Factors predicting 10-year survival after heart transplantation

International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024

The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.

Cardiac magnetic resonance in advanced heart failure

Heart failure (HF) is a chronic and progressive disease that often progresses to an advanced stage where conventional therapy is insufficient to relieve patients' symptoms. Despite the availability of advanced therapies such as mechanical circulatory support or heart transplantation, the complexity of defining advanced HF, which requires multiple parameters and multimodality assessment, often leads to delays in referral to dedicated specialists with the result of a worsening prognosis. In this review, we aim to explore the role of cardiac magnetic resonance (CMR) in advanced HF by showing how CMR is useful at every step in managing these patients: from diagnosis to prognostic stratification, hemodynamic evaluation, follow-up and advanced therapies such as heart transplantation. The technical challenges of scanning advanced HF patients, which often require troubleshooting of intracardiac devices and dedicated scans, will be also discussed.

Absolute Quantification of Donor-Derived Cell-Free DNA in Pediatric and Adult Patients After Heart Transplantation: A Prospective Study

In this prospective study we investigated a cohort after heart transplantation with a novel PCR-based approach with focus on treated rejection. Blood samples were collected coincidentally to biopsies, and both absolute levels of dd-cfDNA and donor fraction were reported using digital PCR. 52 patients (11 children and 41 adults) were enrolled (NCT03477383, clinicaltrials.gov), and 557 plasma samples were analyzed. 13 treated rejection episodes >14 days after transplantation were observed in 7 patients. Donor fraction showed a median of 0.08% in the cohort and was significantly elevated during rejection (median 0.19%, p < 0.0001), using a cut-off of 0.1%, the sensitivity/specificity were 92%/56% (AUC ROC-curve: 0.78). Absolute levels of dd-cfDNA showed a median of 8.8 copies/mL and were significantly elevated during rejection (median 23, p = 0.0001). Using a cut-off of 7.5 copies/mL, the sensitivity/specificity were 92%/43% for donor fraction (AUC ROC-curve: 0.75). The results support the feasibility of this approach in analyzing dd-cfDNA after heart transplantation. The obtained values are well aligned with results from other trials. The possibility to quantify absolute levels adds important value to the differentiation between ongoing graft damage and quiescent situations.

Positive donor blood cultures are not associated with worse heart transplant survival

BACKGROUND

Recent evidence has demonstrated that transplantation of hearts with blood culture positive donors (BCPDs) to pediatric recipients is safe and effective. Few studies have analyzed the effect of BCPD on adult heart transplant recipients.

METHODS

The United Network for Organ Sharing (UNOS) database was retrospectively reviewed from September, 1987 to March, 2021. Exclusion criteria included pediatric donors/recipients, donor ejection fraction <10% or >85%, inactive listed recipients, donors missing blood cultures, and recipients missing follow-up time. Outcomes were compared with fully adjusted logistic models. To account for discrepancies in BCPD and non-BCPD covariates, an inverse proportionally weighted model with regression adjustment (IPWRA) was used.

RESULTS

A total of 60 592 donors were non-BCPD, while 4009 were BCPD. 7% of hearts not transplanted were BCPD, while 6% of hearts transplanted were BCPD (p = .001). These rates have been nearly constant since 2005. There were no differences in short term survival between the two groups in the adjusted or IPWRA models (p = .103 and .277, respectively). Additionally, the BCPD group had longer ischemic time (3.24 vs. 3.06 h, p < .001), older donor age (32.73 vs. 31.65 years, p < .001), and older recipient age (52.76 vs. 52.09 years, p = .001). The IPWRA revealed an average additional 3.4 years of overall survival and 2.25 years of graft function for BCPD versus non-BCPD recipients, although these results failed to reach statistical significance (p = .387 and .527, respectively).

CONCLUSIONS

Given the need for more donor hearts, donors with positive blood cultures should be considered. Great care in evaluating such patients is advised to eliminate donors with untreated infections, while carefully selected donors can be considered and used.

Textbook outcomes in heart transplantation: A quality metric for the modern era

BACKGROUND

Traditional quality metrics like one-year survival do not fully encapsulate the multifaceted nature of solid organ transplantation in contemporary practice. Therefore, investigators have proposed using a more comprehensive measure, the textbook outcome. However, the textbook outcome remains ill-defined in the setting of heart transplantation.

METHODS

Within the Organ Procurement and Transplantation Network database, the textbook outcome was defined as having: (1) No postoperative stroke, pacemaker insertion, or dialysis, (2) no extracorporeal membrane oxygenation requirement within 72 hours of transplantation, (3) index length of stay <21 days, (4) no acute rejection or primary graft dysfunction, (5) no readmission for rejection or infection, or re-transplantation within one year, and (6) an ejection fraction >50% at one year.

RESULTS

Of 26,885 heart transplantation recipients between 2011 to 2022, 9,841 (37%) achieved a textbook outcome. Following adjustment, textbook outcome patients demonstrated significantly reduced hazard of mortality at 5- (hazard ratio 0.71, 95% CI 0.65-0.78; P < .001) and 10-years (hazard ratio 0.73, CI 0.68-0.79; P < .001), and significantly greater likelihood of graft survival at 5- (hazard ratio 0.69, CI 0.63-0.75; P < .001) and 10-years (hazard ratio 0.72, CI 0.67-0.77; P < .001). Following estimation of random effects, hospital-specific, risk-adjusted rates of textbook outcome ranged from 39% to 91%, compared to a range of 97% to 99% for one-year patient survival. Multi-level modeling of post-transplantation rates of textbook outcomes revealed that 9% of the variation between transplant programs was attributable to inter-hospital differences.

CONCLUSION

Textbook outcomes offer a nuanced, composite alternative to using one-year survival when evaluating heart transplantation outcomes and comparing transplant program performance.

Cardiovascular Magnetic Resonance for Rejection Surveillance After Cardiac Transplantation

BACKGROUND

Endomyocardial biopsy (EMB) is the gold standard method for surveillance of acute cardiac allograft rejection (ACAR) despite its invasive nature. Cardiovascular magnetic resonance (CMR)-based myocardial tissue characterization allows detection of myocarditis. The feasibility of CMR-based surveillance for ACAR-induced myocarditis in the first year after heart transplantation is currently undescribed.

METHODS

CMR-based multiparametric mapping was initially assessed in a prospective cross-sectional fashion to establish agreement between CMR- and EMB-based ACAR and to determine CMR cutoff values between rejection grades. A prospective randomized noninferiority pilot study was then undertaken in adult orthotopic heart transplant recipients who were randomized at 4 weeks after orthotopic heart transplantation to either CMR- or EMB-based rejection surveillance. Clinical end points were assessed at 52 weeks.

RESULTS

Four hundred one CMR studies and 354 EMB procedures were performed in 106 participants. Forty heart transplant recipients were randomized. CMR-based multiparametric assessment was highly reproducible and reliable at detecting ACAR (area under the curve, 0.92; sensitivity, 93%; specificity, 92%; negative predictive value, 99%) with greater specificity and negative predictive value than either T1 or T2 parametric CMR mapping alone. High-grade rejection occurred in similar numbers of patients in each randomized group (CMR, n=7; EMB, n=8; P=0.74). Despite similarities in immunosuppression requirements, kidney function, and mortality between groups, the rates of hospitalization (9 of 20 [45%] versus 18 of 20 [90%]; odds ratio, 0.091; P=0.006) and infection (7 of 20 [35%] versus 14 of 20 [70%]; odds ratio, 0.192; P=0,019) were lower in the CMR group. On 15 occasions (6%), patients who were randomized to the CMR arm underwent EMB for clarification or logistic reasons, representing a 94% reduction in the requirement for EMB-based surveillance.

CONCLUSIONS

A noninvasive CMR-based surveillance strategy for ACAR in the first year after orthotopic heart transplantation is feasible compared with EMB-based surveillance.

REGISTRATION

HREC/13/SVH/66 and HREC/17/SVH/80.

AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY

ACTRN12618000672257.

Pre-transplant Type 2 Diabetes Mellitus Is Associated With Higher Graft Failure and Increased 5-Year Mortality After Heart Transplantation

Aims

Cardiac transplant recipients often suffer from type 2 diabetes mellitus (T2DM) but its influence on graft failure and post-transplant mortality remains unknown. The aim of this study was to investigate the long-term effects of pre-transplant T2DM in patients after heart transplantation (HTX).

Methods

This study included a total of 376 adult patients who received HTX at Heidelberg Heart Center between 01/01/2000 and 01/10/2016. HTX recipients were stratified by diagnosis of T2DM at the time of HTX. Patients with T2DM were further subdivided by hemoglobin A1c (HbA1c ≥ 7.0%). Analysis included donor and recipient data, immunosuppressive drugs, concomitant medications, post-transplant mortality, and causes of death. Five-year post-transplant mortality was further assessed by multivariate analysis (Cox regression) and Kaplan–Meier estimator.

Results

About one-third of all HTX recipients had T2DM (121 of 376 [32.2%]). Patients with T2DM showed an increased 5-year post-transplant mortality (41.3% versus 29.8%; P = 0.027) and had a higher percentage of death due to graft failure (14.9% versus 7.8%; P = 0.035). Multivariate analysis showed T2DM (HR: 1.563; 95% CI: 1.053–2.319; P = 0.027) as an independent risk factor for 5-year mortality after HTX. Kaplan–Meier analysis showed a significantly better 5-year post-transplant survival of patients with T2DM and a HbA1c < 7.0% than patients with T2DM and a HbA1c ≥ 7.0% (68.7% versus 46.3%; P = 0.008) emphasizing the clinical relevance of a well-controlled T2DM in HTX recipients.

Conclusion

Pre-transplant T2DM is associated with higher graft failure and increased 5-year mortality after HTX.

Pre-transplant immune cell function assay as a predictor of early cardiac allograft rejection

INTRODUCTION

ImmuKnow, an immune cell function assay that quantifies overall immune system activity can assist in post-transplant immunosuppression adjustment. However, the utility of pre-transplant ImmuKnow results representing a patient's baseline immune system activity is unknown. This study sought to assess if pre-transplant ImmuKnow results are predictive of rejection at the time of first biopsy in our cardiac transplant population.

METHODS

This is a single center, retrospective observational study of consecutive patients from January 1, 2018 to October 1, 2020 who underwent orthotopic cardiac transplantation at NYU Langone Health. Patients were excluded if a pre-transplant ImmuKnow assay was not performed. ImmuKnow results were categorized according to clinical interpretation ranges (low, moderate, and high activity), and patients were divided into two groups: a low activity group versus a combined moderate-high activity group. Pre-transplant clinical characteristics, induction immunosuppression use, early postoperative tacrolimus levels, and first endomyocardial biopsy results were collected for all patients. Rates of clinically significant early rejection (defined as rejection ≥ 1R/1B) were compared between pre-transplant ImmuKnow groups.

RESULTS

Of 110 patients who underwent cardiac transplant, 81 had pre-transplant ImmuKnow results. The low ImmuKnow activity group was comprised of 15 patients, and 66 patients were in the combined moderate-high group. Baseline characteristics were similar between groups. Early rejection occurred in 0 (0%) patients with low pre-transplant ImmuKnow levels. Among the moderate- high pre-transplant ImmuKnow group, 16 (24.2%) patients experienced early rejection (P = .033). The mean ImmuKnow level in the non-rejection group was the 364.9 ng/ml of ATP compared to 499.3 ng/ml of ATP for those with rejection (P = .020).

CONCLUSION

Patients with low pre-transplant ImmuKnow levels had lower risk of early rejection when compared with patients with moderate or high levels. Our study suggests a possible utility in performing pre-transplant ImmuKnow to identify patients at-risk for early rejection who may benefit from intensified upfront immunosuppression as well as to recognize those where slower calcineurin inhibitor initiation may be appropriate.

Impact of diabetes mellitus on clinical outcomes after heart transplantation

PURPOSE

Diabetes mellitus (DM) is common among recipients of heart transplantation (HTx) but its impact on clinical outcomes is unclear. We evaluated the associations between pretransplant DM and posttransplant DM (PTDM) and outcomes among adults receiving HTx at a single center.

METHODS

We performed a retrospective study (range 01/2008 - 07/2018), n = 244. The primary outcome was survival; secondary outcomes included acute rejection, cardiac allograft vasculopathy, infection requiring hospitalization, macrovascular events, and dialysis initiation post-transplant. Comparisons were performed using Kaplan-Meier and multivariable Cox regression analyses.

RESULTS

Pretransplant DM was present in 75 (30.7%) patients and was associated with a higher risk for infection requiring hospitalization (p<0.05), but not with survival or other outcomes. Among the 144 patients without pretransplant DM surviving to one year, 29 (20.1%) were diagnosed with PTDM at the 1-year follow-up. After multivariable adjustment, PTDM diagnosis at 1-year remained associated with worse subsequent survival (hazard ratio 2.72, 95% confidence interval 1.03-7.16). Predictors of PTDM at 1-year included cytomegalovirus seropositivity and higher prednisone dose (>5mg/day) at 1-year follow-up.

CONCLUSIONS

Compared to HTx recipients without baseline DM, those with baseline DM have a higher risk for infections requiring hospitalization, and those who develop DM after HTx have worse survival. This article is protected by copyright. All rights reserved.

Validation of the usefulness of 2-dimensional strain parameters to exclude acute rejection after heart transplantation: a multicenter study

INTRODUCTION AND OBJECTIVES

Two-dimensional speckle-tracking echocardiography has emerged as a promising alternative to endomyocardial biopsy to rule out acute cellular rejection after orthotopic heart transplantation (OHT) in single center studies. In an original cohort, 15.5% and 17% of cutoff points for left ventricular global longitudinal strain (LVGLS) and free-wall right ventricular longitudinal strain, respectively, achieved 100% negative predictive value to exclude moderate or severe acute cellular rejection (ACR ≥ 2R). Our objective was to demonstrate the usefulness of speckle-tracking and validate these cutoff points in an external cohort.

METHODS

A prospective, multicenter study that included patients who were monitored during their first year after OHT was conducted. Echocardiographic studies analyzed by local investigators were compared with simultaneous paired endomyocardial biopsies samples.

RESULTS

A total of 501 endomyocardial biopsy-echocardiographic studies were included in 99 patients. ACR≥2R was present in 7.4% of samples. LVGLS and free-wall right ventricular longitudinal strain were significantly reduced during ACR≥2R on univariate analysis. On multivariate analysis, LVGLS was independently associated with the presence of ACR≥2R. The original cutoff points demonstrated a negative predictive value of 94.3% to exclude ACR≥2R.

CONCLUSIONS

This study maintained a strong negative predictive value to exclude ACR≥2R after OHT and LVGLS was independently associated with the presence of ACR≥2R. We propose the use of speckle-tracking, especially LVGLS, as part of the noninvasive diagnosis and management of ACR.

Sex-mismatch influence on survival after heart transplantation: A systematic review and meta-analysis of observational studies

INTRODUCTION AND OBJECTIVES

Heart transplantation (HT) is the treatment for patients with end-stage heart disease. Despite contradictory reports, survival seems to be worse when donor/recipient sex is mismatched. This systematic review and meta-analysis aims to synthesize the evidence on the effect of donor/recipient sex mismatch after HT.

METHODS

We searched PubMed and EMBASE until November 2017. Comparative cohort and registry studies were included. Published articles were systematically selected and, when possible, pooled in a meta-analysis. The primary endpoint was one-year mortality.

RESULTS

After retrieving 556 articles, ten studies (76 175 patients) were included in the quantitative meta-analysis. Significant differences were found in one-year survival between sex-matched and mismatched recipients (odds ratio (OR) 1.30, 95% confidence interval (CI) 1.25-1.35, P < .001). In female recipients, we found that sex mismatch was not a risk factor for one-year mortality (OR = 0.93, 95% CI = 0.85-1.00, P = .06). However, in male recipients, we found that it was a risk factor for one-year mortality (OR = 1.38, 95% CI = 1.31-1.44, P < .001).

CONCLUSIONS

Sex mismatch increases one-year mortality after HT in male recipients. Its influence in long-term survival should be further explored with high-quality studies.

Hyperlipidemia and Allograft Rejection

Purpose of review

Advances in the development of immunosuppressive drug regimens have led to impressive survival rates in the year following organ transplantation. However rates of long-term graft dysfunction remain undesirably high. Recently it has been shown that co-morbidities in the patient population may affect graft survival. In mouse models, hyperlipidemia, a co-morbidity present in the majority of cardiac transplant patients, can significantly alter T cell responses to cardiac and skin allografts, and accelerate graft rejection. Here we review recent advances in our understanding of how alterations in lipids affect immune function and graft survival.

Recent Findings

Recent work in humans has highlighted the importance of controlling low density lipoprotein (LDL) levels in transplant recipients to reduce the development of chronic allograft vasculopathy (CAV). High serum levels of cholesterol containing particles leads to extensive immune system changes to T cell proliferation, differentiation and suppression. Changes in B cell subsets, and the ability of antigen presenting cells to stimulate T cells in hyperlipidemic animals may also contribute to increased organ allograft rejection.

Summary

Cholesterol metabolism is a critical cellular pathway for proper control of immune cell homeostasis and activation. Increasing evidence in both human, and in mouse models shows that elevated levels of serum cholesterol can have profound impact on the immune system. Hyperlipidemia has been shown to increase T cell activation, alter the development of T helper subsets, increase the inflammatory capacity of antigen presenting cells (APC) and significantly accelerate graft rejection in several models.

Impact of hyperlipidemia on alloimmunity

PURPOSE OF REVIEW

Hyperlipidemia is a comorbidity affecting a significant number of transplant patients despite treatment with cholesterol lowering drugs. Recently, it has been shown that hyperlipidemia can significantly alter T-cell responses to cardiac allografts in mice, and graft rejection is accelerated in dyslipidemic mice. Here, we review recent advances in our understanding of hyperlipidemia in graft rejection.

RECENT FINDINGS

Hyperlipidemic mice have significant increases in serum levels of proinflammatory cytokines, and neutralization of interleukin 17 (IL-17) slows graft rejection, suggesting that IL-17 production by Th17 cells was necessary but not sufficient for rejection. Hyperlipidemia also causes an increase in alloreactive T-cell responses prior to antigen exposure. Analysis of peripheral tolerance mechanisms indicated that this was at least in part due to alterations in FoxP3 T cells that led to reduced Treg function and the expansion of FoxP3 CD4 T cells expressing low levels of CD25. Functionally, alterations in Treg function prevented the ability to induce operational tolerance to fully allogeneic heart transplants through costimulatory-molecule blockade, a strategy that requires Tregs.

SUMMARY

These findings highlight the importance of considering the contribution of inflammatory comorbidities to cardiac allograft rejection, and point to the potential importance of managing hyperlipidemia in the transplant population.

Comparison of posttransplant outcomes in patients with no, acute, or chronic amiodarone use before heart transplantation

Background

Major concerns about the safety of pretransplant amiodarone use have been raised. As a result of its long half-life, the cardiac allograft is exposed to amiodarone posing potential risks such as bradycardia, requirement for pacemaker implantation, or increased mortality after heart transplantation (HTX).

Objective

The aim of this study is to investigate the posttransplant outcomes of patients with no, acute, or chronic amiodarone use before HTX.

Methods

This retrospective single-center study included 530 adult patients who received HTX between 06/1989 and 12/2012. Patients were stratified by their amiodarone therapy before HTX: no continuous amiodarone use (≤90 days before HTX), acute amiodarone use (≤90 days before HTX), and chronic amiodarone use (>90 days before HTX). Differences between the 3 groups in demographics, posttransplant medication, echocardiographic features, heart rates including occurrences of bradycardia, permanent pacemaker implantation, atrial fibrillation (AF), and survival were analyzed.

Results

A total of 412 patients (77.7%) were in the “no amiodarone” group, 23 patients (4.4%) in the “acute amiodarone” group, and 95 patients (17.9%) in the “chronic amiodarone” group. Left ventricular ejection fraction (P=0.5819), heart rates including occurrence of bradycardia during posttransplant week 1 (P=0.0979 and P=0.2695), week 2 (P=0.1214 and P=0.8644), week 3 (P=0.1033 and P=0.8894), and week 4 (P=0.2892 and P=0.8644), permanent pacemaker implantation within 30-day (P=0.8644), or overall follow-up after HTX (P=0.8664) were not significant between groups. Patients with chronic pretransplant amiodarone therapy had the lowest rate of early posttransplant AF (P=0.0065). There was no statistically significant difference between groups in 30-day (P=0.8656), 1-year (P=1.0000), 2-year (P=0.8763), 5-year (P=0.5174), or overall posttransplant follow-up mortality (P=0.1936).

Conclusion

Administration of acute or chronic pretransplant amiodarone was not related to an increased occurrence of bradycardia, requirement for permanent pacemaker implantation, or mortality after HTX. Importantly, chronic amiodarone use effectively reduced early AF after HTX, whereas acute amiodarone use showed no such effect.

Mortality, rehospitalization, and post-transplant complications in gender-mismatched heart transplant recipients

BACKGROUND

Limited research has been published on outcomes in heart transplant (HT) recipients with gender-mismatched donors.

OBJECTIVE

Compare 3-year post-transplant outcomes in 2 groups of gender-mismatched HT recipients and a no-mismatch group.

METHODS

Sample: 347 HT recipients: 21.3% (74) received a heart from the opposite gender: Group 1: same gender donor/recipient (273, 78.7%); Group 2: female donor/male recipient (40, 11.5%); Group 3: male donor/female recipient (34, 9.8%).

OUTCOMES

mortality, hospitalization, and complications.

RESULTS

Female patients with male heart donors had shorter 3-year survival, were rehospitalized more days after HT discharge, and had more treated acute rejection episodes and cardiac allograft vasculopathy. No differences were found in: HT length of stay, respiratory failure, stroke, cancer, renal dysfunction, steroid-induced diabetes, number of IV-treated infections, or the timing of infection and rejection.

CONCLUSION

Female HT recipients with male donors had worse 3-year outcomes as compared to male-mismatch and no-mismatch groups.

Impact of environmental factors on alloimmunity and transplant fate

Although gene-environment interactions have been investigated for many years to understand people's susceptibility to autoimmune diseases or cancer, a role for environmental factors in modulating alloimmune responses and transplant outcomes is only now beginning to emerge. New data suggest that diet, hyperlipidemia, pollutants, commensal microbes, and pathogenic infections can all affect T cell activation, differentiation, and the kinetics of graft rejection. These observations reveal opportunities for novel therapeutic interventions to improve graft outcomes as well as for noninvasive biomarker discovery to predict or diagnose graft deterioration before it becomes irreversible. In this Review, we will focus on the impact of these environmental factors on immune function and, when known, on alloimmune function, as well as on transplant fate.

Cost-Effectiveness of Routine Surveillance Endomyocardial Biopsy After 12 Months Post–Heart Transplantation

Background—

Despite low risk of late rejection after heart transplant (HT), surveillance endomyocardial biopsies (EMBs) are often continued for years. We assessed the cost-effectiveness of routine EMB after 12 months post-HT.

Methods and Results—

Markov model compared the following surveillance EMB strategies to baseline strategy of stopping EMB 12 months post-HT: (1) every 4 months during year 2 post-HT, (2) every 6 months during year 2, (3) every 4 months for years 2 to 3, and (4) every 6 months for years 2 to 3. Patients entered the model 12 months post-HT and were followed until 36 months. In all strategies, patients had EMB with symptoms; in biopsy strategies after 12 months, EMB was also performed as scheduled regardless of symptoms. One-way and Monte Carlo sensitivity analyses were performed. Stopping EMB at 12 months was dominant (more effective, less costly), saving $2884 per patient compared with the next best strategy (every 6 months for year 2) and gaining 0.0011 quality-adjusted life-years. Increasing the annual risk of asymptomatic rejection in years 2 to 3 from previously reported 2.5% to 8.5% resulted in the biopsy every 6 months for year 2 strategy gaining 0.0006 quality-adjusted life-years, but cost $4 913 599 per quality-adjusted life-year gained. EMB for 12 months was also no longer dominant when mortality risk from untreated asymptomatic rejection approached 11%; competing strategies still cost >$200 000 per quality-adjusted life-year as that risk approached 99%.

Conclusions—

Surveillance EMB for 12 months post-HT is more effective and less costly than EMB performed after 12 months, unless risks of asymptomatic cellular rejection and its mortality are strikingly higher than previously observed.

The effects of levosimendan on renal function early after heart transplantation: results from a pilot randomized trial

BACKGROUND

We evaluated the effects of a levosimendan (LS)-based strategy compared with standard inotropic therapy on renal function in heart transplantation.

METHODS AND RESULTS

Using a randomized study design, 94 patients were assigned to LS-based therapy or standard inotropic support. At the time of transplantation, the groups did not differ in age, gender, heart failure etiology, hemodynamic profile, LVEF, or comorbidities. While there were no differences in serum creatinine (sCr) or eGFR between groups at baseline, patients in the LS group had a greater increase in their relative eGFR (62% vs. 12%, p = 0.002) and a lower incidence of acute kidney injury (AKI) (28% vs. 6%, p = 0.01) during the first post-transplant week. On logistic regression analysis, correlates of AKI were randomization to LS therapy (OR = 0.21 [0.09-0.62], p = 0.01), baseline renal dysfunction (OR = 3.9 [1.1-13.6], p = 0.032), and diabetes mellitus (OR = 4.2 [1.1-16.5], p = 0.038). However, LS was associated with a greater need for additional norepinephrine therapy (40 [85%] vs. 15 [31%], p < 0.001) and a trend toward longer intensive care unit stay (9.5 ± 9.0 d vs. 7.0 ± 6.0 d, p = 0.13).

CONCLUSIONS

In patients undergoing heart transplantation, levosimendan-based strategy may be associated with better renal function when compared to standard therapy.

Cardiac transplantation in African Americans: a single-center experience

BACKGROUND

In view of limited data on the subject of graft and patient survival differences between African American (AA) and non-AA heart transplant recipients, we reviewed our experience.

HYPOTHESIS

There is a higher mortality among AA recipients compared with non-AA recipients after cardiac transplantation.

METHODS

The study included all AA patients who have received a heart transplant in our center since 1983. Stepwise Cox regression was used for covariates affecting the survival. The χ(2) test was employed to identify the effects of a mechanical assist device and pretransplant creatinine (Cr) on the outcomes in AA and non-AA patients. Kaplan-Meier curves were used to examine survival.

RESULTS

The average survival among AA recipients was 5.4 years, compared with 12 years for the non-AA recipients, with 1-, 5-, and 10-year survival rates of 80%, 55%, and 25%, respectively. This was found to be statistically inferior to the survival probabilities of 92%, 78%, and 58% for the non-AA group (P < 0.005). Based on stepwise Cox regression, the variables such as ethnicity (P < 0.05), pretransplant Cr (P < 0.05), presence of a mechanical assist device (P < 0.005), and United Network for Organ Sharing (UNOS) status at transplant (P < 0.05) independently predicted the outcomes. Kaplan-Meier analysis of pretransplant Cr level and survival showed that the AA group did significantly worse for all Cr classes.

CONCLUSIONS

There is a statistically significant difference in outcomes between AA and non-AA patients after cardiac transplantation. African American patients have decreased survival over a period of time. Pretransplant Cr, ethnicity, presence of a mechanical assist device, and UNOS status at transplantation are independent predictors of outcomes.

Characteristics of patients with survival longer than 20 years following heart transplantation

INTRODUCTION AND OBJECTIVES

The number of heart-transplant recipients exceeding 20 years of follow-up is steadily increasing. However, little is known about their functional status, comorbidities, and mortality. Identifying the predictors of prolonged survival could guide the selection of candidates for the low number of available donors.

METHODS

Functional status, morbidities, and mortality of heart-transplant patients between 1984 and 1992 were analyzed. To identify predictors of 20-year survival, a logistic regression model was constructed using the covariates associated with survival in the univariate analysis.

RESULTS

A total of 39 patients who survived 20 years (26% of patients transplanted before 1992) were compared to 90 recipients from the same period who died between 1 and 20 years post-transplantation. Major complications were hypertension, renal dysfunction, infections, and cancer. After a mean follow-up of 30 months, 6 survivors had died, yielding a mortality rate of 6% per year (vs 2.5%-3% in years 1-19). Causes of mortality were infection (50%), malignancy (33%), and allograft vasculopathy (17%). Long-term survivors were younger and leaner, and had nonischemic cardiomyopathy and lower ischemic time. Logistic regression identified recipient age <45 years (odds ratio=3.9; 95% confidence interval, 1.6-9.7; P=.002) and idiopathic cardiomyopathy (odds ratio=3; 95% confidence interval, 1.4-7.8; P=.012) as independent predictors for 20-year survival.

CONCLUSIONS

One fourth of all heart-transplant patients in our series survived >20 years with the same graft, and most enjoy independent lives despite significant comorbidities. Recipient age <45 years and idiopathic cardiomyopathy were associated with survival beyond 2 decades. These data may help decide donor allocation.

First-year clinical outcomes in gender-mismatched heart transplant recipients

BACKGROUND

Research indicates that gender mismatch of organ donor and recipient may adversely affect outcomes in heart transplant (HT) patients. However, there is a paucity of literature on gender-mismatched outcomes in patients receiving an HT, and only a few outcomes have been investigated.

OBJECTIVES

Objectives were to (1) determine if gender-mismatched HT recipients experienced decreased survival, more posttransplantation complications, and more days of hospitalization during the first postoperative year as compared with gender-matched recipients and (2) identify risk factors for decreased survival.

METHODS

Patients were 347 HT recipients; 21.3% (74) received a heart from the opposite gender. Three groups were compared: group 1: same gender donor-recipient (273 [78.7%]: 36 women, 237 men); group 2: female donor-male recipient (40 [11.5%]); group 3: male donor-female recipient (34 [9.8%]). Ten outcomes were compared with Kaplan-Meier survival analysis, logistic regression, and multivariate analysis of covariance, using a Bonferroni-adjusted P ≤ .005. Risk factors for decreased survival were examined with Cox regression.

RESULTS

Gender-mismatched HT patients with a male donor and a female recipient (group 3) had more treated acute rejections and were rehospitalized for more days after HT discharge during the first postoperative year as compared with gender-matched patients. No significant differences were found in 8 other first-year outcomes: number of deaths, survival time, hospital length of stay for HT surgery, cardiac allograft vasculopathy, severe renal dysfunction, new-onset steroid-induced diabetes, nonskin cancers, or the number of infections treated with an intravenous antibiotic. Risk factors for decreased year 1 survival were higher year 1 cholesterol, earlier intravenous-treated infection, severe renal dysfunction, earlier treated rejection, and diabetes (both preexisting and new-onset steroid-induced diabetes).

CONCLUSION

Gender-mismatched HT recipients had more complications due to rejection and higher resource utilization due to more rehospitalization during the first postoperative year as compared with gender-matched recipients. Therefore, these problem areas may provide targets for possible interventions.

Persistent racial disparities in survival after heart transplantation

BACKGROUND

Racial and ethnic disparities are well documented in many areas of health care, but have not been comprehensively evaluated among recipients of heart transplants.

METHODS AND RESULTS

We performed a retrospective cohort study of 39075 adult primary heart transplant recipients from 1987 to 2009 using national data from the United Network of Organ Sharing and compared mortality for nonwhite and white patients using the Cox proportional hazards model. During the study period, 8082 nonwhite and 30 993 white patients underwent heart transplantation. Nonwhite heart transplant recipients increased over time, comprising nearly 30% of transplantations since 2005. Nonwhite recipients had a higher clinical risk profile than white recipients at the time of transplantation, but had significantly higher posttransplantation mortality even after adjustment for baseline risk. Among the nonwhite group, only black recipients had an increased risk of death compared with white recipients after multivariable adjustment for recipient, transplant, and socioeconomic factors (hazard ratio, 1.34; 95% confidence interval, 1.21 to 1.47; P<0.001). Five-year mortality was 35.7% (95% confidence interval, 35.2 to 38.3) among black and 26.5% (95% confidence interval, 26.0 to 27.0) among white recipients. Black patients were more likely to die of graft failure or a cardiovascular cause than white patients, but less likely to die of infection or malignancy. Although mortality decreased over time for all transplant recipients, the disparity in mortality between blacks and whites remained essentially unchanged.

CONCLUSIONS

Black heart transplant recipients have had persistently higher mortality than whites recipients over the past 2 decades, perhaps because of a higher rate of graft failure.

Impact of diabetes mellitus on survival rates after heart transplantation

AIMS

Heart transplantation (HTx) is the most effective therapy in patients with end-stage heart failure. Diabetes-related complications are relative contraindications for heart transplantation. The aim of our study was to analyse the impact of DM (diabetes mellitus) at the time of heart transplantation and new-onset post-transplantation DM on long-term survival.

METHODS

A retrospective database analysis was performed on all patients who had undergone HTx at our institution between 4/1997 and 9/2007. Patients were divided into three groups: Group A--patients without DM; Group B--patients with new onset of DM after HTx; Group C--patients with DM prior to HTx.

RESULTS

Patients with DM before the surgery were more obese, their BMI was 27.7 +/- 2.90, compared to groups A and B with BMI of 24.7 +/- 3.37 and 25.3 +/- 3.64 respectively (p = 0.0003). Patients in group B had statistically significantly higher risk of developing acute rejection (G 1B and more according to International Society of Heart and Lung Transplantation--ISHLT--classification) (p = 0.0350). The incidence of infections between individual groups showed no statistically significant differences (p = 0.5839). Five-year survival in group A was 82%, 10-year survival was 73%. Corresponding numbers for group B were 86% and 78%, for group C 86% and 83%. Differences between groups were not statistically significant (p = 0.2560).

CONCLUSIONS

DM in patients after heart transplantation in our study had no effect on long-term survival of patients. Post-transplantation DM increases risk of acute rejections. Pre-transplantation DM was associated with excessive bodyweight or obesity.

Gene-expression profiling for rejection surveillance after cardiac transplantation

BACKGROUND

Endomyocardial biopsy is the standard method of monitoring for rejection in recipients of a cardiac transplant. However, this procedure is uncomfortable, and there are risks associated with it. Gene-expression profiling of peripheral-blood specimens has been shown to correlate with the results of an endomyocardial biopsy.

METHODS

We randomly assigned 602 patients who had undergone cardiac transplantation 6 months to 5 years previously to be monitored for rejection with the use of gene-expression profiling or with the use of routine endomyocardial biopsies, in addition to clinical and echocardiographic assessment of graft function. We performed a noninferiority comparison of the two approaches with respect to the composite primary outcome of rejection with hemodynamic compromise, graft dysfunction due to other causes, death, or retransplantation.

RESULTS

During a median follow-up period of 19 months, patients who were monitored with gene-expression profiling and those who underwent routine biopsies had similar 2-year cumulative rates of the composite primary outcome (14.5% and 15.3%, respectively; hazard ratio with gene-expression profiling, 1.04; 95% confidence interval, 0.67 to 1.68). The 2-year rates of death from any cause were also similar in the two groups (6.3% and 5.5%, respectively; P=0.82). Patients who were monitored with the use of gene-expression profiling underwent fewer biopsies per person-year of follow-up than did patients who were monitored with the use of endomyocardial biopsies (0.5 vs. 3.0, P<0.001).

CONCLUSIONS

Among selected patients who had received a cardiac transplant more than 6 months previously and who were at a low risk for rejection, a strategy of monitoring for rejection that involved gene-expression profiling, as compared with routine biopsies, was not associated with an increased risk of serious adverse outcomes and resulted in the performance of significantly fewer biopsies. (ClinicalTrials.gov number, NCT00351559.)

Apollon/RNF41 myocardial messenger RNA diagnoses cardiac allograft apoptosis in rejection

BACKGROUND

Endomyocardial biopsy (EMB) remains the gold standard for acute cellular rejection (ACR) diagnosis in cardiac transplantation yet is subject to interobserver variability. A method that could avoid discordant EMB analysis would be desirable. The apoptosis rate in EMB correlates with ACR severity. Apollon inhibits apoptosis, and RNF41 catalyzes its degradation. Whether tissue Apollon/RNF41 could diagnose ACR is not known. This study addressed this issue.

METHODS

Apollon/RNF41 messenger RNA (mRNA) was measured by real time reverse-transcriptase polymerase chain reaction and apoptosis was quantified with TUNEL assays in EMBs of 268 transplant recipients. EMBs were obtained at 1, 2, 3, 4, 7, 12, 24, and 52 posttransplant weeks.

RESULTS

At all time points posttransplant, Apollon mRNA decreased significantly in EMBs with ACR grades 2R/3R combined (P<or=0.0010) compared with 0/1R combined, although RNF41 mRNA significantly increased in EMBs with ACR grade 1R (P<0.0001) or 2R/3R combined (P<0.0001) compared with 0. At the identified cut-off level of less than or equal to 168.2 arbitrary units, Apollon mRNA identified ACR grades 2R/3R with 100% sensitivity and 84% specificity, whereas RNF41 mRNA at the cut-off level of more than or equal to 51.8 identified ACR grades 1R-3R with 99% sensitivity and 95% specificity. Increased RNF41 (rs, 0.728; P<0.0001) and decreased Apollon (rs, -0.562; P<0.0001) expression correlated significantly with the degree of apoptosis in EMBs.

CONCLUSIONS

Combined Apollon/RNF41 mRNA quantitatively and specifically identifies ACR associated with apoptosis in cardiac allografts and could validate ACR grading variability associated with histologic EMB analysis.

Incidence and importance of de novo diabetes mellitus after heart transplantation

INTRODUCTION

Diabetes mellitus is one of the main metabolic complications after heart transplantation. The aims of our study were to determine the incidence and factors that determine the appearance of posttransplantation diabetes mellitus (PTDM) and its prognostic value.

MATERIALS AND METHODS

We performed a retrospective study of all heart transplant recipients in our hospital from January 1993 to December 2005, including 116 patients with prolonged monitoring with 59-month median follow-up. We divided the patients into two groups, according to whether they had de novo diabetes (group 1) or no diabetes (group 2).

RESULTS

Patients with PTDM were significantly older, with a median difference (MD) of 5.4 years (95% confidence interval [CI], 1.53-9.28) and a greater body mass index (MD, 3.37 kg/m(2); 95% CI, 1.68-5.06). Moreover, a greater percentage of patients in group 1 had ischemia compared to other etiologies. However, no significant differences were observed regarding other cardiovascular risk factors. PTDM was associated with a greater incidence of posttransplant hypertension (51.6% in group 1 vs 48.4% in group 2, P = .08) and posttransplant renal failure (59.5% in group 1 vs 40.5% in group 2, P = .001). However, no differences were observed in overall survival.

CONCLUSIONS

Age, overweight, and ischemic origin of cardiopathy were the main risk factors for the development of PTDM in our population. Although no differences were observed in survival rates, PTDM was associated with a greater incidence of hypertension and renal insufficiency, which may have long-term influences on patient survival.

Predictors of rehospitalization time during the first year after heart transplant

BACKGROUND

Patient problems after heart transplant (HT) can lead to rehospitalization.

OBJECTIVE

To examine rehospitalization patterns and identify predictors of the number of days rehospitalized at the transplant site during the first year after HT surgery.

METHODS

Hierarchical regression identified predictors of greater rehospitalization time from chart data collected from two transplant sites during the first posttransplant year on 269 adult HT recipients. Variables (total = 32) were entered in six steps: clinical site, demographics, perioperative variables, cardiac function, immunosuppressant dosages, and post-HT complications.

RESULTS

The number of days rehospitalized at the transplant site during the first year after HT ranged from 0 to 142 (mean = 25, median = 16); 64% were rehospitalized; 37% were rehospitalized more than once. Main reasons were rejections, infections, cardiovascular problems, and gastrointestinal (GI) problems. The regression model explained 48.7% of the variance in rehospitalization time, with post-HT complications explaining the most variance. Ten predictors were significant: intravenously treated infections, treated acute rejections, shorter stay for HT surgery, GI complications, higher prednisone dose, female gender, coma, sex mismatch between donor and recipient, renal complications, and clinical site.

CONCLUSION

Sixty-four percent of the patients were rehospitalized at the transplant site during the first year after HT surgery (with a median of 16 hospital days); 37% were rehospitalized more than once. Significant predictors of the amount of time rehospitalized pertained to five types of complications (rejections, infections, GI, renal, coma), shorter HT surgical stay, female gender, higher prednisone dose, sex-mismatched donor, and clinical site. The study identifies who uses the most hospital resources during the first year after HT.

Donor-recipient race mismatch and graft survival after pediatric heart transplantation

BACKGROUND

Black recipient race has been shown to predict poorer graft survival after pediatric heart transplantation. We analyzed our single-center experience comparing graft survival by race and the impact of donor-recipient race mismatch.

METHODS

One hundred sixty-nine consecutive primary pediatric heart transplant patients were analyzed by donor and recipient race (white recipient, 99; black recipient, 60; other, 10). The groups were similar in preoperative characteristics. There were fewer donor-recipient race matches in blacks compared with whites (10 versus 71; p < 0.0001).

RESULTS

Although 30-day and 6-month graft survival was similar for black and white recipients (93.9% and 85.8% versus 93.3% and 83.3%, respectively), overall actuarial graft survival was significantly lower in blacks (p < 0.019). Blacks tended to have a higher incidence of positive retrospective crossmatch (n = 26, 43%) than whites (n = 29, 29%), but this was not statistically significant (p = 0.053). The median graft survival for black recipients was 5.5 years compared with 11.6 years for whites. Donor-recipient race mismatch predicted poorer graft survival (5-year graft survival 48.9% versus 72.3%; p = 0.0032). The median graft survival for donor-recipient race-matched patients was more than twice that for mismatched patients (11.6 years versus 4.4 years). Cox proportional hazard analysis showed that donor-recipient race mismatch neutralized the effect of race on graft survival.

CONCLUSIONS

Graft survival after pediatric heart transplantation is inferior for black recipients compared with white recipients. These differences may be explained by a high incidence of donor-recipient race mismatch, which also predicts poorer outcome for all racial groups with pediatric heart transplantation. These data may have implications for future donor allocation schemes.

Influence of donor cocaine use on outcome after cardiac transplantation: analysis of the United Network for Organ Sharing Thoracic Registry

Heart transplantation from donors with a history of cocaine abuse remains controversial. Therefore, we examined the consequence of donor cocaine-use history on all-cause mortality and the development of coronary artery disease after heart transplantation. Using the United Network for Organ Sharing Thoracic Registry we identified 9,217 first-time heart-only adult transplant recipients between January 1999 and December 2003, and then divided this cohort into sub-groups based on the reported history of donor cocaine use. Multivariate analysis revealed no difference in mortality or development of coronary artery disease at 1 and 5 years between transplant recipients who received an organ from donors with a history of cocaine use when compared with donors having no history of cocaine use.

Ethnicity as a predictor of graft longevity and recipient mortality in heart transplantation

BACKGROUND

There is a dearth of data about the effect of donor and recipient ethnicity on survival and rejection rate after clinical heart transplantation, although the subject had been partly studied before. We compared the mortality and rejection rate among different ethnic groups at our institution.

METHODS

In retrospect, 525 consecutive donors provided cardiac allografts to adult and pediatric patients undergoing orthotropic heart transplantation at a single, urban US medical center between 2000 and 2005. Donors and recipients were categorized according to ethnicity: African American, Asian, Caucasian, Hispanic, and Others (Indian, Mediterranean/Arabic, Afghans). Donor and recipient ethnicity-as an independent factor and the interaction between them-were examined as a risk factor for mortality and rejection after heart transplantation. Mean follow-up period was 3.2+/-1.9 years (range, 0.1 to 6.6). All recipients received triple immunosuppression consisting of a calcineurin inhibitor, an antiproliferative agent, and steroids. No patients received induction immunotherapy. The end points of the study were early and late mortality, rejection rate, and rejection-free survival time.

RESULTS

The overall mortality was 17.3% (91 patients). Recipient mortality rate according to donor race was: African American, 23.1%; Asian, 11.1%; Caucasian, 18.7%; and Hispanic, 14.6%. No statistical significance was found, although the mortality differences presented. Recipient mortality with regard to recipients ethnicity was: African American, 22.2%; Asian, 6.3%; Caucasian, 18%; Hispanic, 18.9%; and others 40% (P=.048). Donor-recipient race match was not found as a risk factor influencing mortality as the matched group mortality was 17.5% comparing with the mismatched group mortality of 17.8% (P=.874). The overall rejection rate was 3.8% (20 rejection events). Rejection rate according donor race was: African American, 7.7%; Asian, 10.7%; Caucasian, 4%; and Hispanic, 1.3% (P=.027). Rejection rate with respect to recipients ethnicity was: African American, 0; Asian, 3.2%; Caucasian, 4.4%; Hispanic, 2.7%; and others, 20% with no statistical significance (P=.236). Donor recipient race match was not found as a risk factor influencing rejection rate (P=.58).

CONCLUSIONS

Recipients' ethnicity was found as a significant risk factor for mortality. Rejection rate were found higher among the African American donors and significantly lower in the Hispanic donors. Significantly lower mortality rate was found among Asian recipients. Donor-recipient race match did not influence the mortality or rejection rate.

Does diabetes increase the risk for fractures after solid organ transplantation? A nested case-control study

To assess the risk of fractures after a solid organ transplantation among diabetic versus nondiabetic patients, we conducted a nested case-control study. Pretransplant diabetes was associated with a 2-fold increase in post-transplant fractures.

INTRODUCTION

Diabetes has been associated with osteoporosis in the general population. However, among patients receiving solid organ transplantation, the association between pretransplant diabetes and post-transplant fractures is not clear, although both diabetes and fractures are prevalent among this patient population. We aimed to determine whether pretransplant diabetes increases the risk of fractures among patients receiving solid organ transplantation.

MATERIALS AND METHODS

We conducted a nested case-control study in a cohort of subjects 18 years and older, enrolled in the Quebec Drug Insurance Plan, who received a first solid organ transplantation between January 1986 and December 2005. Cases had sustained a fracture between the date of discharge from the hospitalization for solid organ transplantation and the end of the study period. All remaining patients were eligible controls. The fracture date was the case index date. Cases were matched to up to four controls on the type of organ transplanted and the date of transplantation. The index date of a control patient was that of his/her matched case. Crude and adjusted ORs were obtained with univariate and multivariate conditional logistic regression models.

RESULTS

The study included 238 cases and 873 controls. Pretransplant diabetes was present in 30% of the cases and 22% of the controls (crude OR: 2.16; 95% CI: 1.7-2.8). After adjusting for age, sex, previous fractures, past hyperthyroidism, hospitalization duration, use of narcotics, benzodiazepines, antidepressants, loop diuretics, thiazide diuretics, glucocorticoids, immunosuppressants, estrogens, bisphosphonates, calcium, vitamin D, and calcitonin, pretransplantation diabetes remained a significant risk factor for fractures (adjusted OR: 1.94; 95% CI: 1.5-2.6). Use of narcotics (OR: 3.0; 95% CI: 2.0-4.4) and antidepressants (OR: 1.9; 95% CI: 1.2-3.1) in the month preceding the index date and use of loop diuretics in the year preceding the index date (OR: 1.4; 95% CI: 1.1-1.9) were also associated with increased risks of fractures.

CONCLUSIONS

Pretransplant diabetes seemed to significantly increase post-transplant fractures among adults receiving solid organ transplantation. Pretransplant fracture prophylaxis should be considered in these patients.

Molecular Testing for Long-term Rejection Surveillance in Heart Transplant Recipients: Design of the Invasive Monitoring Attenuation Through Gene Expression (IMAGE) Trial

BACKGROUND

Acute rejection continues to occur beyond the first year after cardiac transplantation, but the optimal strategy for detecting rejection during this late period is still controversial. Gene expression profiling (GEP), with its high negative predictive value for acute cellular rejection (ACR), appears to be well suited to identify low-risk patients who can be safely managed without routine invasive endomyocardial biopsy (EMB).

METHODS

The Invasive Monitoring Attenuation Through Gene Expression (IMAGE) study is a prospective, multicenter, non-blinded, randomized clinical trial designed to test the hypothesis that a primarily non-invasive rejection surveillance strategy utilizing GEP testing is not inferior to an invasive EMB-based strategy with respect to cardiac allograft dysfunction, rejection with hemodynamic compromise (HDC) and all-cause mortality.

RESULTS

A total of 199 heart transplant recipients in their second through fifth post-transplant years have been enrolled in the IMAGE study since January 13, 2005. The study is expected to continue through 2008.

CONCLUSIONS

The IMAGE study is the first randomized, controlled comparison of two rejection surveillance strategies measuring outcomes in heart transplant recipients who are beyond their first year post-transplant. The move away from routine histologic evaluation for allograft rejection represents an important paradigm shift in cardiac transplantation, and the results of this study have important implications for the future management of heart transplant patients.

[Impact of diabetes mellitus on heart transplant recipients]

INTRODUCTION AND OBJECTIVES

At present, there is some controversy about the impact of diabetes mellitus on heart transplant patients. The effect of the disease on mortality and on other complications, such as infection or rejection, is unclear. The objective of this study was to investigate these factors in our heart transplant patients.

METHODS

We studied 365 consecutive patients who underwent heart transplantation between November 1987 and May 2003. We divided them in three groups according to whether they had pretransplantation diabetes (group 1), de novo diabetes (group 2), or no diabetes (group 3). Baseline variables and the development of complications were recorded, and findings were analyzed using Student's t test, chi squared test, and Kaplan-Meier survival analysis.

RESULTS

There was no difference in the 1-year or 5-year survival rate between the groups (P=.24 and P=.32, respectively). Patients with pretransplantation and de novo diabetes were older (54.6 years vs 54.9 years vs 50.6 years, P=.04), had a higher prevalence of hypertension (48% vs 36% vs 23%, P=.001), and had more frequently been treated with tacrolimus (10% vs 12% vs 4%, P=.04) or steroids (92% vs 86% vs 70%, P=.001). The incidence of rejection during follow-up was greater in these two groups (64% vs 70% vs 45%, P=.001).

CONCLUSIONS

Neither pretransplantation diabetes nor de novo diabetes had a negative impact on survival in our heart transplant patients. The disease's presence was associated with treatment with steroids and tacrolimus. In these patients it would be preferable to individualize immunosuppressive therapy.

Multivariate Predictors of Heart Transplantation Outcomes in the Era of Chronic Mechanical Circulatory Support

BACKGROUND

Determining which pretransplantation (TX) characteristics predict the development of chronic renal dysfunction (CRD) or death after heart TX would enable more accurate risk assessment at the time of candidate evaluation.

METHODS

A cohort of 278 patients underwent TX in three hospitals between 1993 and 2002. Predictive models for CRD (serum creatinine consistently above 2 mg/dL) and allograft loss (death or re-TX) were constructed using logistic and Cox regression, respectively.

RESULTS

Using logistic regression, CRD was more likely to develop in TX patients if they had a larger body surface area (odds ratio [OR] = 5.8 per m2, 95% confidence interval [CI] = 1.04 to 31.9, p = 0.04) or were inotrope dependent (OR = 1.8, 95% CI = 0.90 to 3.7, p = 0.09). Notably, the implementation of mechanical circulatory support as bridge to transplantation decreased the risk of CRD (OR = 0.30, 95% CI = 0.12 to 0.72, p = 0.007). Cox analysis demonstrated independent predictive ability of improved survival for males (hazard ratio [HR] = 0.42, 95% CI = 0.21 to 0.83, p = 0.01). Worse survival was observed with prior sternotomy (HR = 3.5, 95% CI = 2.0 to 6.0, p < 0.001), diabetes mellitus (HR = 1.9, 95% CI = 0.98 to 3.9, p = 0.06), and elevated serum creatinine (HR = 2.8 per mg/dL, 95% CI = 1.3 to 5.8, p = 0.007).

CONCLUSIONS

Certain pretransplant characteristics clearly predispose a patient to the development of CRD or increased mortality after heart transplantation. Interestingly, the risk of CRD after heart transplantation is greater for patients bridged to transplant with inotropes than with mechanical circulatory support. When hemodynamically indicated, timely implementation of pretransplant mechanical circulatory support should be considered.

Adult-age donors offer acceptable long-term survival to pediatric heart transplant recipients: an analysis of the United Network of Organ Sharing database

OBJECTIVES

A critical shortage of donor organs has caused many centers to use less restrictive donor criteria, including the use of adult-age donors for pediatric recipients. The purpose of this study is (1) to describe the supply of pediatric (0-18 years) heart donors, (2) to explore the relationship between donor age and long-term survival, and (3) to define threshold age ranges associated with decreased long-term survival.

METHODS

The United Network of Organ Sharing provided deidentified patient-level data. Primary analysis focused on 1887 heart transplant recipients aged 9 to 18 years undergoing transplantation from October 1, 1987, to September 25, 2005. Kaplan-Meier analysis and log-rank tests were used in time-to-event analysis. Receiver operating characteristic curves and stratum-specific likelihood ratios were generated to compare survival at various donor age thresholds.

RESULTS

The number of pediatric donors decreased (P < .001) over the study period, particularly from 1993 (n = 640) through 2004 (n = 432). Among recipients aged 9 to 18 years, univariate analysis demonstrated a statistically significant (P < .001) inverse relationship between donor age and survival. Stratum-specific likelihood ratio analysis generated 3 strata for donor age: the low-risk, intermediate-risk, and high-risk groups consisted of donors aged 13 years or younger (n = 611, 32.41%), 14 to 51 years (n = 1258, 66.7%), and 52 years and older (n = 16, 0.85%), respectively. In the low-risk, intermediate-risk, and high-risk groups median survival was 4069 days (11.1 years), 3495 days (9.57 years), and 1197 days (3.28 years), respectively.

CONCLUSIONS

Although donors aged 13 years or less offer pediatric recipients the best chance for achieving long-term survival, donors aged 14 to 51 years offer good outcomes to pediatric recipients. Consideration should be given to expanded use of well-selected adult-age donors for pediatric recipients.

Does multiorgan donation influence survival in heart transplantation?

Current heart transplant survival in Spain at 1, 5, and 10 years is 80%, 70%, and 60%, respectively. Our objective was to establish how donor type affects survival in heart transplantation.

MATERIALS AND METHODS

This was a retrospective study of heart transplant recipients from 102 donors, divided into three types: (a) heart-liver-kidney donors (group I); (b) heart-liver-kidney-lung donors (group II); and (c) heart-liver-kidney-lung-pancreas donors (group III). We excluded retransplantations, pediatric transplantations, and cardiopulmonary transplantations. The outcome variable was the actuarial survival by type of donation. Statistical analysis was performed for event-free survival based on the Kaplan-Meier method (log-rank test).

RESULTS

Groups I, II, and III included 63, 26, and 13 donors, respectively. The survival curves showed similar values for all three groups (P > .05).

CONCLUSIONS

The different combinations of multiorgan donation do not entail a poorer prognosis in terms of cardiac transplant patient survival.

Superior prevention of acute rejection by tacrolimus vs. cyclosporine in heart transplant recipients--a large European trial

We compared efficacy and safety of tacrolimus (Tac)-based vs. cyclosporine (CyA) microemulsion-based immunosuppression in combination with azathioprine (Aza) and corticosteroids in heart transplant recipients. During antibody induction, patients were randomized (1:1) to oral treatment with Tac or CyA. Episodes of acute rejection were assessed by protocol biopsies, which underwent local and blinded central evaluation. The full analysis set comprised 157 patients per group. Patient/graft survival was 92.9% for Tac and 89.8% for CyA at 18 months. The primary end point, incidence of first biopsy proven acute rejection (BPAR) of grade >/= 1B at month 6, was 54.0% for Tac vs. 66.4% for CyA (p = 0.029) according to central assessment. Also, incidence of first BPAR of grade >/= 3A at month 6 was significantly lower for Tac vs. CyA; 28.0% vs. 42.0%, respectively (p = 0.013). Significant differences (p < 0.05) emerged between groups for these clinically relevant adverse events: new-onset diabetes mellitus (20.3% vs. 10.5%); post-transplant arterial hypertension (65.6% vs. 77.7%); and dyslipidemia (28.7% vs. 40.1%) for Tac vs. CyA, respectively. Incidence and pattern of infections over 18 months were comparable between groups, as was renal function. Primary use of Tac during antibody induction resulted in superior prevention of acute rejection without an associated increase in infections.

Clinical outcomes in patients with chronic congestive heart failure who undergo left ventricular assist device implantation

OBJECTIVE

The use of left ventricular assist devices as a bridge to transplantation for patients with chronic congestive heart failure is well accepted. However, few studies have examined outcomes solely for these patients. This study details one center's left ventricular assist device experience with this population.

METHODS

Two hundred one patients received HeartMate left ventricular assist devices (Thoratec Corp, Pleasanton, Calif) from January 1, 1996, to April 30, 2004. Of these, 119 (59.2%) had chronic congestive heart failure (diagnosis >6 months) as the primary indication. Outcome parameters included early mortality after left ventricular assist device placement (<30 days), bridge-to-transplantation rate, and posttransplantation survival. Variables examined included patient demographic data; preoperative pacemaker, internal defibrillator, and balloon pump use; and preoperative laboratory values.

RESULTS

Advanced age, female sex, and diabetes were independent predictors of early death (P = .048, odds ratio 1.879 per 10 years of age, 95% confidence interval 1.005-3.515; P = .002, odds ratio 10.029, 95% confidence interval 2.256-44.583; P = .040, odds ratio 3.974, 95% confidence interval 1.063-14.861). Advanced age, female sex, and low preoperative albumin were independent predictors of poor bridge-to-transplantation rate (P = .029, odds ratio 0.135 per 10 years of age, 95% confidence interval 0.022-0.819; P = .002, odds ratio 0.013, 95% confidence interval 0.001-0.197; P = .023, odds ratio 19.178 per 1 g/dL albumin, 95% confidence interval 1.504-244.598). There were no independent predictors of poor posttransplantation survival and prolonged intensive care unit stay. Overall bridge-to-transplantation rate was 81.5%. The 1-, 3-, 5-, and 7-year posttransplantation survivals were 88.4%, 84.5%, 78.4%, and 76.0%.

CONCLUSION

Among patients with chronic congestive heart failure, advanced age, female sex, diabetes, and low preoperative albumin predict poor clinical course. Careful risk stratification and comprehensive evaluation by care providers should be performed for candidates who are female, are elderly, and have diabetes, and preoperative nutritional optimization should be encouraged to enhance patient outcomes.