Does Recipient Age Impact Functional Outcomes of Orthotopic Heart Transplantation?
ABSTRACT This study evaluated changes in physical functional performance after orthotopic heart transplantation (OHT) with particular attention to the impact of recipient age on functional outcomes.
Retrospective review of all first-time, single-organ adult OHTs in the United States between 2005 and 2010. Patients were primarily stratified by age. The validated Karnofsky performance scale, which ranges from 0 (death) to 100 (fully independent with no evidence of disease and no complaints), was used to measure functional status.
A total of 10,049 OHT recipients were identified, with 1,431 (14%) aged 65 years or greater. Mean Karnofsky score prior to OHT was comparable between cohorts (younger: 50.7 ± 25.2 versus older: 50.1 ± 25.0; p = 0.38). At a median follow-up of 2.1 years (interquartile range 0.7 to 3.3 years), 64% of OHT recipients had improved functional performance. The mean improvement in Karnofsky score was similar between younger and older patients (19.6 ± 42.0 vs 17.5 ± 41.8; p = 0.10). Twenty percent of younger patients were functionally independent prior to OHT, with 67% being functionally independent at last follow-up (p < 0.001). Similarly, in the older cohort, 20% were functionally independent prior to OHT, with 66% being functionally independent at last follow-up (p < 0.001). Multivariable analysis adjusting for potential confounders confirmed that age, both as a continuous and categoric variable, did not impact odds of functional improvement after OHT. Subanalysis using 70 years as the age cutoff produced similar results.
In the modern era, OHT is associated with improvements in functional performance in most recipients, and this beneficial effect is preserved across the age spectrum. These data provide a benchmark for functional outcomes after OHT and may have important implications in organ allocation.
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ABSTRACT: In this study we sought the following: (1) To objectively assess the risk related to various pretransplant recipient and donor characteristics; (2) to devise a preoperative risk stratification score (RSS) based on pretransplant recipient and donor characteristics predicting graft loss at 1 year; and (3) to define different risk strata based on RSS. The United Network for Organ Sharing provided de-identified patient-level data. Analysis included 11,703 orthotopic heart transplant recipients aged 18 years or greater and transplanted between January 1, 2001 and December 31, 2007. The primary outcome was 1-year graft failure. Multivariable logistic regression analysis (backward p value<0.20) was used to determine the relationship between pretransplant characteristics and 1-year graft failure. Using the odds ratio for each identified variable, an RSS was devised. The RSS strata were defined by calculating receiver operating characteristic curves and stratum specific likelihood ratios. The strongest negative predictors of 1-year graft failure included the following: right ventricular assist device only, extracorporeal membrane oxygenation, renal failure, extracorporeal left ventricular assist device, total artificial heart, and advanced age. Threshold analysis identified 5 discrete RSS strata: low risk (LR, RSS: <2.55; n=3242, 27.7%), intermediate risk (IR, RSS: 2.55-5.72; n=6,347, 54.2%), moderate risk (MR, RSS: 5.73-8.13; n=1,543, 13.2%), elevated risk (ER, RSS: 8.14-9.48; n=310, 2.6%), and high risk (HR, RSS: >9.48; n=261, 2.2%). The 1-year actuarial survival (%) in the LR, IR, MR, ER, and HR groups were 93.8, 89.2, 81.3, 67.0, and 47.0, respectively. Pretransplant recipient variables significantly influence early and late graft failure after heart transplantation. The RSS may improve organ allocation strategies by reducing the potential negative impact of transplanting candidates who are at a high risk for poor postoperative outcomes.The Annals of thoracic surgery 06/2011; 92(2):520-7; discussion 527. DOI:10.1016/j.athoracsur.2011.02.086 · 3.65 Impact Factor
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ABSTRACT: No recipient risk index exists predicting short-term mortality after orthotopic heart transplantation (OHT). We utilized United Network for Organ Sharing (UNOS) data to develop a novel quantitative recipient risk score for use in OHT. A prospectively collected open cohort of 21,378 primary OHT patients (1997 to 2008) was randomly divided into subgroups. The training cohort (n=17,079) was used for score derivation and the test cohort (n=4,299) was used for independent validation. Recipient specific variables associated with 1-year mortality (exploratory p value<0.2) were incorporated stepwise into a multivariable logistic regression model. The final model contained variables which maximized explanatory power (assessed by pseudo R2, area under the curve, and likelihood-ratio test). A risk index was created by apportioning points approximating the relative impact of variables on 1-year mortality. The Kaplan-Meier method was used to assess impact of risk score on short-term survival. The 50-point scoring system incorporated 12 recipient specific variables. Derivation and validation cohort scores ranged from 0 to 33 and 0 to 27, respectively (mean 6.1±3.7 and 6.1±3.7). Each point increased the odds of 1-year death by 14% in the derivation cohort (odds ratio 1.14 [1.13 to 1.15], p<0.001) and 15% in the validation cohort (odds ratio 1.15 [1.12 to 1.17], p<0001). One-year survivals in the validation cohort (by increments of 3 points) were the following: 0 to 2 (92.5%); 3 to 5 (89.9%); 7 to 9 (86.3%); and 10 or greater (74.9%); p<0.001. Patients transplanted with risk scores of 20 or higher had 1-year mortality rates greater than 50%. We present a novel internally validated OHT recipient risk score, which is highly predictive of 1-year mortality. This risk index may prove valuable for patient prognosis, organ allocation, and research stratification in OHT.The Annals of thoracic surgery 09/2011; 92(3):914-21; discussion 921-2. DOI:10.1016/j.athoracsur.2011.04.030 · 3.65 Impact Factor
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ABSTRACT: Advanced age has been viewed as a contraindication to orthotopic heart transplantation (OHT). We analyzed the outcome of OHT in patients who were aged 70 years or older and compared the results with those in younger patients during a two-decade period. A total of 519 patients underwent first-time single-organ OHT at our institution from 1988 to 2009. Patients were divided into three groups by age: ≥70-years old (group 1, n=37), 60 to 69-years old (group 2, n=206), and ≤60-years old (group 3, n=276). Primary endpoints were 30-days, and 1-, 5-, and 10-years survival. Secondary outcomes included re-operation for bleeding, postoperative need for dialysis, and length of postoperative intubation. There was no significant difference in survival between the greater than or equal to 70-year-old group and the two younger age groups for the first 10 years after OHT. Survival rates at 30 days, and 1-, 5-, and 10-years, and median survival in group 1 recipients were 100%, 94.6%, 83.2%, 51.7%, and 10.9 years (CI 7.1-11.0), respectively; in group 2 those numbers were 97.6%, 92.7%, 73.8%, 47.7%, and 9.1 years (CI 6.7-10.9), respectively; and in group 3 those numbers were 96.4%, 92.0%, 74.7%, 57.1%, and 12.2 years (CI 10.7-15.4; P=NS), respectively. There was no significant difference in secondary outcomes of re-operation for bleeding, postoperative need for dialysis, and prolonged intubation among the three age groups. Patients who are aged 70 years and older can undergo heart transplantation with similar morbidity and mortality when compared with younger recipients. Advanced heart failure patients who are aged 70 years and older should not be excluded from transplant consideration based solely on an age criterion. Stringent patient selection, however, is necessary.Transplantation Proceedings 12/2011; 43(10):3851-6. DOI:10.1016/j.transproceed.2011.08.086 · 0.95 Impact Factor