated center variability in the utilization of induction therapy for OHT and its implications on clinical outcomes. Methods: Adult OHT patients between 2010 and 2018 were identified from the UNOS registry. Transplant centers were stratified based on their rates of induction therapy utilization. Mixed-effects logistic regression models were created with drug-treated rejection within 1-year as primary endpoint and individual centers as random parameter. Risk-adjusted Cox regression was used to evaluate patient-level mortality outcomes. Results: In 17,524 OHTs performed at 100 centers, induction therapy was utilized in 48.6% (n=8411) with substantial variability between centers (IQR 21.4 – 79.1%).There were 36, 30, and 34 centers in the low (<29%), intermediate (29-66%), and high (>67%) induction utilization terciles groups, respectively. Induction therapy did not account for the observed variability in the treated rejection rate at 1-year among centers after adjusting for donor and recipient factors (p=0.20). No differences were observed in postoperative outcomes among induction utilization centers groups (all, p>0.05). Furthermore, there was a weak correlation between the percentage of induction therapy utilization at the center-level and recipients found to have moderate (r=0.03) or high (r=0.04) baseline risks for acute rejection at 1-year. Conclusions: This analysis demonstrates there is substantial variability in the use of induction therapy among OHT centers. In addition, there was a minimal correlation with baseline recipient risk or 1-year rejection rates, suggesting a need for better-standardized practices for induction therapy use in OHT.