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.
Article: Invited commentary.The Annals of thoracic surgery 03/2012; 93(3):717. DOI:10.1016/j.athoracsur.2012.01.025 · 3.65 Impact Factor
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ABSTRACT: BACKGROUND: -Alternate waiting list strategies expand listing criteria for patients awaiting heart transplantation (HTx). We retrospectively analyzed clinical events and outcome of patients listed as "high risk" recipients for HTx. METHODS AND RESULTS: -We analyzed 822 adult patients who underwent HTx of whom 111 patients met high risk criteria. Clinical data were collected from medical records and outcome factors calculated for 61 characteristics. Significant factors were summarized in a prognostic score. Age>65 years (67%) and amyloidosis (19%) were the most common reason for alternate listing. High risk recipients were older (63.2±10.2 versus 51.4±11.8 yrs; p<0.001), had more renal dysfunction, prior cancer and smoking. Survival analysis revealed lower post-HTx survival in high risk recipients (82.2 versus 87.4 % at 1-yr; 59.8 versus 76.3 % at 5-yrs post-HTx; p=0.0005). Prior CVA, Albumin<3.5 mg/dL, Re-HTx, Renal dysfunction (GFR<40 ml/min) and >2 prior Sternotomies were associated with poor survival following HTx. A prognostic risk score (CARRS) derived from these factors stratified survival post-HTx in high risk (3+ points) versus low risk (0-2 points) patients (87.9 versus 52.9 % at 1-yr; 65.9 versus 28.4 % at 5-yrs post-HTx; p<0.001). Low risk alternate patients had survival comparable to regular patients (87.9 versus 87.0 % at 1-yr and 65.9 versus 74.5 % at 5-yrs post-HTx; p=0.46). CONCLUSIONS: -High risk patients had reduced survival compared to regular patients post-HTx. Among patients previously accepted for alternate donor listing, application of the CARRS score identifies patients with unacceptably high mortality following HTx and those with a survival similar to regularly listed patients.Circulation Heart Failure 03/2013; 6(3). DOI:10.1161/CIRCHEARTFAILURE.112.000092 · 5.95 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