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: This study compared outcomes of patients bridged with extracorporeal membrane oxygenation (ECMO) to orthotopic heart transplantation (OHT) following the recent heart allocation policy change. Methods: The United Network of Organ Sharing Registry (UNOS) database was queried to examine OHT patients between 2010-2020 that were bridged with ECMO. Waitlist outcomes and one-year posttransplant survival were compared between patients waitlisted and/or transplanted before and after the heart allocation policy change. Secondary outcomes included posttransplant stroke, renal failure, and one-year rejection. Results: 285 waitlisted patients were included, 173 (60.7%) waitlisted under the old policy and 112 (39.3%) under the new policy. New policy patients were more likely to receive OHT (82.2% vs 40.6%), and less likely to be removed from the waitlist due to death or clinical deterioration (15.0% vs 41.3%) (both P<0.001). 165 patients bridged from ECMO to OHT were analyzed, 72 (43.6%) transplanted during the old policy and 93 (56.3%) under the new. Median waitlist time was reduced under the new policy (4 days [IQR 2-6] vs 47 days [IQR 10-228]). Postoperative renal failure was higher in the new policy group (23% vs 6%; P=0.002), but rates of stroke and one-year acute rejection were equivalent. One-year survival was lower the new policy but was not significant (79.8% vs 90.3%; P=0.3917). Conclusions: The UNOS heart allocation policy change has resulted in decreased waitlist times and higher likelihood of transplant in patients supported with ECMO. Posttransplant one-year survival has remained comparable although absolute rates are lower.
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.
BACKGROUND Prior studies have suggested that LVAD implantation technique and positioning may be associated with subsequent thromboembolic complications. This study evaluated the impact of inflow cannula positioning of the HeartWare LVAD (HVAD) on clinical outcomes. METHODS Adults undergoing primary HVAD implantation between 2009-2018 at a single center were reviewed. HVAD position parameters were calculated from plain chest radiographs and included cannula angle, pump depth, and pump area. These were measured at the day of HVAD implant, at 1 month post-HVAD, and at 6 months post-HVAD. Changes in these parameters over time were measured. Multivariable analysis was also conducted to evaluate associations between pump position parameters on the day of implant and one-year composite outcome of thromboembolic complication (embolic stroke or pump thrombosis) and death. RESULTS 159 HVAD recipients were included with a median follow up of 2.6 years (IQR 1.3 - 4.8 years). Pump area decreased from immediate post-HVAD implantation to one-month follow up (-0.7 cm2; p=0.002), but no significant changes were noted with other position parameters. Increasing preoperative serum creatinine level (HR 1.46, 95% CI 1.03 - 2.08, p=0.034) was associated with increased hazards for the composite outcome in multivariable analysis. Cannula angle, pump depth, nor pump area were associated with the one-year composite outcome, readmission, or other one-year complications including thromboembolic events or mortality when separately modeled. CONCLUSION This review of HVAD recipients demonstrates device position as assessed by chest X-ray does not have significant predictive associations with one-year outcomes.