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Chen Q, Malas J, Chan J, Esmailian G, Emerson D, Megna D, Catarino P, Bowdish ME, Kittleson M, Patel J, Chikwe J, Kobashigawa J, Esmailian F. Evaluating age-based eligibility thresholds for heart re-transplantation - an analysis of the united network for organ sharing database. J Heart Lung Transplant 2023; 42:593-602. [PMID: 36535808 PMCID: PMC10121767 DOI: 10.1016/j.healun.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/20/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Risk-adjusted survival after late heart re-transplantation may be comparable to primary transplant, but the efficacy of re-transplantation in older candidates is not established. We evaluated outcomes after heart re-transplantation in recipients > 60 years. METHODS We identified 1026 adult patients undergoing isolated heart re-transplantation between 2003 and 2020 from the United Network for Organ Sharing database. Older recipients (> 60 years, n=177) were compared to younger recipients (≤ 60 years, n=849). Five and ten-year post-transplant survival was estimated using the Kalpan-Meier method and adjusted with multivariable Cox models. RESULTS Older recipients were more likely to be male and have diabetes or previous malignancies with higher baseline creatinine. They also more frequently required pre-transplant ECMO (11.9% vs. 6.8%, p=0.02) and received re-transplantation due to primary graft failure (13.6% vs. 8.5%, p=0.03). After the transplant, older recipients had a higher incidence of stroke (6.8% vs. 2.6%, p=0.01) and dialysis requirements (20.3% vs. 13.2%) before discharge (both p<0.05), and more frequently died from malignancy-related causes (16.3% vs. 3.9%, p<0.001). After adjustment, recipient age >60 was associated with an increased risk of both 5-year (HR 1.42, 95% CI 1.02-2.01, p=0.04) and 10-year mortality (HR 1.72, 95% CI 1.20-2.45, p=0.003). Restricted cubic spline showed a non-linear relationship between recipient age and 10-year mortality. CONCLUSIONS Heart re-transplantation in recipients > 60 years has inferior outcomes compared to younger recipients. Strict patient selection and close follow-up are warranted to ensure the appropriate utilization of donor hearts and to improve long-term outcomes.
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Affiliation(s)
- Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Jad Malas
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Joshua Chan
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Gabriel Esmailian
- The George Washington School of Medicine and Health Sciences, Washington, District of Columbia
| | - Dominic Emerson
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Dominick Megna
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Pedro Catarino
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Michael E Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Michelle Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Jignesh Patel
- Department of Cardiology, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Jon Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Fardad Esmailian
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California.
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Kainuma A, Ning Y, Kurlansky PA, Wang AS, Latif F, Sayer GT, Uriel N, Kaku Y, Naka Y, Takeda K. Predictors of one-year outcome after cardiac re-transplantation: Machine learning analysis. Clin Transplant 2022; 36:e14761. [PMID: 35730923 DOI: 10.1111/ctr.14761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 06/02/2022] [Accepted: 06/20/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND As cardiac re-transplantation is associated with inferior outcomes compared with primary transplantation, allocating scarce resources to appropriate re-transplant candidates is important. The aim of this study is to elucidate the factors associated with 1-year mortality in cardiac re-transplantation using the random forests algorithm for survival analysis. METHODS We retrospectively reviewed the United Network for Organ Sharing registry and identified all adult (>17 years old) recipients who underwent cardiac re-transplantation between January 2000 and March 2020. The random forest algorithm on Cox modeling was used to calculate the variable importance (VIMP) of independent variables for contributing to one-year mortality. RESULTS A total of 1294 patients underwent cardiac re-transplantation. Of these, 137 patients were re-transplanted within one year of their first transplant, while 1157 patients were re-transplanted more than one year after their first transplant. One-year mortality was significantly higher for patients receiving early transplantation compared with those receiving late transplantation (Early 40.6% vs. Late 13.6%, log-rank P<0.001). Machine learning analysis showed that total bilirubin (>2 mg/dl) (VIMP, 2.99%) was an independent predictor of one-year mortality after early re-transplant. High BMI (>30.0 kg/m2) (VIMP, 1.43%) and ventilator dependence (VIMP, 1.47%) were independent predictors of one-year mortality for the late re-transplantation group. CONCLUSION Machine learning showed that optimal one-year survival following cardiac re-transplantation was significantly related to liver function in early re-transplantation, and to obesity and preoperative ventilator dependence in late re-transplantation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Atsushi Kainuma
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Yuming Ning
- Center for Innovation and Outcomes Research, Columbia University, New York, NY, USA
| | - Paul A Kurlansky
- Center for Innovation and Outcomes Research, Columbia University, New York, NY, USA.,Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Amy S Wang
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Farhana Latif
- Department of Medicine/Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Gabriel T Sayer
- Department of Medicine/Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Nir Uriel
- Department of Medicine/Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Yuji Kaku
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA
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Salterain-González N, Rábago Juan-Aracil G, Gómez-Bueno M, Almenar-Bonet L, Crespo-Leiro MG, Arizón del Prado JM, García-Cosío MD, Martínez-Sellés M, Mirabet-Pérez S, Sobrino-Márquez JM, González-Costello J, Pérez-Villa F, Díaz-Molina B, de la Fuente-Galán L, Blasco-Peiró T, Garrido-Bravo IP, García-Guereta Silva L, Gil-Villanueva N, Gran F, González-Vilchez F. Resultados del retrasplante cardiaco: subanálisis del Registro Español de Trasplante Cardiaco. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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4
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Salterain-González N, Rábago Juan-Aracil G, Gómez-Bueno M, Almenar-Bonet L, Crespo-Leiro MG, Arizón Del Prado JM, García-Cosío MD, Martínez-Sellés M, Mirabet-Pérez S, Sobrino-Márquez JM, González-Costello J, Pérez-Villa F, Díaz-Molina B, de la Fuente-Galán L, Blasco-Peiró T, Garrido-Bravo IP, García-Guereta Silva L, Gil-Villanueva N, Gran F, González-Vilchez F. Results of heart retransplantation: subanalysis of the Spanish Heart Transplant Registry. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:60-66. [PMID: 34253459 DOI: 10.1016/j.rec.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 06/08/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION AND OBJECTIVES Heart retransplantation (ReHT) is controversial in the current era. The aim of this study was to describe and analyze the results of ReHT in Spain. METHODS We performed a retrospective cohort analysis from the Spanish Heart Transplant Registry from 1984 to 2018. Data were collected on donors, recipients, surgical procedure characteristics, immunosuppression, and survival. The main outcome was posttransplant all-cause mortality or need for ReHT. We studied differences in survival according to indication for ReHT, the time interval between transplants and era of ReHT. RESULTS A total of 7592 heart transplants (HT) and 173 (2.3%) ReHT were studied (median age, 52.0 and 55.0 years, respectively). Cardiac allograft vasculopathy was the most frequent indication for ReHT (42.2%) and 59 patients (80.8%) received ReHT >5 years after the initial transplant. Acute rejection and primary graft failure decreased as indications over the study period. Renal dysfunction, hypertension, need for mechanical ventilation or intra-aortic balloon pump and longer cold ischemia time were more frequent in ReHT. Median follow-up for ReHT was 5.8 years. ReHT had worse survival than HT (weighted HR, 1.43; 95%CI, 1.17-1.44; P<.001). The indication of acute rejection (HR, 2.49; 95%CI, 1.45-4.27; P<.001) was related to the worst outcome. ReHT beyond 5 years after initial HT portended similar results as primary HT (weighted HR, 1.14; 95%CI, 0.86-1.50; P<.001). CONCLUSIONS ReHT was associated with higher mortality than HT, especially when indicated for acute rejection. ReHT beyond 5 years had a similar prognosis to primary HT.
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Affiliation(s)
| | | | - Manuel Gómez-Bueno
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante, Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Luis Almenar-Bonet
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Unidad de Insuficiencia Cardiaca y Trasplante, Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Universitat de València, Valencia, Spain
| | - María Generosa Crespo-Leiro
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica A Coruña (INIBIC), Universidade da Coruña (UDC), A Coruña, Spain
| | | | - María Dolores García-Cosío
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Madrid, Spain; Facultad de Ciencias Biomédicas y de la Salud, Universidad Europea, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Sonia Mirabet-Pérez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Unidad de Insuficiencia Cardiaca y Programa de Trasplante Cardiaco, Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - José González-Costello
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Félix Pérez-Villa
- Unidad de Insuficiencia Cardiaca, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Beatriz Díaz-Molina
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardico, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Luis de la Fuente-Galán
- Unidad de Insuficiencia Cardiaca y Trasplante Cardiaco, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Teresa Blasco-Peiró
- Servicio de Cardiología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Iris P Garrido-Bravo
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | | | - Nuria Gil-Villanueva
- Unidad de Insuficiencia Cardiaca y Trasplante, Hospital Materno Infantil Gregorio Marañón, Madrid, Spain
| | - Ferrán Gran
- Servicio Cardiología pediátrica, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Francisco González-Vilchez
- Unidad de Insuficiencia Cardiaca y Transplante, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
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(Cardiac allograft vasculopathy nowadays). COR ET VASA 2021. [DOI: 10.33678/cor.2020.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Zhu Y, Shudo Y, Lingala B, Baiocchi M, Oyer PE, Woo YJ. Outcomes after heart retransplantation: A 50-year single-center experience. J Thorac Cardiovasc Surg 2020; 163:712-720.e6. [DOI: 10.1016/j.jtcvs.2020.06.121] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 06/10/2020] [Accepted: 06/27/2020] [Indexed: 12/15/2022]
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Sivakumar K, Alam M, Singh A, Pavithran S, Subban V, Mullasari A. Percutaneous coronary intervention for coronary allograft vasculopathy with drug-eluting stent in Indian subcontinent: Issues in diagnosis and management. Ann Pediatr Cardiol 2020; 13:234-237. [PMID: 32863660 PMCID: PMC7437615 DOI: 10.4103/apc.apc_69_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 10/24/2019] [Accepted: 03/17/2020] [Indexed: 11/04/2022] Open
Abstract
Coronary allograft vasculopathy fails to give a warning anginal pain due to denervation and often presents with acute coronary syndrome, ventricular dysfunction, or sudden cardiac death. Early diagnosis in a pediatric patient is difficult as it involves invasive coronary angiography or advanced imaging such as intravascular ultrasound or optical coherence tomography. A 12-year-old boy developed acute coronary syndrome, elevated troponins, and right bundle branch block, 5 years after cardiac transplantation and was treated with culprit-vessel angioplasty with a drug-eluting stent. Advanced imaging showed the involvement of nonculprit vessels too. In a detailed literature search, we failed to identify a similar clinical presentation and management in the subcontinent, hence our interest in publishing this report for educational value. Issues in diagnosis, management, prognosis, and prevention are discussed.
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8
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Miller RJ, Clarke BA, Howlett JG, Khush KK, Teuteberg JJ, Haddad F. Outcomes in patients undergoing cardiac retransplantation: A propensity matched cohort analysis of the UNOS Registry. J Heart Lung Transplant 2019; 38:1067-1074. [DOI: 10.1016/j.healun.2019.07.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 06/18/2019] [Accepted: 07/02/2019] [Indexed: 01/06/2023] Open
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9
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Lee MS, Tadwalkar RV, Fearon WF, Kirtane AJ, Patel AJ, Patel CB, Ali Z, Rao SV. Cardiac allograft vasculopathy: A review. Catheter Cardiovasc Interv 2018; 92:E527-E536. [DOI: 10.1002/ccd.27893] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 08/29/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Michael S. Lee
- Division of Cardiology, UCLA Medical Center Los Angeles California
| | | | - William F. Fearon
- Division of CardiologyStanford University School of Medicine Stanford California
| | - Ajay J. Kirtane
- Division of CardiologyColumbia University Medical Center New York New York
| | - Amisha J. Patel
- Division of CardiologyColumbia University Medical Center New York New York
| | - Chetan B. Patel
- Division of CardiologyDuke University Medical Center Durham North Carolina
| | - Ziad Ali
- Division of CardiologyColumbia University Medical Center New York New York
| | - Sunil V. Rao
- Division of CardiologyDuke University Medical Center Durham North Carolina
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Rizvi SSA, Luc JGY, Choi JH, Phan K, Moncho Escrivà E, Patel S, Massey HT, Tchantchaleishvili V. Outcomes and survival following heart retransplantation for cardiac allograft failure: a systematic review and meta-analysis. Ann Cardiothorac Surg 2018; 7:12-18. [PMID: 29492380 DOI: 10.21037/acs.2018.01.09] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Long-term efficacy of heart retransplantation (RTx) for end-stage cardiac allograft failure remains unclear given the limited worldwide experience and is an important question to elucidate given the shortage of donor organs. The aim of this systematic review was to examine the outcomes of RTx in patients with cardiac allograft failure. Methods Electronic search was performed to identify all studies in the English literature assessing RTx for cardiac allograft failure. All identified articles were systematically assessed for inclusion and exclusion criteria. Results Eleven studies were included for analysis, with a total of 7,791 patients. A total of 7,446 patients underwent primary heart transplantation (HTx) whereas 345 patients underwent RTx with average time from primary HTx to RTx interval of 5.03 years (95% CI: 3.13-6.94 years). There were 35.2% of patients received RTx within 30 days of primary transplant. Early mortality was significantly higher among RTx patients (RTx 28.2% vs. HTx 11.2%, P<0.001) whereas survival was significantly higher among HTx patients when compared to RTx patients at 1 year (HTx 81.8% vs. RTx 59.1%, P<0.001), 2 years (HTx 77.9% vs. RTx 53.6%, P<0.001), 3 years (HTx 76.1% vs. RTx 49.8%, P<0.001), 5 years (HTx 68.8% vs. RTx 41.4%, P<0.001) and 10 years (HTx 53.9% vs. RTx 31.7%, P<0.001). There were no significant differences between HTx and RTx in terms of freedom from rejection at 1 year (HTx 61.0% vs. RTx 53.7%, P=0.43), 2 years (HTx 63.8% vs. RTx 53.7%, P=0.26), 3 years (HTx 62.9% vs. RTx 51.9%, P=0.30) and 5 years (HTx 61.0% vs. RTx 51.9%, P=0.36). Conclusions Patients who underwent heart RTx had a significant lower survival when compared to those who only underwent primary HTx. There were no significant differences in post-transplantation freedom from rejection. Careful patient selection and perioperative care can make heart RTx a viable option for selected recipients.
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Affiliation(s)
- Syed-Saif Abbas Rizvi
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jessica G Y Luc
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jae Hwan Choi
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kevin Phan
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | | | - Sinal Patel
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - H Todd Massey
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Schachtner T, Stein M, Reinke P. Kidney transplant recipients after nonrenal solid organ transplantation show low alloreactivity but an increased risk of infection. Transpl Int 2016; 29:1296-1306. [PMID: 27638250 DOI: 10.1111/tri.12856] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 07/29/2016] [Accepted: 09/04/2016] [Indexed: 12/13/2022]
Abstract
The number of kidney transplant recipients (KTRs) after nonrenal solid organ transplantation (SOT) has increased to almost 5%. Knowledge on patient and allograft outcomes, infections, and alloreactivity, however, remains scarce. We studied 40 KTRs after nonrenal SOT. Seven hundred and twenty primary KTRs and 119 repeat KTRs were used for comparison. Samples were collected pretransplantation, at +1, +2, and +3 months post-transplantation. Alloreactive and CMV-specific T cells were measured by interferon-γ ELISPOT assay. Patient survival in KTRs after SOT, primary and repeat KTRs was comparable. While death-censored allograft survival was comparable between KTRs after SOT and primary KTRs, KTRs after SOT showed superior 5-year death-censored allograft survival of 92.5% compared to 81.2% in repeat KTRs. Interestingly, KTRs after SOT show less preformed panel-reactive antibodies, frequencies of alloreactive T cells, and acute rejections compared to repeat KTRs. KTRs after SOT, however, show higher incidences of EBV viremia and PTLD, sepsis, and death from sepsis. Impaired CMV-specific cellular immunity was associated with more CMV replication compared to repeat KTRs. Our results suggest comparable patient and allograft outcomes in KTRs after SOT and primary KTRs. The observed low alloreactivity may contribute to excellent allograft outcomes. Caution should be taken in KTRs after SOT regarding infectious complications due to overimmunosuppression.
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Affiliation(s)
- Thomas Schachtner
- Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany.,Berlin-Brandenburg Center of Regenerative Therapies (BCRT), Berlin, Germany.,Charité and Max-Delbrück Center, Berlin Institute of Health (BIH), Berlin, Germany
| | - Maik Stein
- Berlin-Brandenburg Center of Regenerative Therapies (BCRT), Berlin, Germany
| | - Petra Reinke
- Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany.,Berlin-Brandenburg Center of Regenerative Therapies (BCRT), Berlin, Germany
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Abstract
The prevalence of heart failure continues to rise due to the aging population and longer survival of people with conditions that lead to heart failure, eg, hypertension, diabetes, and coronary artery disease. Although medical therapy has had an important impact on survival of patients and improving quality of life, heart transplantation remains the definitive therapy for patients that eventually deteriorate. Since the first successful heart transplantation in 1967, significant improvements have been made regarding donor and recipient selection, surgical techniques, and postoperative care. However, the number of potential organ donors has not changed and the growing number of patients in need for transplantation has resulted an increase in waiting list time, and the need for mechanical support. To overcome this issue, the United Network for Organ Sharing implemented an allocation system to prioritize the sickest patients on the list to receive organs. Despite the careful selection of patients, pretransplant immunological screening, and multidrug immunosuppressive regimens, acute and chronic rejections occur and potentially limit graft and patient survival. Treatment for rejection largely depends on the type of rejection, the presence of hemodynamic compromise, and time after transplantation. The limiting factor for long-term graft survival is allograft vasculopathy, an immune-mediated process causing diffuse narrowing of the coronary arteries. Percutaneous coronary intervention and coronary artery bypass surgery are often not an option for this vasculopathy due to the lack of focal lesions, and retransplantation is the only option in appropriate patients.
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14
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Savla J, Lin KY, Pradhan M, Ruebner RL, Rogers RS, Haskins SS, Owens AT, Abt P, Gaynor JW, Shaddy RE, Rossano JW. Heart Retransplant Recipients Have Better Survival With Concurrent Kidney Transplant Than With Heart Retransplant Alone. J Am Heart Assoc 2015; 4:e002435. [PMID: 26656863 PMCID: PMC4845285 DOI: 10.1161/jaha.115.002435] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 10/27/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Heart retransplant (HRT) recipients represent a growing number of transplant patients. The impact of concurrent kidney transplants (KTs) in this population has not been well studied. We tested the hypothesis that recipients of HRT with concurrent KT (HRT-KT) would have worse survival than recipients of HRT alone. METHODS AND RESULTS A retrospective analysis of the United Network of Organ Sharing database was performed for all patients undergoing HRT from 1987 to 2011. There were 1660 HRT patients, of which 116 (7%) received concurrent KT. Those who received HRT-KT had older age, longer wait-list time, worse kidney function, and more known diabetes. Survival among recipients of HRT-KT was significantly better than that of recipients of HRT alone (P=0.005). A subgroup of 323 HRT patients with severe kidney dysfunction (estimated glomerular filtration rate <30 mL/min per 1.73 m(2) or on dialysis) was studied in more detail, and 76 (24%) received concurrent KT. Those on dialysis at the time of HRT had better survival with versus without concurrent KT (P<0.0001). On multivariable analysis, concurrent KT was independently associated with better outcomes for all patients with HRT and for the subgroup of patients with severe kidney dysfunction. CONCLUSIONS Recipients of HRT-KT have better survival than recipients of HRT alone. Further research is needed to determine which HRT patients may benefit the most from concurrent KT.
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Affiliation(s)
- Jill Savla
- Department of PediatricsThe Cardiac CenterThe Children's Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Kimberly Y. Lin
- Department of PediatricsThe Cardiac CenterThe Children's Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Madhura Pradhan
- Department of PediatricsThe Cardiac CenterThe Children's Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Rebecca L. Ruebner
- Department of PediatricsThe Cardiac CenterThe Children's Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Rachel S. Rogers
- Department of PediatricsThe Cardiac CenterThe Children's Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Somaly S. Haskins
- Department of PediatricsThe Cardiac CenterThe Children's Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Anjali T. Owens
- Department of PediatricsThe Cardiac CenterThe Children's Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Peter Abt
- Department of PediatricsThe Cardiac CenterThe Children's Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - J. William Gaynor
- Department of PediatricsThe Cardiac CenterThe Children's Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Robert E. Shaddy
- Department of PediatricsThe Cardiac CenterThe Children's Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Joseph W. Rossano
- Department of PediatricsThe Cardiac CenterThe Children's Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
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Skorić B, Čikeš M, Ljubas Maček J, Baričević Ž, Škorak I, Gašparović H, Biočina B, Miličić D. Cardiac allograft vasculopathy: diagnosis, therapy, and prognosis. Croat Med J 2015; 55:562-76. [PMID: 25559827 PMCID: PMC4295072 DOI: 10.3325/cmj.2014.55.562] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Development of cardiac allograft vasculopathy represents the major determinant of long-term survival in patients after heart transplantation. Due to graft denervation, these patients seldom present with classic symptoms of angina pectoris, and the first clinical presentations are progressive heart failure or sudden cardiac death. Although coronary angiography remains the routine technique for coronary artery disease detection, it is not sensitive enough for screening purposes. This is especially the case in the first year after transplantation when diffuse and concentric vascular changes can be easily detected only by intravascular ultrasound. The treatment of the established vasculopathy is disappointing, so the primary effort should be directed toward early prevention and diagnosis. Due to diffuse vascular changes, revascularization procedures are restricted only to a relatively small proportion of patients with favorable coronary anatomy. Percutaneous coronary intervention is preferred over surgical revascularization since it leads to better acute results and patient survival. Although there is no proven long-term advantage of drug-eluting stents for the treatment of in-stent restenosis, they are preferred over bare-metal stents. Severe vasculopathy has a poor prognosis and the only definitive treatment is retransplantation. This article reviews the present knowledge on the pathogenesis, diagnosis, treatment, and prognosis of cardiac allograft vasculopathy.
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Affiliation(s)
- Boško Skorić
- Bosko Skoric, University of Zagreb School of Medicine, Department of Cardiovascular Diseases, University Hospital Center Zagreb, Kispaticeva 12, 10 000 Zagreb, Croatia,
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Dedieu N, Greil G, Wong J, Fenton M, Burch M, Hussain T. Diagnosis and management of coronary allograft vasculopathy in children and adolescents. World J Transplant 2014; 4:276-293. [PMID: 25540736 PMCID: PMC4274597 DOI: 10.5500/wjt.v4.i4.276] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 08/12/2014] [Accepted: 09/17/2014] [Indexed: 02/05/2023] Open
Abstract
Coronary allograft vasculopathy remains one of the leading causes of death beyond the first year post transplant. As a result of denervation following transplantation, patients lack ischaemic symptoms and presentation is often late when the graft is already compromised. Current diagnostic tools are rather invasive, or in case of angiography, significantly lack sensitivity. Therefore a non-invasive tool that could allow early diagnosis would be invaluable.This paper review the disease form its different diagnosis techniques,including new and less invasive diagnostic tools to its pharmacological management and possible treatments.
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Copeland H, Gustafson M, Coelho-Anderson R, Mineburg N, Friedman M, Copeland JG. Fourth time cardiac retransplantation. World J Pediatr Congenit Heart Surg 2014; 5:88-90. [PMID: 24403361 DOI: 10.1177/2150135113507291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Beginning at age 11 years, our patient has had four heart transplants. Now, 26 years later at age 37, he is fully active. This case is presented to document a unique experience and to consider the difficult decision-making process and ethical issues of multiple cardiac retransplantation.
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Kinkhabwala MP, Mancini D. Patient selection for cardiac transplant in 2012. Expert Rev Cardiovasc Ther 2014; 11:179-91. [DOI: 10.1586/erc.12.186] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Pozzi M, d'Alessandro C, Fernandez F, Nguyen A, Pavie A, Leprince P, Varnous S, Kirsch M. Who Gets a Second Heart? A Current Picture of Cardiac Retransplantation. Transplant Proc 2014; 46:202-7. [DOI: 10.1016/j.transproceed.2013.08.109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 08/30/2013] [Indexed: 11/27/2022]
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Benatti RD, Taylor DO. Evolving concepts and treatment strategies for cardiac allograft vasculopathy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 16:278. [PMID: 24346852 DOI: 10.1007/s11936-013-0278-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT The central event in the development of allograft vasculopathy is the inflammatory response to immune-mediated and nonimmune-mediated endothelial damage. This response is characterized by the release of inflammatory cytokines, upregulation of cell-surface adhesion molecules, and subsequent binding of leukocytes. Growth factors stimulate smooth muscle cell proliferation and circulating progenitor cells are recruited to sites of arterial injury leading to neointima formation. Because of its diffuse nature, intravascular ultrasound is more sensitive than angiography for early diagnosis. Proliferation signal inhibitors (PSIs) have the capacity to slow vasculopathy progression by inhibiting smooth muscle cell proliferation, but its side effects profile makes its use as a first line agent difficult. Retransplantation is still the only definitive therapy but is available only in selected cases. The current hope is that immunomodulation at the time of transplant could induce long-term tolerance and graft accommodation, leading to less vasculopathy.
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Affiliation(s)
- Rodolfo Denadai Benatti
- Kaufman Center for Heart Failure, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J3-4 desk, Cleveland, OH, 44195, USA
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21
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Kobashigawa JA, Itagaki BK, Razi RR, Patel JK, Chai W, Kawano MA, Goldstein Z, Kittleson MM, Fishbein MC. Correlation between myocardial fibrosis and restrictive cardiac physiology in patients undergoing retransplantation. Clin Transplant 2013; 27:E679-84. [DOI: 10.1111/ctr.12250] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Jon A. Kobashigawa
- Cedars-Sinai Heart Institute; Heart Transplant Program; Los Angeles CA USA
| | - Brandon K. Itagaki
- Department of Cardiology; Kaiser Permanente; Los Angeles Medical Center; Los Angeles CA USA
| | - Rabia R. Razi
- Cedars-Sinai Heart Institute; Heart Transplant Program; Los Angeles CA USA
| | - Jignesh K. Patel
- Cedars-Sinai Heart Institute; Heart Transplant Program; Los Angeles CA USA
| | - Wanxing Chai
- Cedars-Sinai Heart Institute; Heart Transplant Program; Los Angeles CA USA
| | - Matthew A. Kawano
- Cedars-Sinai Heart Institute; Heart Transplant Program; Los Angeles CA USA
| | - Zachary Goldstein
- Cedars-Sinai Heart Institute; Heart Transplant Program; Los Angeles CA USA
| | | | - Michael C. Fishbein
- Department of Pathology and Laboratory Medicine; UCLA Medical Center; Los Angeles CA USA
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Saito A, Novick RJ, Kiaii B, McKenzie FN, Quantz M, Pflugfelder P, Fisher G, Chu MW. Early and late outcomes after cardiac retransplantation. Can J Surg 2013; 56:21-6. [PMID: 23187039 PMCID: PMC3569470 DOI: 10.1503/cjs.012511] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2011] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Cardiac retransplantation remains the most viable option for patients with allograft heart failure; however, careful patient selection is paramount considering limited allograft resources. We analyzed clinical outcomes following retransplantation in an academic, tertiary care institution. METHODS Between 1981 and 2011, 593 heart transplantations, including 22 retransplantations were performed at our institution. We analyzed the preoperative demographic characteristics, cause of allograft loss, short- and long-term surgical outcomes and cause of death among patients who had cardiac retransplantations. RESULTS Twenty-two patients underwent retransplantation: 10 for graft vascular disease, 7 for acute rejection and 5 for primary graft failure. Mean age at retransplantation was 43 (standard deviation [SD] 15) years; 6 patients were women. Thirteen patients were critically ill preoperatively, requiring inotropes and/or mechanical support. The median interval between primary and retransplantation was 2.2 (range 0-16) years. Thirty-day mortality was 31.8%, and conditional (> 30 d) 1-, 5- and 10-year survival after retransplantation were 93%, 79% and 59%, respectively. A diagnosis of allograft vasculopathy (p = 0.008) and an interval between primary and retransplantation greater than 1 year (p = 0.016) had a significantly favourable impact on 30-day mortality. The median and mean survival after retransplantation were 3.3 and 5 (SD 6, range 0-18) years, respectively; graft vascular disease and multiorgan failure were the most common causes of death. CONCLUSION Long-term outcomes for primary and retransplantation are similar if patients survive the 30-day postoperative period. Retransplantation within 1 year of the primary transplantation resulted in a high perioperative mortality and thus may be a contraindication to retransplantation.
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Affiliation(s)
- Aya Saito
- Division of Cardiac Surgery, Department of Surgery, University of Western Ontario, London Health Sciences Centre, Lawson Health Research Institute, London, Ont
- Department of Cardiothoracic Surgery, University ofTokyo, Tokyo, Japan
| | - Richard J. Novick
- Division of Cardiac Surgery, Department of Surgery, University of Western Ontario, London Health Sciences Centre, Lawson Health Research Institute, London, Ont
| | - Bob Kiaii
- Division of Cardiac Surgery, Department of Surgery, University of Western Ontario, London Health Sciences Centre, Lawson Health Research Institute, London, Ont
| | - F. Neil McKenzie
- Division of Cardiac Surgery, Department of Surgery, University of Western Ontario, London Health Sciences Centre, Lawson Health Research Institute, London, Ont
| | - Mackenzie Quantz
- Division of Cardiac Surgery, Department of Surgery, University of Western Ontario, London Health Sciences Centre, Lawson Health Research Institute, London, Ont
| | - Peter Pflugfelder
- Division of Cardiology, Department of Medicine, University of Western Ontario and London Health Sciences Centre, London, Ont
| | - Grant Fisher
- Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont
| | - Michael W.A. Chu
- Division of Cardiac Surgery, Department of Surgery, University of Western Ontario, London Health Sciences Centre, Lawson Health Research Institute, London, Ont
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Colvin-Adams M, Harcourt N, Duprez D. Endothelial dysfunction and cardiac allograft vasculopathy. J Cardiovasc Transl Res 2012; 6:263-77. [PMID: 23135991 DOI: 10.1007/s12265-012-9414-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 10/02/2012] [Indexed: 12/19/2022]
Abstract
Cardiac allograft vasculopathy remains a major challenge to long-term survival after heart transplantation. Endothelial injury and dysfunction, as a result of multifactorial immunologic and nonimmunologic insults in the donor and the recipient, are prevalent early after transplant and may be precursors to overt cardiac allograft vasculopathy. Current strategies for managing cardiac allograft vasculopathy, however, rely on the identification and treatment of established disease. Improved understanding of mechanisms leading to endothelial dysfunction in heart transplant recipients may provide the foundation for the development of sensitive screening techniques and preventive therapies.
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Affiliation(s)
- Monica Colvin-Adams
- Cardiovascular Division, University of Minnesota, Minneapolis, MN 55455, USA.
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25
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Kilic A, Weiss ES, Arnaoutakis GJ, George TJ, Conte JV, Shah AS, Yuh DD. Identifying Recipients at High Risk for Graft Failure After Heart Retransplantation. Ann Thorac Surg 2012; 93:712-6. [DOI: 10.1016/j.athoracsur.2011.10.065] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Revised: 10/21/2011] [Accepted: 10/25/2011] [Indexed: 12/01/2022]
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Iribarne A, Hong KN, Easterwood R, Yang J, Jeevanandam V, Naka Y, Russo MJ. Should heart transplant recipients with early graft failure be considered for retransplantation? Ann Thorac Surg 2011; 92:923-8; discussion 928. [PMID: 21871278 PMCID: PMC3263700 DOI: 10.1016/j.athoracsur.2011.04.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Revised: 04/03/2011] [Accepted: 04/06/2011] [Indexed: 11/15/2022]
Abstract
BACKGROUND The purpose of this study was to determine if orthotopic heart transplantation performed within 90 days of an initial heart transplant (re-Tx) should be a contraindication to retransplantation based on inferior outcomes when compared with primary orthotopic heart transplantation recipients (control). METHODS De-identified data were obtained from the United Network for Organ Sharing. The study population included all adult heart transplant recipients greater than 18 years old from 1995 to 2008 (n=26,804). Multivariable regression was performed in order to assess the simultaneous effect of multiple risk factors on posttransplant graft failure (PTGF) at 90 days. Secondary outcomes of interest included infection, stroke, and dialysis during the transplant hospitalization as well as primary nonfunction of the graft at 90 days. RESULTS Among the study cohort, there were 90 (0.34%) re-Tx patients. Median survival in this group was 1.6 years compared with 10.5 years for controls. Unadjusted PTGF, infection, dialysis, and primary nonfunction were significantly higher (p<0.001) in the re-Tx group. After risk adjustment, however, PTGF (p=0.545), infection (p=0.696), dialysis (p=0.664), stroke (p=0.115), and primary nonfunction (p=0.531), did not differ significantly between the 2 groups. CONCLUSIONS When controlling for pretransplant recipient characteristics, retransplantation within 90 days of a previous transplant is not associated with increased morbidity or mortality. However, unadjusted overall survival was significantly worse in the re-Tx group. This suggests that although retransplantation at 90 days alone is not a risk factor for inferior outcomes, given the significant comorbidities of these patients, the indications for retransplantation within 90 days are rare and must be critically examined.
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Affiliation(s)
- Alexander Iribarne
- University of Chicago Medical Center, Center for Health & the Social Sciences, The University of Chicago, Chicago, IL 60637, USA
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28
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Copeland H, Coelho-Anderson R, Mineburg N, McCarthy M, Copeland JG. Elective cardiac retransplantation: A viable option that can be repeated. J Thorac Cardiovasc Surg 2011; 141:822-7. [DOI: 10.1016/j.jtcvs.2010.11.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 09/13/2010] [Accepted: 11/14/2010] [Indexed: 10/18/2022]
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Robinson CW, Arnaoutakis GJ, Allen JG, George TJ, Conte JV. Allograft Cardiectomy and Biventricular Assist Device Placement as a Salvage Maneuver in a Heart Transplant Recipient. J Card Surg 2011; 26:114-6. [DOI: 10.1111/j.1540-8191.2010.01173.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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32
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Letter to the editor with author response: commentary on "restarting the clock... again". Dimens Crit Care Nurs 2010; 29:103-5; author reply 105. [PMID: 20160554 DOI: 10.1097/dcc.0b013e3181c931b5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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33
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Zimmer RJ, Lee MS. Transplant Coronary Artery Disease. JACC Cardiovasc Interv 2010; 3:367-77. [DOI: 10.1016/j.jcin.2010.02.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 02/05/2010] [Accepted: 02/17/2010] [Indexed: 11/24/2022]
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Tsao L, Uriel N, Leitz K, Naka Y, Mancini D. Higher rate of comorbidities after cardiac retransplantation contributes to decreased survival. J Heart Lung Transplant 2010; 28:1072-4. [PMID: 19782289 DOI: 10.1016/j.healun.2009.06.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2008] [Revised: 06/08/2009] [Accepted: 06/10/2009] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Cardiac retransplantation is the definitive treatment for allograft failure despite decreased long-term survival in these patients. The cause of the poorer outcomes in cardiac retransplant patients is unclear. METHODS This study was a retrospective analysis of 859 adult cardiac transplant patients. Of these, 45 (5.7%) underwent cardiac retransplantation at 8.2 +/- 5.3 (mean +/- SD) years after the first transplant, primarily for severe transplant vasculopathy (n = 42). RESULTS One-year survival for retransplant patients was significantly lower compared with de novo transplant patients (75% vs 87%; p < 0.003). Twenty-three patients died due to either malignancy (n = 8), infection (n = 6), rejection (n = 3), sudden death (n = 2), recurrent transplant coronary artery disease (n = 2) or post-operative bleeding (n = 1). CONCLUSION Although cardiac retransplantation has immediate life-saving benefits, survival is lower compared with de novo cardiac transplantation due to higher rates of malignancy and infection.
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Affiliation(s)
- Lana Tsao
- Department of Medicine, Columbia University Medical Center, New York, New York, USA
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35
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Vistarini N, Pellegrini C, Aiello M, Alloni A, Monterosso C, Cattadori B, Tinelli C, DâArmini AM, Vigano M. Should we perform heart retransplantation in early graft failure? Transpl Int 2010; 23:47-53. [DOI: 10.1111/j.1432-2277.2009.00945.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Cardiac allograft vasculopathy (CAV) continues to limit the long-term success of cardiac transplantation. Recent insights have underscored the fact that innate and adaptive immune responses are involved in the pathogenesis of CAV. Vascular lesions are the result of cumulative endothelial injuries induced both by alloimmune responses and by nonspecific insults (including ischemia-reperfusion injury, viral infections, and metabolic disorders) in the context of impaired repair mechanisms. Intravascular ultrasound is the most sensitive method for detection of CAV, and progressive intimal thickening in the first posttransplant year identifies patients at high risk for future cardiovascular events. Encouraging results with regard to the detection of CAV by noninvasive methods should be an incentive to apply routine noninvasive imaging during mid- to long-term follow-up. Improved immunosuppressive drugs, including mycophenolate mofetil and proliferation signal inhibitors, as well as statins (in part via immunomodulation), have beneficial effects on CAV progression, although there is still a need to confirm the impact of vasodilators in improving outcome after heart transplantation. Coronary revascularization for CAV is only palliative, with no long-term survival benefit. Three main strategies for CAV prevention are currently under investigation: inhibition of growth factors and cytokines, cell therapy, and tolerance induction. However, because individual responses to an allograft change over time, assays to monitor the recipient's immune response and individualized methods for therapeutic immune modulation are clearly needed.
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Affiliation(s)
- Daniel Schmauss
- Medizinische Klinik und Poliklinik I, University Hospital Munich-Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany
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Atluri P, Hiesinger W, Gorman RC, Pochettino A, Jessup M, Acker MA, Morris RJ, Woo YJ. Cardiac retransplantation is an efficacious therapy for primary cardiac allograft failure. J Cardiothorac Surg 2008; 3:26. [PMID: 18462494 PMCID: PMC2432055 DOI: 10.1186/1749-8090-3-26] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 05/07/2008] [Indexed: 12/02/2022] Open
Abstract
Background Although orthotopic heart transplantation has been an effective treatment for end-stage heart failure, the incidence of allograft failure has increased, necessitating treatment options. Cardiac retransplantation remains the only viable long-term solution for end-stage cardiac allograft failure. Given the limited number of available donor hearts, the long term results of this treatment option need to be evaluated. Methods 709 heart transplants were performed over a 20 year period at our institution. Repeat cardiac transplantation was performed in 15 patients (2.1%). A retrospective analysis was performed to determine the efficacy of cardiac retransplantation. Variables investigated included: 1 yr and 5 yr survival, length of hospitalization, post-operative complications, allograft failure, recipient and donor demographics, renal function, allograft ischemic time, UNOS listing status, blood group, allograft rejection, and hemodynamic function. Results Etiology of primary graft failure included transplant arteriopathy (n = 10), acute rejection (n = 3), hyperacute rejection (n = 1), and a post-transplant diagnosis of metastatic melanoma in the donor (n = 1). Mean age at retransplantation was 45.5 ± 9.7 years. 1 and 5 year survival for retransplantation were 86.6% and 71.4% respectively, as compared to 90.9% and 79.1% for primary transplantation. Mean ejection fraction was 67.3 ± 12.2% at a mean follow-up of 32.6 ± 18.5 mos post-retransplant; follow-up biopsy demonstrated either ISHLT grade 1A or 0 rejection (77.5 ± 95.7 mos post-transplant). Conclusion Cardiac retransplantation is an efficacious treatment strategy for cardiac allograft failure.
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Affiliation(s)
- Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Mehra MR, Kobashigawa JA, Deng MC, Fang KC, Klingler TM, Lal PG, Rosenberg S, Uber PA, Starling RC, Murali S, Pauly DF, Dedrick R, Walker MG, Zeevi A, Eisen HJ. Clinical implications and longitudinal alteration of peripheral blood transcriptional signals indicative of future cardiac allograft rejection. J Heart Lung Transplant 2008; 27:297-301. [PMID: 18342752 DOI: 10.1016/j.healun.2007.11.578] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2007] [Revised: 11/26/2007] [Accepted: 11/28/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We have previously demonstrated that a peripheral blood transcriptional profile using 11 distinct genes predicts onset of cardiac allograft rejection weeks to months prior to the actual event. METHODS In this analysis, we ascertained the performance of this transcriptional algorithm in a Bayesian representative population: 28 cardiac transplant recipients who progressed to moderate to severe rejection; 53 who progressed to mild rejection; and 46 who remained rejection-free. Furthermore, we characterized longitudinal alterations in the transcriptional gene expression profile before, during and after recovery from rejection. RESULTS In this patient cohort, we found that a gene expression score (range 0 to 40) of <or =20 represents very low risk of rejection in the subsequent 12 weeks: 0 progressed to treatable (ISHLT Grade > or =3A) rejection; 16 of 53 (30%) from the intermediate group (those who progressed to ISHLT Grade 1B or 2) and 13 of 46 (28%) controls (who remained Grade 0 or 1A) had scores < or =20. A gene score of > or =30 was associated with progression to moderate to severe rejection in 58% of cases. These two extreme scores (< or =20 or > or =30) represented 44% of the cardiac transplant population within 6 months post-transplant. In addition, longitudinal gene expression analysis demonstrated that baseline scores were significantly higher for those who went on to reject, remained high during an episode of rejection, and dropped post-treatment for rejection (p < 0.01). CONCLUSIONS The use of gene expression profiling early after transplantation allows for separation into low-, intermediate- or high-risk categories for future rejection, permitting development of discrete surveillance strategies.
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Affiliation(s)
- Mandeep R Mehra
- Division of Cardiology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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Yoda M, Tenderich G, Zittermann A, Schulte-Eistrup S, Körfer R, Minami K. Long-Term Survival After Cardiac Retransplantation. Int Heart J 2008; 49:213-20. [DOI: 10.1536/ihj.49.213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Masataka Yoda
- Department of Thoracic and Cardiovascular Surgery, Heart Center North-Rhine-Westphalia, Ruhr-University of Bochum
| | - Gero Tenderich
- Department of Thoracic and Cardiovascular Surgery, Heart Center North-Rhine-Westphalia, Ruhr-University of Bochum
| | - Armin Zittermann
- Department of Thoracic and Cardiovascular Surgery, Heart Center North-Rhine-Westphalia, Ruhr-University of Bochum
| | - Sebastian Schulte-Eistrup
- Department of Thoracic and Cardiovascular Surgery, Heart Center North-Rhine-Westphalia, Ruhr-University of Bochum
| | - Reiner Körfer
- Department of Thoracic and Cardiovascular Surgery, Heart Center North-Rhine-Westphalia, Ruhr-University of Bochum
| | - Kazutomo Minami
- Department of Thoracic and Cardiovascular Surgery, Heart Center North-Rhine-Westphalia, Ruhr-University of Bochum
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41
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Kamoda Y, Fujino Y, Tanioka Y, Sakai T, Kuroda Y. Ischemically damaged heart after preservation by the cavitary two-layer method as a possible donor in rat heart transplantation. J Heart Lung Transplant 2007; 26:1320-5. [PMID: 18096485 DOI: 10.1016/j.healun.2007.07.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2007] [Revised: 07/27/2007] [Accepted: 07/27/2007] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The purpose of this study was to examine the possibility of using an ischemically damaged heart, after preservation by the cavitary two-layer (CTL) method, as a donor in heart transplantation. METHODS Each donor heart was heterotopically transplanted to the recipient aorta. The grafts in Group 1 were immediately transplanted. In Group 2, the grafts with (a) 15- or (b) 30-minute warm ischemia were transplanted. The ischemically damaged grafts were transplanted after preservation for 3 hours in University of Wisconsin (UW) solution (Group 3) or CTL (Group 4). Five-day animal survival, tissue adenine triphosphate (ATP) concentration, biochemical assay and histopathologic data were obtained. RESULTS Five-day survival in Group 4a was 7 of 8, with significant recovery of the ATP tissue level (9.31 +/- 0.80 micromol/dry weight). Biochemical and pathologic examinations demonstrated that ischemia-reperfusion injury was prevented in Group 4a compared with Group 2a. CONCLUSIONS An ischemically damaged rat heart preserved for 3 hours by CTL was found to be a potential donor in rat heart transplantation.
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Affiliation(s)
- Yasuhisa Kamoda
- Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Johnson MR, Aaronson KD, Canter CE, Kirklin JK, Mancini DM, Mehra MR, Radovancevic B, Taylor DO, Webber SA. Heart retransplantation. Am J Transplant 2007; 7:2075-81. [PMID: 17640316 DOI: 10.1111/j.1600-6143.2007.01902.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Retransplants comprise only a small minority (3-4%) of heart transplants, however outcome following retransplantation is compromised. Risk factors for a poor outcome following retransplantation include retransplantation early (<6 months) after primary transplant, retransplantation for acute rejection or early allograft failure, and retransplantation in an earlier era. The incidence of rejection and infection is similar following primary transplant and retransplantation. The compromised outcomes and risk factors for a poor outcome are similar in adult and pediatric heart retransplantation. However, due to the short half-life of the transplanted heart, it is an expectation that patients transplanted in childhood may require retransplantation. Based on the data available and the opinion of the working group, indications for heart retransplantation are (i) chronic severe cardiac allograft vasculopathy with symptoms of ischemia or heart failure (should be considered) or asymptomatic moderate or severe left ventricular dysfunction (may be considered) or (ii) chronic graft dysfunction with symptoms of progressive heart failure in the absence of active rejection. Patients with graft failure due to acute rejection with hemodynamic compromise, especially <6 months post-transplant, are inappropriate candidates for retransplantation. In addition, guidelines established for primary transplant candidacy should be strictly followed.
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Magee JC, Barr ML, Basadonna GP, Johnson MR, Mahadevan S, McBride MA, Schaubel DE, Leichtman AB. Repeat organ transplantation in the United States, 1996-2005. Am J Transplant 2007; 7:1424-33. [PMID: 17428290 DOI: 10.1111/j.1600-6143.2007.01786.x] [Citation(s) in RCA: 158] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The prospect of graft loss is a problem faced by all transplant recipients, and retransplantation is often an option when loss occurs. To assess current trends in retransplantation, we analyzed data for retransplant candidates and recipients over the last 10 years, as well as current outcomes. During 2005, retransplant candidates represented 13.5%, 7.9%, 4.1% and 5.5% of all newly registered kidney, liver, heart and lung candidates, respectively. At the end of 2005, candidates for retransplantation accounted for 15.3% of kidney transplant candidates, and lower proportions of liver (5.1%), heart (5.3%) and lung (3.3%) candidates. Retransplants represented 12.4% of kidney, 9.0% of liver, 4.7% of heart and 5.3% of lung transplants performed in 2005. The absolute number of retransplants has grown most notably in kidney transplantation, increasing 40% over the last 10 years; the relative growth of retransplantation was most marked in heart and lung transplantation, increasing 66% and 217%, respectively. The growth of liver retransplantation was only 11%. Unadjusted graft survival remains significantly lower after retransplantation in the most recent cohorts analyzed. Even with careful case mix adjustments, the risk of graft failure following retransplantation is significantly higher than that observed for primary transplants.
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Affiliation(s)
- J C Magee
- Scientific Registry of Transplant Recipients/University of Michigan, Ann Arbor, Michigan, USA.
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Kokkinos C, Athanasiou T, Rao C, Constantinidis V, Poullis C, Smith A, Ridgway M, Tekkis PP, Darzi A. Does Re-operation have an Effect on Outcome Following Heart Transplantation? Heart Lung Circ 2007; 16:93-102. [PMID: 17314069 DOI: 10.1016/j.hlc.2006.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2006] [Revised: 11/07/2006] [Accepted: 11/09/2006] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Previous cardiac operation has traditionally been considered as a potential risk factor for patients undergoing heart transplantation. This study aimed to evaluate the outcome of patients undergoing heart transplantation as a second cardiac procedure and compare it with primary heart transplantation, using meta-analytical methodology. METHODS A literature search was undertaken to identify relevant comparative studies. Outcomes of interest were classified into four categories: (a) intra-operative times; (b) post-operative outcomes; (c) resources; (d) actuarial outcomes. RESULTS Seven studies matched the selection criteria, reporting on 1004 patients. Six hundred and twenty-three had transplantation as primary operation and 381 as re-operation. The 1-year, 2-year, and 5-year mortality were similar for the two groups (HR=0.85, p=0.54; HR=0.97, p=0.88; and HR=1.04, p=0.92, respectively). Total operative, cold-ischaemic, by-pass, and cross-clamp times were significantly longer for the re-operation group by 59.44 (p<0.001), 14.62 (p=0.05), 25.24 (p<0.001), and 7.93 (p<0.001)min, respectively. Both ICU and hospital stay were longer for the re-operation group but only the former was statistically significant (WMD=1.37; p=0.02). Post-operative complications were similar, except re-exploration rate and blood transfusion requirement, which were higher in the re-operation group (OR=3.51; p<0.001 and WMD=2.21; p<0.001, respectively). CONCLUSIONS Heart transplantation following previous cardiac operation is technically demanding requiring longer operative times compared to primary heart transplantation. It does not, however, add a significant risk to the survival of the patient, and associated morbidity is not significantly compromised.
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Affiliation(s)
- Constantinos Kokkinos
- Imperial College London, Department of Bio-Surgery and Technology, St. Mary's Hospital, London, United Kingdom
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Abstract
As the number of recipients of heart transplantation grows over time and they survive longer, more are at risk for developing severe cardiac allograft vasculopathy and allograft dysfunction, which might lead to consideration for retransplantation. Clearly, outcomes following cardiac retransplantation are compromised, and with donor shortage, the selection of candidates must be judicious. Retransplantation appears most appropriate for those patients more than 6 months following original heart transplantation, who have severe cardiac allograft vasculopathy and associated left ventricular dysfunction, or allograft dysfunction and progressive symptoms of heart failure in the absence of acute rejection. Relative contraindications to transplantation (ie, advanced age, comorbidities, psychosocial issues) require thorough assessment when retransplantation is being considered.
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Affiliation(s)
- Maryl R Johnson
- University of Wisconsin Hospital and Clinics, Madison, WI 53792, USA.
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Mathier MA, Murali S. Cardiac Transplantation and Circulatory Support Devices. Cardiovasc Ther 2007. [DOI: 10.1016/b978-1-4160-3358-5.50024-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
PURPOSE OF REVIEW The evolution of scientific advancements that paved the way for clinical cardiac transplantation spans the era of the 20 century, heart transplantation has revolutionized therapy for end-stage heart failure. Demand far exceeds supply, resulting in a long waiting period, and an increasing number of deaths while on a waiting list. The shortage of donors poses dilemmas for allocation of organs and managing the waiting list. RECENT FINDINGS The disparity between the demand and supply for donor hearts makes cardiac retransplantation an ethical issue with some patients being allowed a second transplant while some patients are dying on the waiting list before receiving their first transplant, especially with overall sub-optimal outcomes compared with primary transplantation. SUMMARY The cardiac transplant community is mandated to closely monitor the results of cardiac retransplantation to identify the appropriate candidate who should receive a retransplantation.
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