Heart Transplantation for Adults With Congenital Heart Disease: Analysis of the United Network for Organ Sharing Database

B-type natriuretic peptide: powerful predictor of end-stage chronic heart failure in individuals with systolic dysfunction of the systemic right ventricle

AIM

To assess whether B-type natriuretic peptide (BNP) can serve as a predictor of end-stage chronic heart failure (CHF) in patients with severe systolic dysfunction of the systemic right ventricle (SRV).

METHODS

We performed a retrospective analysis in 28 patients with severe systolic dysfunction of the SRV (ejection fraction 23 ± 6%) who were evaluated as heart transplant (HTx) candidates between May 2007 and October 2014. The primary endpoints of the study (end-stage CHF) were progressive CHF, urgent HTx, and ventricular assist device (VAD) implantation. Plasma BNP levels were measured using a chemiluminescent immunoassay.

RESULTS

During median follow-up of 29 months (interquartile range, 9-50), 3 patients died of progressive CHF, 5 patients required an urgent HTx, and 6 patients underwent VAD implantation. BNP was a strong predictor of end-stage CHF (hazard ratio per 100 ng/L: 1.079, 95% confidence interval, 1.042-1.117, P<0.001). The following variables with corresponding areas under the curve (AUC) were identified as the most significant predictors of end-stage CHF: BNP (AUC 1.00), New York Heart Association functional class class III or IV (AUC 0.98), decompensated CHF in the last year (AUC 0.96), and systolic dysfunction of the subpulmonal ventricle (AUC 0.96).

CONCLUSION

BNP is a powerful predictor of end-stage CHF in individuals with systolic dysfunction of the SRV.

HeartWare Ventricular Assist Device Implantation in Patients With Fontan Physiology

We aim to describe the clinical course of a series of patients with hypoplastic left heart syndrome and refractory systolic heart failure supported with a HeartWare ventricular assist device (HVAD) following Fontan palliation. This is a retrospective review of three consecutive patients supported with a HVAD following Fontan palliation through February 2016. Data include patient characteristics, operative variables, postimplantation hemodynamic/device parameters, event outcomes, and duration of HVAD support. Patient ages were 11.7, 13.5, and 17.5 years, respectively, at the time of HVAD implant. The duration of HVAD support was 148, 272, and 271 days, respectively, of which 86, 222, and 211 were outpatient days. Inflow cannula position was the morphologic right ventricle with depth adjustment and manipulation of the tricuspid subvalvar apparatus to ensure good inflow. Echocardiographic, hemodynamic, and noninvasive oximetric monitoring resulted in high RPM settings for all patients. Despite various complications, all patients were successfully transplanted and discharged home alive. We present three patients bridged to transplantation using the HVAD following Fontan palliation. We demonstrate potential for durable support with transition to outpatient care while awaiting heart transplantation in a subset of patients status post Fontan surgery.

Current Expectations for Cardiac Transplantation in Patients With Congenital Heart Disease

Congenital heart disease accounts for 40% of pediatric heart transplants and presents unique challenges to the transplant team. Suitability for transplantation is defined in part by degree of sensitization, pulmonary vascular resistance, and hepatic reserves. The incremental transplant risk for patients with congenital heart disease occurs within the first 3 months, after which survival is equivalent to transplantation for cardiomyopathy. Single ventricle with prior palliation, and especially the failing Fontan, carry the highest risk for transplantation and are least amenable to bridging with mechanical circulatory support. More effective bridging to transplant with mechanical circulatory support will require improvements in the adverse event profile of available pumps and the introduction of miniaturized continuous flow technology. The major barriers to routine long-term survival are chronic allograft failure and allograft vasculopathy. Despite these many challenges, continuing improvements in the care of pediatric heart transplant patients have pushed the median posttransplant survival past 15 years for children and to 20 years for infants.

Does Survival on the Heart Transplant Waiting List Depend on the Underlying Heart Disease?

OBJECTIVES

The aim of this study was to identify differences in survival on the basis of type of heart disease while awaiting orthotopic heart transplantation (OHT).

BACKGROUND

Patients with restrictive cardiomyopathy (RCM), congenital heart disease (CHD), or hypertrophic cardiomyopathy (HCM) may be at a disadvantage while awaiting OHT because they often are poor candidates for mechanical circulatory support and/or inotropes.

METHODS

The study included all adults in the Scientific Registry of Transplant Recipients database awaiting OHT from 2004 to 2014, and outcomes were evaluated on the basis of type of heart disease. The primary endpoint was time to all-cause mortality, censored at last patient follow-up and time of transplantation. Multivariate Cox proportional hazards modeling was performed to evaluate survival by type of cardiomyopathy.

RESULTS

There were 14,447 patients with DCM, 823 with RCM, 11,799 with ischemic cardiomyopathy (ICM), 602 with HCM, 964 with CHD, 584 with valvular disease, and 1,528 in the "other" category (including 1,216 for retransplantation). During median follow-up of 3.7 months, 4,943 patients died (1,253 women, 3,690 men). After adjusting for possible confounding variables including age, renal function, inotropes, mechanical ventilation, and mechanical circulatory support, the adjusted hazard ratios by diagnoses relative to DCM were 1.70 for RCM (95% confidence interval [CI]: 1.43 to 2.02), 1.10 for ICM (95% CI: 1.03 to 1.18), 1.23 for HCM (95% CI: 0.98 to 1.54), 1.30 for valvular disease (95% CI: 1.07 to 1.57), 1.37 for CHD (95% CI: 1.17 to 1.61), and 1.51 for "other" diagnoses (95% CI: 1.34 to 1.69). Sex was a significant modifier of mortality for ICM, RCM, and "other" diagnoses (p < 0.05 for interaction).

CONCLUSIONS

In the United States, patients with RCM, CHD, or prior heart transplantation had a higher risk for death while awaiting OHT than patients with DCM, ICM, HCM, or valvular heart disease.

Trends and outcomes of patients with adult congenital heart disease and pulmonary hypertension listed for orthotopic heart transplantation in the United States

BACKGROUND

Heart transplantation is increasing in patients with adult congenital heart disease (ACHD). In this population, the association of pulmonary hypertension (PH) with post-transplant outcomes is not well-defined.

METHODS

Using data from the United Network for Organ Sharing database (1987 to 2014), we identified ACHD patients listed for heart transplantation, and examined survival between those with and without PH (pre-transplant PH defined as transpulmonary pressure gradient >12 mm Hg).

RESULTS

Among 983 ACHD patients, 216 (22%) had PH. At time of listing, PH patients had a transpulmonary pressure gradient of 17.0 mm Hg vs 6.0 mm Hg (p < 0.01) in the no-PH group. Although left ventricular assist device (LVAD) use was infrequent, 3.1% of PH patients were treated with an LVAD versus 6.8% of the no-PH patients. Days from listing to transplant, days from listing to death on the waitlist and length of post-transplant hospitalization were not significantly different between the PH and no-PH groups. However, PH was associated with higher waitlist mortality (HR 1.73, CI 1.25 to 2.41). Pre-transplant PH was not associated with post-transplant mortality at 30 days (HR 0.51, CI 0.23 to 1.13), 1 year (HR 0.68, 95% CI 0.40 to 1.18) or 5 years (HR 0.84, 95% CI 0.55 to 1.29).

CONCLUSIONS

PH is common among ACHD patients listed for transplant and is associated with increased waitlist mortality. Conversely, PH was not associated with worse survival after transplant. Bridge-to-transplant LVAD therapy was uncommon in this ACHD population.

Pediatric heart transplantation

Pediatric heart transplantation (pHTx) represents a small (14%) but very important and particular part in the field of cardiac transplantation. This treatment has lifelong impact on children. To achieve the best short and especially long-term survival with adequate quality of life, which is of crucial importance for this young patient population, one has to realize and understand the differences with adult HTx. Indication for transplantation, waitlist management including ABO incompatible (ABOi) transplantation and immunosuppression differ. Although young transplant recipients are ultimately likely to be considered for re-transplantation. One has to distinguish between myopathy and complex congenital heart disease (CHD). The differences in anatomy and physiology make the surgical procedure much more complex and create unique challenges. These recipients need a well-organized and educated team with pediatric cardiologists and intensivists, including a high skilled surgeon, which is dedicated to pHTx. Therefore, these types of transplants are best concentrated in specialized centers to achieve promising outcome.

Heart transplantation with and without prior sternotomy: analysis of the United Network for Organ Sharing database

INTRODUCTION

Patients with history of prior sternotomy may have poorer outcomes after heart transplantation. Quantitation of risk from prior sternotomy has not been well established. The United Network for Organ Sharing (UNOS) database was analyzed to assess early and late survival and predictors of outcome in adult heart transplant recipients with and without prior sternotomy.

METHODS

Of 11,266 adults with first heart-only transplantation from 1997 to 2011, recipients were divided into 2 groups: those without prior sternotomy (first sternotomy group; n = 6006 or 53.3%) and those with at least 1 prior sternotomy (redo sternotomy group; n = 5260 or 46.7%). A multivariable Cox model was used to identify predictors of mortality.

RESULTS

Survival was lower in the redo group at 60 days (92.6% vs 95.9%; hazard ratio [HR] 1.83, 95% confidence interval [CI]: 1.56-2.15; P < .001). Conditional 5-year survival in 60-day survivors was similar in the 2 groups (HR = 1.01, 95% CI 0.90-1.12, P = .90). During the first 60 days post-transplant, the redo group had more cardiac reoperations (12.3% vs 8.8%, P = .0008), a higher frequency of dialysis (8.9% vs 5.2%, P < .0001), a greater percentage of drug-treated infections (23.2% vs 19%, P = .003), and a higher percentage of strokes (2.5% vs 1.4%, P = .0001). A multivariable Cox proportional hazards model identified prior sternotomy as a significant independent predictor of mortality, in addition to age, female gender, congenital cardiomyopathy, need for ventilation, mechanical circulatory support, dialysis prior to transplant, pretransplant serum bilirubin (≥ 3 mg/dL), and preoperative serum creatinine (≥ 2 mg/dL).

CONCLUSIONS

Prior sternotomy is associated with an excess 3.3% mortality and higher morbidity within the first 60 days after heart transplantation, as measured by frequency of dialysis, drug-treated infections, and strokes. Conditional 5-year survival after 60 days is unaffected by prior sternotomy. These findings should be taken into account for risk assessment of patients undergoing heart transplantation.

Heart Transplantation in Pediatric and Congenital Heart Disease

Purpose:

To describe the indications and outcomes for pediatric patients and patients with congenital heart disease (CHD) undergoing heart transplantation (HT) in New Zealand.

Methods:

A retrospective audit of 253 patients who underwent HT from 1987 to end 2012 was undertaken. Thirty-seven patients were subdivided into two groups, those aged <18 years—pediatric heart disease (PHD) and those with CHD. Six patients aged <18 years were included in both the analyses. Demographic and clinical information were collected and outcomes established.

Results:

Overall actuarial survival of 37 patients with PHD or CHD was 92% at one year, 85% at five years, and 52% at ten years. The PHD group comprised 22 (8.7%) patients, median age 14 years (range 6-17), 14 (64%) male, with cardiomyopathy in 13, CHD in 6, and rheumatic heart disease in 3. At follow-up, 11 patients had died. Actuarial survival was 91% at one year and 79% at five years. Of the four patients with a mechanical assist device to bridge, three were transplanted and alive at follow-up. The CHD group comprised 21 (8.3%) patients, median age 25 years (range 6-48) and 19 (90%) were male. At follow-up, three patients had died. Actuarial survival was 95% at one year, 94% at five years, and 85% at ten years. All five patients with pre-HT Fontan circulation were alive a median of eight years following HT.

Conclusion:

Heart transplantation for carefully selected pediatric patients and patients with CHD can be successfully performed with favorable outcomes in a geographically isolated unit.

Heart transplantation with or without prior mechanical circulatory support in adults with congenital heart disease

OBJECTIVES

Recent analyses establish that heart transplantation is increasing among adults with congenital heart disease (ACHD), but the effects of pretransplant mechanical circulatory support (MCS) on perioperative and post-transplant outcomes have not been examined in the ACHD population.

METHODS

Scientific Registry of Transplant Recipients data on all adult heart transplants from September 1987 to September 2012 (n = 47 160) were classified based on primary diagnosis codes as CHD or non-CHD and MCS or non-MCS. Demographic, procedural, outcome and survival variables were compared between MCS and non-MCS ACHD patient groups.

RESULTS

MCS was used in 83 (6.8%) ACHD patients compared with 8625 (18.8%) patients without CHD (P < 0.001). MCS as a fraction of ACHD transplants increased over time (P = 0.002). MCS patients spent more time on the wait list, had a higher baseline serum creatinine and were more likely to be male, status 1A, hospitalized, in the ICU and/or on a ventilator prior to transplant. However, MCS patients experienced equivalent short-term survival (30-day mortality = 10.8% in MCS vs 13.5% in non-MCS, P = 0.62) and overall survival by Kaplan-Meier analysis (P = 0.57). MCS patients had a longer post-transplant length of stay and were more likely to be transfused, but otherwise had no significant differences in adverse outcomes.

CONCLUSIONS

MCS is less commonly used in adult CHD patients compared with all patients undergoing heart transplant, but has been increasing over time. Within the ACHD population, patients with MCS have a higher risk profile, but except for increased transfusion rate and longer length of stay, do not experience less favourable post-transplant outcomes.

Organ allocation in adults with congenital heart disease listed for heart transplant: impact of ventricular assist devices

BACKGROUND

Adults with congenital heart disease (CHD) listed for heart transplantation are rarely supported by ventricular assist devices (VADs). This may be a disadvantage to their priority for organ allocation. We sought to determine the relationship between VAD implantation and successful transplantation among patients listed for heart transplant.

METHODS

Adults with CHD patients (N = 1,250) were identified from the United Network for Organ Sharing (UNOS) database from 1985 to 2010 and compared to patients without congenital etiology for heart failure (N = 59,606). VAD use at listing, listing status, status upgrades and reasons for upgrade prior to transplant were trended at 5-year intervals and appropriate statistical comparisons were made between groups.

RESULTS

Since 1985, VAD use prior to transplant has increased significantly in patients without CHD, but not in CHD patients (17% vs 3% in 2006 to 2010, p < 0.0001). CHD patients were more likely to be listed as Status 2, compared to those without (66% vs 40%, p < 0.001 for 2006 to 2010), and less likely to be upgraded to Status 1 after listing (43% vs 55%, p = 0.03). Among those upgraded to Status 1, CHD patients were less likely to have a VAD at transplant than those without (3% vs 18%, p = 0.005). VAD use was more likely to result in death in CHD patients.

CONCLUSIONS

VAD use is less common in CHD patients than in patients without CHD, both at the time of listing and transplantation. Reduced VAD use appears to contribute to lower listing status and organ allocation. These differences have grown more disparate over time. Separate criteria for organ allocation for CHD patients may be justified.

End-of-life care in adults with congenital heart disease: now is the time to act

PURPOSE OF REVIEW

There are increasing numbers of adults with congenital heart disease (CHD) and these patients remain at long-term risk of complications and premature death. This review focuses on the changing picture of adult CHD with more complex patients surviving, the challenges of balancing life-prolonging intervention, the barriers to discussing the end-of-life (EOL) issues and draws on the experience of other specialities in managing young patients.

RECENT FINDINGS

The prevalence of adults with the most severe forms of CHD has increased, especially those with a Fontan circulation. The eventual decline is inevitable with limited treatment options. There should be a parallel palliative care approach in patients who are being considered for high-risk, life-prolonging interventions. Oncologists caring for the young patients with cancer and cystic fibrosis specialists have demonstrated the unique needs of young patients with chronic diseases that may be applicable to adult CHD patients and help with their EOL planning.

SUMMARY

These patients require an early and proactive approach to EOL discussions, and the unique needs of young patients should be recognized. Further research is needed to develop local and national guidelines for the palliative care approach in these patients.

Long-term Issues After the Fontan Procedure

The Fontan procedure is used to treat various serious congenital heart defects. Although many people who have had the procedure live productively into adulthood, as they age, they face several health issues due to the physiology of the Fontan circulation. This article reviews the 4 types of Fontan procedures and the changes caused by the surgery, including single-ventricle physiology, nonpulsatile pulmonary perfusion, systemic venous hypertension, and intracardiac scarring, as well as their sequelae. Key nursing assessment items and possible treatment strategies are reviewed. Additional topics, including pregnancy in patients who have undergone the procedure, infective endocarditis prophylaxis, and health-related quality of life, are briefly discussed. Options for Fontan failure, including Fontan conversion or transplantation, are presented. Potential future solutions are outlined.

Is race associated with morbidity and mortality after hospital discharge among neonates undergoing heart surgery?

This study aimed to characterize the impact of race on morbidity and mortality after hospital discharge from neonatal congenital heart surgery. A retrospective chart review examined all the neonates who underwent neonatal heart surgery from January 2005 to June 2006 at The Children's Hospital of Philadelphia. After risk adjustment for the type of surgery using the Risk Adjustment for Congenital Heart Surgery 1 (RACHS-1) method, the association of race with mortality after hospital discharge was assessed using Fisher's exact test for statistical analysis. A cross-sectional telephone survey of surviving patients also was conducted to examine the association of race and social factors with adverse events (admissions or reinterventions). Mortality status was known for 201 of the 217 patients screened. The mortality rate after discharge was 8 %, with a higher mortality rate for nonwhite patients (14 %) than for white patients (4 %) (p = 0.01). After risk adjustment, this effect was limited to nonwhite patients with less complex heart disease (RACHS-1 categories 1-3; 17 vs 2 %, respectively; p = 0.01). The survey completion rate was 54 %. In this cohort, race also was independently associated with adverse events among patients with less complex heart disease (RACHS-1 categories 1-3; nonwhites 53 % vs whites 25 %; p = 0.046). Among the patients with less complex heart disease, the nonwhite patients had a significantly higher risk of morbidity and mortality after hospital discharge than the white patients.

State of the art in paediatric heart transplantation: the Berlin experience

Enormous progress has been made in paediatric heart transplantation since the first unsuccessful effort by Kantrowitz in 1967. Early reports of children undergoing heart transplantation showed alarmingly high perioperative mortality rates of 25-60%, with the diagnosis of congenital heart disease (CHD) representing a particularly high-risk subset compared with cardiomyopathy. Many of these early failures were related to poor patient selection, suboptimal immunosuppression and technical problems. We learned a great deal from these earlier difficulties. Presently, with more refined techniques, better-defined patient selection criteria, excellent graft rejection monitoring and optimal immunosuppression, the ISHLT 2011 registry reported a 10-year survival rate of 60% for patients transplanted for end-stage CHD and >70% for those transplanted for cardiomyopathy. The technical dilemmas in complex CHD were overcome by surgical ingenuity and creativity, innovative solutions and careful surgical planning, adapting the complex recipient anatomy to the normal donor anatomy. The miniaturized Berlin Heart pulsatile ventricular assist devices in children as a bridge to transplantation have revolutionized treatment and become a significant contribution in heart-failure therapy. The intramyocardial electrogram and echocardiographic strain rate imaging have been employed as non-invasive techniques of rejection monitoring. Immunosuppressive drugs have a major impact on the development and progression of cardiac allograft vasculopathy, the main cause of cardiac allograft loss and a leading cause of mortality after the first year post-transplantation. The questions of whether a transplanted heart in a newborn grows to adult size along with the child and whether the dimensional cardiac growth allows adequate function over time have been largely answered in our previous investigations. As more transplanted children reach adulthood, concerns about their life expectancy when they have reached 10 years of life post-transplant are raised, particularly with respect to establishing partnerships and families, their ability to earn a living and the fulfilment of personal life perspectives. Some heart-transplanted patients require retransplantation to remain alive. The disparity between the demand for and supply of donor hearts makes retransplantation an ethical issue. We 'do not refuse' any patient who needs retransplantation. Mechanical circulatory support devices for long-term use are now largely available to accommodate such cases.

Heart transplantation in adults with end-stage congenital heart disease

Residual abnormalities in cardiac structure and function predispose adults with congenital heart disease to late-onset heart failure and its complications. Evaluation of this population requires collaboration between adult congenital and heart failure specialists. In addition to assessing heart transplant eligibility, clinicians must balance the risks of premature listing against progressive heart failure and increased waiting list mortality. Following heart transplantation, adults with congenital heart disease have higher mortality due to an increased risk of bleeding, infection and donor right heart failure secondary to pulmonary hypertension. Concerns relating to increased early mortality should be balanced against superior long-term survival in adult congenital heart disease patients surviving beyond the first year after heart transplantation.

Dynamic pulmonary artery obstruction causing right ventricular failure after cardiac transplantation in a patient with Mustard-Senning corrected d-transposition of the great arteries

Patients with congenital d-transposition of the great arteries (d-TGA) undergoing palliative atrial baffle surgery in infancy often develop systemic ventricular failure in adulthood. If they undergo cardiac transplantation, they are prone to morphologic right ventricular (RV) failure secondary to severe pulmonary hypertension as a result of systemic ventricular failure. We report a case of a patient with d-TGA and biventricular ventricular failure requiring heart transplantation (HT) that developed RV failure postoperatively because of dynamic pulmonary artery (PA) obstruction at the anastomotic site of PA. Obstruction at the site of PA anastomosis due to torsion or redundancy of the donor or recipient PA is a rare but treatable cause of postoperative RV failure. In this case, rapid identification of the etiology of RV failure and implementation of corrective therapies before the development of end-organ dysfunction, resulted in complete RV recovery and normal allograft function. This case represents the first known report of dynamic PA anastomoticobstruction resulting in RV failure after HT that was corrected with pulmonary arterioplasty, and RV assist device resulting in complete recovery.

Development of a quantitative donor risk index to predict short-term mortality in orthotopic heart transplantation

BACKGROUND

No standard index based on donor factors exists for predicting mortality after orthotopic heart transplantation (OHT). We utilized United Network for Organ Sharing (UNOS) data to develop a quantitative donor risk score for OHT.

METHODS

We examined a prospectively collected open cohort of 22,252 patients who underwent primary OHT (1996 to 2007). Of the 284 donor-specific variables, those associated with 1-year (year) mortality (exploratory p-value < 0.2) were incorporated into a multivariate (MV) logistic regression model. The final model contained donor factors that improved the explanatory power (by pseudo-R2, area under the curve and likelihood ratio test). A quantitative donor risk score was created using odds ratios (ORs) from the final model. For external validity, a cross-validation strategy was employed whereby the score was generated using a randomly generated subset of cases (n = 17,788) and then independently validated on the remaining patients (n = 4,464).

RESULTS

A 15-point scoring system incorporated 4 variables: ischemic time; donor age; race mismatching; and blood urea nitrogen (BUN)/creatinine ratio. Derivation and validation cohort scores ranged from 1 to 15 and 1 to 12, respectively (mean 4.0 ± 2.1 for each). Each increase of 1 point increased the risk of 1-year death by 9% (OR = 0.09 [1.07 to 0.12]) in the derivation cohort and 13% (OR = 0.13 [1.08 to 0.18]) in the validation cohort (each p < 0.001). The odds of 1-year mortality by increments of 3 points were: 0 to 2 points (reference); 3 to 5 points (OR = 0.25 [1.12 to 0.40], p < 0.001); 6 to 8 pts (OR = 0.77 [1.56 to 2.02], p < 0.001); and 9 to 15 points (OR = 1.92 [1.54 to 2.39], p < 0.001). Donor risk score was predictive for 30-day mortality (OR = 0.11 [1.08 to 0.14], p < 0.001) and 5-year cumulative mortality (OR = 0.11 [1.09 to 0.13], p < 0.001).

CONCLUSIONS

We present a novel donor risk index for OHT predicting short- and long-term mortality. This donor risk score may prove valuable for donor heart allocation and prognosis after OHT.

Listing and Transplanting Adults With Congenital Heart Disease

Background—

An increasing number of patients with congenital heart disease (CHD) are reaching adulthood and may require heart transplantation. The survival of these patients after listing and transplantation has not been evaluated.

Methods and Results—

A total of 41 849 patients (aged >18 years) were listed for primary transplantation during 1995–2009. Patients with a history of CHD (n=1035; 2.5%) were compared with those with other causes (non-CHD group) (n=40 814; 97.5%); 26 055 (62.3%) reached transplantation and were subdivided into those with (reoperation group; n=10 484; 40.2%) and without (nonreoperation group; n=15 571; 59.8%) a previous sternotomy. Survival on the waiting list was similar between groups, but mechanical ventricular assistance was not associated with superior survival to transplantation among CHD patients. CHD patients were more likely to have body mass index <18.5 at transplantation ( P <0.0001), were younger, and had fewer comorbidities. Early mortality among patients with CHD was high (reoperation, 18.9% versus 9.6%; P <0.0001; nonreoperation, 16.6% versus 6.3%; P <0.0001), but by 10 years, overall survival was equivalent (53.8% versus 53.6%). Analysis was limited by the lack of specific information regarding the CHD diagnosis in most patients.

Conclusions—

Adults with CHD have high 30-day mortality but better late survival after heart transplantation. Mechanical circulatory assistance does not improve waiting list survival in these patients. This may be due to a combination of highly complex reoperative surgery and often poor preoperative systemic health.