Identifying Recipients at High Risk for Graft Failure After Heart Retransplantation
ABSTRACT The aim of this study was to identify recipient factors that are associated with a high risk of graft failure after heart retransplantation (HRT).
The prospectively collected United Network for Organ Sharing registry was used to identify patients undergoing HRT among 24,477 patients who had undergone cardiac transplantation between 1997 and 2009. The primary outcome was graft failure within 1 year of HRT. The impact of 35 recipient variables on the primary outcome was tested in exploratory univariate logistic regression analysis. Those factors found to be significantly associated with graft failure were entered into a multivariable logistic regression model.
A total of 671 patients underwent HRT during the study period. Overall, 302 (45%) grafts failed after HRT at a mean follow-up of 4.3±3.7 years. Three recipient factors were found to be associated with 1-year graft failure in the multivariate model: older age, increasing serum creatinine, and mechanical ventilation before HRT. Moreover, each decade increase in recipient age was associated with a 20% increase in odds of 1-year graft failure (odds ratio, 1.02; 95% confidence interval, 1.01 to 1.04; p=0.005). Similarly, each 1-mg/dL increase in serum creatinine increased odds of graft failure by 58% (odds ratio, 1.58; 95% confidence interval, 1.27 to 1.97; p<0.001). Patients who were mechanically ventilated had a fourfold higher likelihood of 1-year graft failure (odds ratio, 4.32; 95% confidence interval, 2.28 to 8.18; p<0.001).
The risk of graft failure after HRT increases with an increasing number of significant recipient risk factors, namely older age, increasing serum creatinine, and mechanical ventilation. These risk factors should serve as relative contraindications to HRT, especially when present in combination, given the higher rate of graft failure in these patients.
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ABSTRACT: Important developments have occurred over the past two years in the field of heart transplantation. These include refinements in donor management, preservation and allocation; and evaluation of immunosuppression strategies both for rejection and allograft vascular disease. Finally long term outcomes addressing areas of significant morbidity for patients including renal dysfunction and cancer have seen important advances. This contemporary review will highlight the key articles for 2012-2013.The Journal of Heart and Lung Transplantation 08/2014; DOI:10.1016/j.healun.2014.04.019 · 5.61 Impact Factor
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ABSTRACT: The aim of our study was to identify preoperative risk factors affecting overall survival after cardiac retransplantation (ReTX) in a contemporary era. The United Network for Organ Sharing database was used to identify patients undergoing ReTX between 1995 and 2012. Of the total 28,464 primary transplants performed, 987 (3.5%) were retransplants. The primary outcome investigated was overall survival. The influence of preoperative donor and recipient characteristics on survival were then tested with univariate logistic regression and multivariate Cox regression models. Of 987 patients who underwent ReTX, median survival was 9 years. Estimated survival at 1, 3, 5, 10, and 15 years following retransplant was 80% (95% confidence interval [CI], 78%-83%), 70% (95% CI, 67%-73%), 64% (95% CI, 61%-67%), 47% (95% CI, 43%-51%), and 30% (95% CI, 25%-37%), respectively. Clinical predictors of survival using multivariable analysis included donor age (relative risk [RR], 1.14; P = .004), ischemic time > 4 hours (RR, 1.48; P = .004); preoperative support with extracorporeal membrane oxygenator (RR, 3.91; P < .001), and the time between previous and current transplant (P = .004). Patients with ReTX have 1.27 times higher relative risk of death compared with patients undergoing primary transplant only (RR, 1.27; 95% CI, 1.13-1.42; P < .001). Patients who undergo cardiac ReTX can expect to have a 1-year survival less than a patient undergoing primary transplant with an acceptable median overall survival. Both donor and recipient preoperative factors contribute to overall survival following cardiac ReTx. Donor characteristics include age of the donor and ischemic time. Recipient factors include the need for extracorporeal membrane oxygenator and the number of days between the first and second transplant. Optimal survival following cardiac ReTX can best be predicted by choosing patients who are farther out from their initial transplant, not dependent upon preoperative extracorporeal support, and by choosing donor hearts younger in age and those likely to have shorter ischemic times.The Journal of thoracic and cardiovascular surgery 02/2014; 147(6). DOI:10.1016/j.jtcvs.2014.02.013 · 3.99 Impact Factor
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ABSTRACT: Objective: To evaluate immediate and long-term results of cardiac transplantation at two different levels of urgency. Methods: From November 2003 to December 2012, 228 patients underwent cardiac transplantation. Children and patients in cardiogenic shock were excluded from the study. From the final group (n=212), 58 patients (27%) were hospitalized under inotropic support (Group A), while 154 (73%) were awaiting transplantation at home (Group B). Patients in Group A were younger (52.0 +/- 11.3 vs. 55.2 +/- 10.4 years, P=0.050) and had shorter waiting times (29.4 +/- 43.8 vs. 48.8 +/- 45.2 days; P=0.006). No difference was found for sex or other comorbidities. Haemoglobin was lower and creatinine higher in Group A. The characteristics of the donors were similar. Follow-up was 4.5 +/- 2.7 years. Results: No differences were found in time of ischemia (89.1 +/- 37.0 vs. 91.5 +/- 34.5 min, P=0.660) or inotropic support (13.8% vs. 11.0%, P=0.579), neither in the incidence of cellular or humoral rejection and of cardiac allograft vasculopathy. De novo diabetes de novo in the first year was slightly higher in Group A (15.5% vs. 11.7%, P=0.456), and these patients were at increased risk of serious infection (22.4% vs. 12.3%, P=0.068). Hospital mortality was similar (3.4% vs. 4.5%, P=0.724), as well as long-term survival (7.8 +/- 0.5 vs. 7.4 +/- 0.3 years). Conclusions: The results obtained in patients hospitalized under inotropic support were similar to those of patients awaiting transplantation at home. Allocation of donors to the first group does not seem to compromise the benefit of transplantation. These results may not be extensible to more critical patients.Revista Brasileira de Cirurgia Cardiovascular 09/2014; 29(3):379-87. DOI:10.5935/1678-9741.20140072 · 0.63 Impact Factor