Cardiac transplantation for older patients: Characteristics and outcomes in the septuagenarian population

Donor and Recipient Age Influence Outcomes Following Orthotopic Heart Transplantation in the 2018 US Heart Allocation System

BACKGROUND

This study evaluates the interaction of donor and recipient age with outcomes following heart transplantation under the 2018 heart allocation system.

METHODS

The United Network for Organ Sharing registry was queried to analyze adult primary isolated orthotopic heart transplant recipients and associated donors from August 18, 2018, to June 30, 2021. Both recipient and donor cohorts were grouped according to age: <65 and ≥65 y for recipients and <50 and ≥50 y for donors. The primary outcome was survival. Subanalyses were performed to evaluate the impact of donor age.

RESULTS

A total of 7601 recipients and 7601 donors were analyzed. Of these, 1584 recipients (20.8%) were ≥65 y old and 560 donors (7.4%) were ≥50 y old. Compared with recipients <65, recipients ≥65 had decreased 1-y (88.8% versus 92.3%) and 2-y (85.1% versus 88.5%) survival rates (P < 0.001). The association of recipient age ≥65 with lower survival persisted after adjusting for potential cofounders (hazard ratio, 1.38; 95% confidence interval, 1.18-1.61; P < 0.001). Recipients <65 with donors ≥50 had comparable 1-y and 2-y survival rates to recipients <65 with donors <50 (P =0.997). Conversely, transplantation of older allografts was associated with lower 1-y (84.2% versus 89.4%) and 2-y (79.5% versus 85.8%) survival rates in recipients ≥65 (P = 0.025).

CONCLUSIONS

Recipient age ≥65 continues to be associated with worse survival following heart transplantation in the 2018 heart allocation system compared with younger recipients. Donors ≥50 may be acceptable among recipients <65 with comparable outcomes. However, careful donor age selection should be considered for recipients ≥65, as the use of younger donor allografts appears to improve posttransplantation survival.

Trends in heart transplant outcomes for patients over the age of 70 years in the United States: An analysis of the scientific registry of transplant recipients database

BACKGROUND

Patients of advanced age are often considered to be poor candidates for heart transplant (HT). As the U.S. population continues to age, it is important for clinicians to understand how best to select patients for advanced therapies.

METHODS

This was a retrospective analysis of the U.S. Scientific Registry of Transplant Recipients data from 2006 to August 2022 in adult recipients. Patients were excluded if they were multiorgan transplant, re-do transplants, or less than 1 year post transplant.

RESULTS

Recipients ≥70 had a 1-year survival of 87.5%, compared to 91.1% for <60%, and 88.4% for 60-69 years (p < 0.001). Survival improved numerically, but not significantly, as transplant eras progressed for those ≥70 years. Survival by Kaplan-Meier analysis was greatest at 5 years for <60 years (80.6%), compared to 60-69 years (78.2%) and ≥70 years (77.1%). When comparing 60-69 years to ≥70 years by this same metric, there was significant difference (p = 0.12). One year survival for those ≥70 years has improved from 2000-2009 (80.7%) to 88.5% since October 2018 (p < 0.001). As recipients increased in age, they were more likely to be male, and less likely to be Black or Hispanic/Latino (p < 0.001).

CONCLUSION

Overall, HT outcomes are excellent for carefully selected patients ≥70 years, and transplanting patients in this age cohort can be considered.

Aging in Heart Failure: Embracing Biology Over Chronology: JACC Family Series

Age is among the most potent risk factors for developing heart failure and is strongly associated with adverse outcomes. As the global population continues to age and the prevalence of heart failure rises, understanding the role of aging in the development and progression of this chronic disease is essential. Although chronologic age is on a fixed course, biological aging is more variable and potentially modifiable in patients with heart failure. This review describes the current knowledge on mechanisms of biological aging that contribute to the pathogenesis of heart failure. The discussion focuses on 3 hallmarks of aging-impaired proteostasis, mitochondrial dysfunction, and deregulated nutrient sensing-that are currently being targeted in therapeutic development for older adults with heart failure. In assessing existing and emerging therapeutic strategies, the review also enumerates the importance of incorporating geriatric conditions into the management of older adults with heart failure and in ongoing clinical trials.

Special Considerations for Advanced Heart Failure Surgeries: Durable Left Ventricular Devices and Heart Transplantation

Heart transplantation and durable left ventricular assist devices (LVADs) represent two definitive therapies for end-stage heart failure in the modern era. Despite technological advances, both treatment modalities continue to experience unique risks that impact surgical and perioperative decision-making. Here, we review special populations and factors that impact risk in LVAD and heart transplant surgery and examine critical decisions in the management of these patients. As both heart transplantation and the use of durable LVADs as destination therapy continue to increase, these considerations will be of increasing relevance in managing advanced heart failure and improving outcomes.

Cardiogenic Shock in Older Adults: A Focus on Age-Associated Risks and Approach to Management: A Scientific Statement From the American Heart Association

Cardiogenic shock continues to portend poor outcomes, conferring short-term mortality rates of 30% to 50% despite recent scientific advances. Age is a nonmodifiable risk factor for mortality in patients with cardiogenic shock and is often considered in the decision-making process for eligibility for various therapies. Older adults have been largely excluded from analyses of therapeutic options in patients with cardiogenic shock. As a result, despite the association of advanced age with worse outcomes, focused strategies in the assessment and management of cardiogenic shock in this high-risk and growing population are lacking. Individual programs oftentimes develop upper age limits for various interventional strategies for their patients, including heart transplantation and durable left ventricular assist devices. However, age as a lone parameter should not be used to guide individual patient management decisions in cardiogenic shock. In the assessment of risk in older adults with cardiogenic shock, a comprehensive, interdisciplinary approach is central to developing best practices. In this American Heart Association scientific statement, we aim to summarize our contemporary understanding of the epidemiology, risk assessment, and in-hospital approach to management of cardiogenic shock, with a unique focus on older adults.

Changes in heart transplant outcomes of elderly patients in the new allocation era

OBJECTIVE

Studies demonstrate that heart transplantation can be performed safely in septuagenarians. We evaluate the outcomes of septuagenarians undergoing heart transplantation after the US heart allocation change in 2018.

METHODS

The United Network for Organ Sharing registry was used to identify heart transplant recipients aged 70 years or more between 2010 and 2021. Primary outcomes were 90-day and 1-year mortality. Kaplan-Meier, multivariable Cox proportional hazards, and accelerated failure time models were used for unadjusted and risk-adjusted analyses.

RESULTS

A total of 27,403 patients underwent heart transplantation, with 1059 (3.9%) aged 70 years or more. Patients aged 70 years or more increased from 3.7% before 2018 to 4.5% after 2018 (P = .003). Patients aged 70 years or more before 2018 had comparable 90-day and 1-year survivals relative to patients aged less than 70 years (90 days: 93.8% vs 94.2%, log-rank P = .650; 1 year: 89.4% vs 91.1%, log-rank P = .130). After 2018, septuagenarians had lower 90-day and 1-year survivals (90 days: 91.4% vs 95.0%, log-rank P = .021; 1 year: 86.5% vs 90.9%, log-rank P = .018). Risk-adjusted analysis showed comparable 90-day mortality (hazard ratio, 1.29; 0.94-1.76, P = .110) but worse 1-year mortality (hazard ratio, 1.32; 1.03-1.68, P = .028) before policy change. After policy change, both 90-day and 1-year mortalities were higher (90 days: HR, 1.99; 1.23-3.22, P = .005; 1 year: hazard ratio, 1.71; 1.14-2.56, P = .010). An accelerated failure time model showed comparable 90-day (0.42; 0.16-1.44; P = .088) and 1-year (0.48; 0.18-1.26; P = .133) survival postallocation change.

CONCLUSIONS

Septuagenarians comprise a greater proportion of heart transplant recipients after the allocation change, and their post-transplant outcomes relative to younger recipients have worsened.

Do age and functional dependence affect outcomes of simultaneous heart-kidney transplantation?

Objective

This study assessed characteristics and outcomes of younger (18-65) versus older (>65) recipients of simultaneous heart-kidney (SHK) transplantation with varying functional dependence.

Methods

This study retrospectively analyzed 1398 patients from the United Network for Organ Sharing database who received SHK between 2010 and 2021. Patients who were <18 year old, underwent transplant of additional organs simultaneously, or had previous heart transplant were excluded. The primary end point was all-cause mortality, and secondary end points included adverse events and cause of death. Outcomes were also evaluated by propensity score-matched comparison.

Results

The number of annual SHK transplantation in the United States has significantly increased among both age groups over the past 2 decades (P < .0001). After propensity score matching of recipients aged 18 to 65 years (n = 1162) versus age >65 years (n = 236), baseline characteristics were similar and well-balanced between the 2 cohorts. Between matched cohorts, older recipients did not have increased posttransplant mortality compared with younger recipients (90-day survival, P = .85; 7-year survival, P = .61). Multivariable Cox regression analysis found that age (hazard ratio [HR], 1.039 [0.975-1.106], P = .2415) and pretransplant functional status with interaction term for age (some assistance, HR, 0.965 [0.902-1.033], P = .3079; total assistance, HR, 0.976 [0.914-1.041], P = .4610) were not significant risk factors for 7-year post-SHK transplantation mortality.

Conclusions

Older and more functionally dependent recipients in this study did not have increased post-SHK transplantation mortality. These findings have important implications for organ allocation among elderly patients, as they support the need for thorough assessment of SHK candidates in terms of comorbidities, rather than exclusion solely based on age and functional dependence.

The ABC of Heart Transplantation-Part 1: Indication, Eligibility, Donor Selection, and Surgical Technique

Cardiac transplantation represents the gold standard of treatment for selected patients with advanced heart failure who have poor functional capacity and prognosis despite guideline-directed medical therapy and device-based therapy. Proper patient selection and appropriate referral of patients to centers for the treatment of advanced heart failure are the first but decisive steps for screening patients eligible for cardiac transplantation. The eligibility and the decision to list for cardiac transplantation, even for patients with relative contraindications, are based on a multidisciplinary evaluation of a transplant team. This review will discuss the practical indications, the process of patient eligibility for cardiac transplantation, the principle of donor selection, as well as the surgical technique.

Evaluating age-based eligibility thresholds for heart re-transplantation - an analysis of the united network for organ sharing database

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.

Elderly Patients With Higher Acuity Have Similar Left Ventricular Assist Device Outcomes as Younger Patients at a Nontransplant Center

Although left ventricular assist device (LVAD) implantation is associated with acceptable survival, previous reports have demonstrated that advanced age is associated with increased short-term mortality. Because age is a relative contraindication to transplantation, nontransplant centers tend to implant a disproportionate number of elderly patients. We undertook this study to evaluate the impact of advanced age on LVAD outcomes at a nontransplant center. We conducted a retrospective review of all LVAD implants at our center from 2017 to 2022. Primary stratification was by age >70 years. The primary outcome was survival as assessed by the Kaplan-Meier method. The risk of 1-year mortality was further evaluated using multivariable Cox proportional hazards regression modeling. From 2017 to 2022, 93 patients underwent LVAD implantation. The mean age was 65.03 ± 11.28 years, with a median age of 68 (60 to 73) years. Most patients were INTERMACS 1 or 2 (71 patients; 76.34%). When stratified by age, 41 patients (44.09%) were aged ≥70 years. Patients aged ≥70 years had similar 30-day (96.15% vs 100.00%, p = 0.213), 1-year (90.05% vs 84.00%, p = 0.444), and 2-year survival (82.03% vs 84.00%, p = 0.870). When only the INTERMACS 1 and 2 patients with higher acuity were included, there was still no difference in 30-day, 1-year, or 2-year survival. On multivariable analysis, age >70 years was not associated with an increased hazard of 1-year mortality (0.90 [0.22 to 3.67], p = 0.878). In conclusion, in carefully selected patients, age >70 years is not associated with increased short-term mortality. Age alone should not be a contraindication to LVAD therapy.

Expanding Selection Criteria to Repairable Diseased Hearts to Meet the Demand of Shortage of Donors in Heart Transplantation

Heart transplant surgery is considered the destination therapy for end-stage heart disease. Unfortunately, many patients in the United States of America who are eligible candidates for transplants cannot undergo surgery due to donor shortage. In addition, some donors' hearts are being labeled as unacceptable for transplant surgery because of the rigorous and restricted rules placed on the approval process of using a donor's heart. Over the last few decades, the rising discrepancy between the scarcity of donor hearts and the demand for such organs has led to the discussion of expanding the donor heart selection criteria. A softer view on using marginal hearts for transplants would help those on the waitlist to receive a heart transplant. Marginal hearts that contain the hepatitis c virus (HCV), COVID-19, older age, or repairable heart defects have become viable options to use for a heart transplant. Also, the prioritization based on the new heart allocation system would help efficiently decide which recipients would be the first to get a donor's heart. Recently there has been a consensus to broaden the eligibility of donor's hearts by accepting valvular abnormalities, coronary artery disease, and congenital abnormalities. This review highlights some of those expansions in selection criteria in particular using repairable hearts, which could be fixed in the operating room on the back table before transplantation.

Heart Failure in Older Adults: Medical Management and Advanced Therapies

As the population ages and the prevalence of heart failure increases, cardiologists and geriatricians can expect to see more elderly patients with heart failure in their everyday practice. With the advancement of medical care and technology, the options for heart failure management have expanded, though current guidelines are based on studies of younger populations, and the evidence in older populations is not as robust. Pharmacologic therapy remains the cornerstone of heart failure management and has improved long-term mortality. Prevention of sudden cardiac death with implantable devices is being more readily utilized in older patients. Advanced therapies have provided more options for end-stage heart failure, though its use is still limited in older patients. In this review, we discuss the current guidelines for medical management of heart failure in older adults, as well as the expanding literature on advanced therapies, such as heart transplantation in older patients with end-stage heart failure. We also discuss the importance of a multidisciplinary care approach including consideration of non-medical co-morbidities such as frailty and cognitive decline.

Association of Differences in Treatment Intensification, Missed Visits, and Scheduled Follow-up Interval With Racial or Ethnic Disparities in Blood Pressure Control

Importance

Black patients with hypertension often have the lowest rates of blood pressure (BP) control in clinical settings. It is unknown to what extent variation in health care processes explains this disparity.

Objective

To assess whether and to what extent treatment intensification, scheduled follow-up interval, and missed visits are associated with racial and ethnic disparities in BP control.

Design, Setting, and Participants

In this cohort study, nested logistic regression models were used to estimate the likelihood of BP control (defined as a systolic BP [SBP] level <140 mm Hg) by race and ethnicity, and a structural equation model was used to assess the association of treatment intensification, scheduled follow-up interval, and missed visits with racial and ethnic disparities in BP control. The study included 16 114 adults aged 20 years or older with hypertension and elevated BP (defined as an SBP level ≥140 mm Hg) during at least 1 clinic visit between January 1, 2015, and November 15, 2017. A total of 11 safety-net clinics within the San Francisco Health Network participated in the study. Data were analyzed from November 2019 to October 2020.

Main Outcomes and Measures

Blood pressure control was assessed using the patient's most recent BP measurement as of November 15, 2017. Treatment intensification was calculated using the standard-based method, scored on a scale from -1.0 to 1.0, with -1.0 being the least amount of intensification and 1.0 being the most. Scheduled follow-up interval was defined as the mean number of days to the next scheduled visit after an elevated BP measurement. Missed visits measured the number of patients who did not show up for visits during the 4 weeks after an elevated BP measurement.

Results

Among 16 114 adults with hypertension, the mean (SD) age was 58.6 (12.1) years, and 8098 patients (50.3%) were female. A total of 4658 patients (28.9%) were Asian, 3743 (23.2%) were Black, 3694 (22.9%) were Latinx, 2906 (18.0%) were White, and 1113 (6.9%) were of other races or ethnicities (including American Indian or Alaska Native [77 patients (0.4%)], Native Hawaiian or Pacific Islander [217 patients (1.3%)], and unknown [819 patients (5.1%)]). Compared with patients from all racial and ethnic groups, Black patients had lower treatment intensification scores (mean [SD], -0.33 [0.26] vs -0.29 [0.25]; β = -0.03, P < .001) and missed more visits (mean [SD], 0.8 [1.5] visits vs 0.4 [1.1] visits; β = 0.35; P < .001). In contrast, Asian patients had higher treatment intensification scores (mean [SD], -0.26 [0.23]; β = 0.02; P < .001) and fewer missed visits (mean [SD], 0.2 [0.7] visits; β = -0.20; P < .001). Black patients were less likely (odds ratio [OR], 0.82; 95% CI, 0.75-0.89; P < .001) and Asian patients were more likely (OR, 1.13; 95% CI, 1.02-1.25; P < .001) to achieve BP control than patients from all racial or ethnic groups. Treatment intensification and missed visits accounted for 21% and 14%, respectively, of the total difference in BP control among Black patients and 26% and 13% of the difference among Asian patients.

Conclusions and Relevance

This study's findings suggest that racial and ethnic inequities in treatment intensification may be associated with more than 20% of observed racial or ethnic disparities in BP control, and racial and ethnic differences in visit attendance may also play a role. Ensuring more equitable provision of treatment intensification could be a beneficial health care strategy to reduce racial and ethnic disparities in BP control.

Heart Transplant in Older Adults

Purpose of Review

Older adults with end-stage heart failure may be candidates for heart transplantation (HT) and changing guidelines and institutional policies have increased the availability of HT for septuagenarians. This review explores historical, pre-HT evaluation, and post-HT outcomes for older adult HT recipients.

Recent Findings

Rates of HT in older adults have increased in the past decade and more than 800 septuagenarians have undergone HT. Older adult HT recipients have similar survival, rehospitalization, and graft failure rates when compared to younger patients despite additional comorbidities and higher risk donors.

Summary

HT is feasible in carefully selected older adults. As the number of older adults who are considered for HT increases, additional research into population-specific assessment tools will be needed. Furthermore, age-related immune changes warrant population-specific studies on immunosuppressive regimens.

Strategies of Wait-listing for Heart Transplant vs Durable Mechanical Circulatory Support Alone for Patients With Advanced Heart Failure

Importance

Given the shortage of donor hearts and improvement in outcomes with left ventricular assist device (LVAD) therapy, a relevant but, to date, unanswered question is whether select patients with advanced heart failure should receive LVAD destination therapy as an alternative to heart transplant.

Objective

To determine whether a strategy of LVAD destination therapy is associated with similar survival benefit as wait-listing for heart transplant with or without LVAD therapy among patients with advanced heart failure.

Design, Setting, and Participants

This retrospective propensity-matched cohort analysis used data on heart transplants from the United Network for Organ Sharing registry and LVAD implants from the Interagency Registry for Mechanically Assisted Circulatory Support from January 1, 2010, to December 31, 2014. The matched LVAD destination therapy cohort included 3411 patients. Data analysis for this study was conducted from December 22, 2017, to May 24, 2019.

Main Outcomes and Measures

Survival at 5 years was analyzed using Cox proportional hazards models.

Results

In total, 8281 patients had albumin level, creatinine level, and BMI data recorded and were included in the analysis. Despite propensity score matching, the 3411 patients receiving LVAD destination therapy still tended to be slightly older than the 3411 patients wait-listed for heart transplant (64.0 years [interquartile range, 55.0-70.0 years] vs 60.0 [interquartile range, 54.0-65.0 years]; P < .001), but there was no significant difference in sex (2701 men [79.2%] vs 2648 men [77.6%]; P = .13). After propensity score matching for age, sex, body mass index, renal function, and albumin level, 3411 patients were wait-listed for heart transplant. This included 1607 patients with bridge to transplant LVAD therapy and 1804 patients without LVAD. The strategy of wait-listing for heart transplant was associated with better 5-year survival than LVAD destination therapy (risk ratio, 0.42; 95% CI, 0.38-0.46) after matching and adjusting for key clinical factors. This survival advantage was associated with heart transplant (adjusted risk ratio for time-dependent transplant status, 0.27; 95% CI, 0.24-0.32).

Conclusions and Relevance

The present analysis suggests that heart transplant with or without bridge to transplant LVAD therapy was associated with superior 5-year survival compared with LVAD destination therapy among patients matched on several relevant clinical factors. Continued improvement in LVAD technology, along with prospective comparative research, appears to be needed to amend this strategy.

A mortality risk score for septuagenarians undergoing orthotopic heart transplantation

BACKGROUND

With septuagenarians undergoing orthotopic heart transplantation (OHT) more frequently, we aimed to develop a risk score for 1-year mortality in this population.

METHODS

Septuagenarian OHT recipients were identified from the UNOS registry between 1987 and 2018. The primary outcome was 1-year post-OHT mortality. Patients were randomly divided into derivation and validation cohorts. Associated covariates were entered into a multivariable logistic regression model. A risk score was created using the magnitudes of the odds ratios from the derivation cohort, and its 1-year post-OHT mortality prediction capacity was tested in the validation cohort.

RESULTS

A total of 1156 septuagenarians were included, and they were randomly divided into derivation (66.7%, n = 771) and validation (33.3%, n = 385) cohorts. An 11-point risk score incorporating 4 variables was created, which included mechanical ventilation, serum bilirubin, serum creatinine, and donor age. The predicted 1-year mortality ranged from 4.2% (0 points) to 48.1% (11-points) (p < .001). After cross-validation, the c-index was 0.67 with a Brier score of 0.10. Risk scores above 3 points portended a survival disadvantage at 1-year follow-up (p < .001).

CONCLUSIONS

This 11-point risk score for septuagenarians is predictive of mortality within 1-year of OHT and has potential utilization in improving recipient evaluation and selection of elderly patients.

Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement on Heart Transplantation: Patient Eligibility, Selection, and Post-Transplantation Care

Significant practice-changing developments have occurred in the care of heart transplantation candidates and recipients over the past decade. This Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement provides evidence-based, expert panel recommendations with values and preferences, and practical tips on: (1) patient selection criteria; (2) selected patient populations; and (3) post transplantation surveillance. The recommendations were developed through systematic review of the literature and using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The evolving areas of importance addressed include transplant recipient age, frailty assessment, pulmonary hypertension evaluation, cannabis use, combined heart and other solid organ transplantation, adult congenital heart disease, cardiac amyloidosis, high sensitization, and post-transplantation management of antibodies to human leukocyte antigen, rejection, cardiac allograft vasculopathy, and long-term noncardiac care. Attention is also given to Canadian-specific management strategies including the prioritization of highly sensitized transplant candidates (status 4S) and heart organ allocation algorithms. The focus topics in this position statement highlight the increased complexity of patients who undergo evaluation for heart transplantation as well as improved patient selection, and advances in post-transplantation management and surveillance that have led to better long-term outcomes for heart transplant recipients.

Septuagenarian population has similar survival and outcomes to younger patients after left ventricular assist device implantation

BACKGROUND

Left ventricular assist device (LVAD) implantation may be an attractive alternative therapeutic option for elderly patients with heart failure who are ineligible for heart transplantation.

AIM

We aimed to describe the characteristics and outcomes of elderly patients (i.e. aged≥70 years) receiving an LVAD.

METHODS

This observational study was conducted in 19 centres between 2006 and 2016. Patients were divided into two groups-younger (aged<70 years) and elderly (aged≥70 years), based on age at time of LVAD implantation.

RESULTS

A total of 652 patients were included in the final analysis, and 74 patients (11.3%) were aged≥70 years at the time of LVAD implantation (maximal age 77.6 years). The proportion of elderly patients receiving an LVAD each year was constant, with a median of 10.6% (interquartile range 8.0-15.4%) per year, and all were implanted as destination therapy. Elderly and younger patients had similar durations of hospitalization in intensive care units and total lengths of hospital stays. Both age groups experienced similar rates of LVAD-related complications (i.e. stroke, bleeding, driveline infection and LVAD exchange), and the occurrence of LVAD complications did not impact survival in the elderly group compared with the younger group. Lastly, when compared with younger patients implanted as destination therapy, the elderly group also exhibited similar mid-term survival.

CONCLUSION

This work strongly suggests that selected elderly adults can be scheduled for LVAD implantation.

Comparison of Trends, Mortality, and Readmissions After Insertion of Left Ventricular Assist Devices in Patients <65 Years Vs ≥65 Years

Left ventricular assist devices (LVADs) use in treatment of stage D heart failure (HF) has evolved and expanded in the past decade. There is paucity of data on LVAD utilization in patients with age ≥65 years with multiple co-morbidities. We aimed to investigate utilization trends, outcomes, and rates and predictors of readmissions in patients receiving LVADs with age ≥65 years (AO) and comparing them with patient age <65 years (AY). We analyzed hospitalization data from the Nationwide Inpatient Sample from 2007 to 2015 to evaluate LVAD utilization trends and outcomes between the 2 patient cohorts. We also queried the Nationwide Readmission Database from 2014 to third quarter of 2015 to identify trends and compare etiologies of readmissions. Implants in AO patients increased from 20% (154) of the total LVADs implanted in 2007 to 33.2% (1,215) in 2014 and 31.8% (910) through September 2015 (p < 0.01). Over the study period there was a steady and significant increase in the mean Elixhauser scores in elderly patients who underwent LVAD implantation from 15.4 in 2007 to 24.54 in 2015 (p < 0.01). Despite this finding, the mean LOS in the AO cohort decreased from 56.0 days in 2007 to 33.8 days in 2015 (p < 0.001). Furthermore, the in-hospital mortality associated with LVAD implantation among the AO group gradually decreased over the study time period (39% in 2007 to 12.2% in 2015, p < 0.001). The overall readmission rate was not significantly different between AO versus AY group (28% vs 33%, p = 0.2). The most common cause in both groups was gastrointestinal bleed but it was significantly higher in AO group (24.3% vs 11.3%, p = 0.01). In conclusion, patients age ≥65 years with multiple co-morbidities are receiving increasing number of LVADs with improved survival outcomes. Their 30-day readmissions are comparable to the younger patients.

Outcomes of Older Patients in the Recent Era of Heart Kidney Transplantation

BACKGROUND AND OBJECTIVE

Variable age thresholds are often used at transplant centers for simultaneous heart and kidney transplantation (HKT). We hypothesize that selected older recipients enjoy comparable outcome to younger recipients in the current era of HKT.

METHODS

We performed a retrospective analysis of HKT outcomes in the United Network for Organ Sharing (UNOS) registry from 2006 to 2018, classifying patients by age at transplant as ≥ 65 or < 65 years. The primary outcome was patient death. Secondary outcomes included all-cause kidney graft failure and death-censored kidney allograft failure.

RESULTS

Of 973 patients, 774 (80%) were younger than 65 years (mean 52 ± 10 years) and 199 (20%) were 65 years or older (mean 67 ± 2 years). The older HKT cohort had fewer blacks (22% vs 35%, P = .01) and women (12 vs 18%, P = .04). Fewer older patients received dialysis (30% vs 54%, P < .001) and mechanical support (36% vs 45%, P = .03) before HKT. Older recipients received organs from slightly older donors. The median follow-up time was shorter for patients 65 years or older than for the younger group (2.3 vs 3.3 years, P < .001). Patient survival was similar between the groups (mean 8.8 vs 9.8 years, P = .3), with the most common causes of death being cardiovascular (29%) and infectious complications (28%). There was no difference in all-cause kidney graft survival (mean 8.7 vs 9.3 years, P = .8). Most commonly, recipients died with a functional renal allograft (59.8%), and this occurred more commonly in older patients (81.4% vs 54.8%, P = .001). Cox proportional hazard modeling showed that higher donor age (hazard ratio [HR] 1.015, P = .01; HR 1.022, P = .02) and use of pre-transplant dialysis (HR 1.5, P = .004; HR 1.8, P = .006) increased the risk for both all-cause and death-censored kidney allograft failure, respectively.

CONCLUSIONS

Our study showed that carefully selected older patients have outcomes similar to those of a younger cohort and argues for comprehensive evaluation of the recipients with age as part of comorbidity assessment rather than use of an arbitrary age threshold for candidacy.

Outcomes in Older Kidney Transplant Recipients After Prior Nonkidney Transplants

BACKGROUND

Recipients of nonkidney solid organ transplants (nkSOT) are living longer, and 11%-18% will develop end stage renal disease (ESRD). While our general inclination is to treat nkSOT recipients who develop ESRD with a kidney transplant (KT), an increasing number are developing ESRD at an older age where KT may not be the most appropriate treatment. It is possible that the risk of older age and prior nkSOT might synergize to make KT too risky, but this has never been explored.

METHODS

To examine death-censored graft loss and mortality for KT recipients with and without prior nkSOT, we used Scientific Registry of Transplant Recipients data to identify 42 089 older (age ≥65) KT recipients between 1995 and 2016. Additionally, to better understand treatment options for these patients and survival benefit of KT, we identified 5023 older (age ≥65) with prior nkSOT recipients listed for subsequent KT, of whom 863 received transplants.

RESULTS

Compared with 41 159 older KT recipients without prior nkSOT, death-censored graft loss was similar (adjusted hazard ratio [aHR]: 1.13, 95% CI: 0.93-1.37, P = 0.2), but mortality (aHR: 1.40, 95% CI: 1.28-1.54, P < 0.001) was greater for older KT recipients with prior nkSOT. Nonetheless, in a survival benefit model (survival with versus without the transplant), among older prior nkSOT recipients, KT decreased the risk of mortality by more than half (aHR: 0.47, 95% CI: 0.42-0.54, P < 0.001).

CONCLUSIONS

Older prior nkSOT recipients who subsequently develop ESRD derive survival benefit from KT, but graft longevity is limited by overall survival in this population. These findings can help guide patient counseling for this challenging population.

Solid organ transplantation in older adults. Infectious and other age-related considerations

In the U.S., older adults aged 65 or above comprise nearly one quarter of the solid organ transplant (SOT) waitlists, and the number of transplants performed in this age group continues to increase. There are no specific guidelines for the assessment and follow up of the older SOT candidate or recipient. Older adults are at increased risk of infectious complications after SOT. Despite these complications and even with the use of suboptimal donors, overall outcomes are favorable. We provide an overview to specific consideration as they relate to the older SOT candidate and recipient.

Description and analysis of patients and outcomes following third-time heart transplantation: An analysis of the United Network for Organ Sharing database from 1985 to 2017

BACKGROUND

Following second heart transplantation (HTx), some patients experience graft failure and require third-time heart transplantation. Little data exist to guide decision-making with regard to repeat retransplantation in older patients.

METHODS

We performed a retrospective cohort analysis of patients receiving a third HTx, as identified in the United Network for Organ Sharing (UNOS) database from 1985 to 2017.

RESULTS

The study cohort consisted of N = 60 patients, with an average age of 29 with a standard deviation of ±18 years. Overall survival for the cohort at 1, 5, and 10 years is 83%, 64%, and 44%, respectively. The rate of third-time HTxs has steadily increased in all age groups. Patients older than 50 years now account for 18.3% of all third-time HTxs. Although this group demonstrated longer average previous graft survival, after third HTx they demonstrate significantly poorer survival outcomes compared to third-time HTx recipients younger than 21 (P = 0.05). Age over 50, BMI over 30, and diabetes were all found to be independent risk factors for decreased survival following third HTx.

CONCLUSIONS

We describe trends in patients undergoing third HTx. We highlight subsets of such recipients who exhibit decreased survival.

Patient activation with respect to advanced heart failure therapy in patients over age 65 years

BACKGROUND

Clinical and ethical issues persist in determining candidacy for advanced heart failure (HF) therapies in elderly patients. Selection takes many factors into account, including "activation" (engagement and ability to self-manage).

OBJECTIVE

To investigate effects of age, activation, and depression/anxiety on selection and 6-month survival of participants considered for therapy.

METHODS

Consecutive people referred for advanced HF therapy completed the Patient Activation Measure and Hospital Anxiety and Depression Scale. We analyzed data from participants by age (≥65 vs. <65 years), stratified by approval for therapy.

RESULTS

Among 168 referred, 109 were approved, with no difference in activation between age groups (88% highly activated). Similarly, activation was not associated with age among those not approved. Activation was related to anxiety in older, approved participants, but not to depression.

CONCLUSIONS

Concerns regarding reduced self-management in the elderly may not be valid. Age alone should not disqualify a candidate for advanced HF therapy.

Effect of Age and Renal Function on Survival After Left Ventricular Assist Device Implantation

Left ventricular assist devices (LVAD) are increasingly used, especially as destination therapy in in older patients. The aim of this study was to evaluate the effect of age on renal function and mortality in the first year after implantation. A retrospective multicenter cohort study was conducted, evaluating all LVAD patients implanted in the 2 participating centers (age ≥18 years). Patients were stratified according to the age groups <45, 45-54, 55-64, and ≥65 years old. Overall, 241 patients were included (mean age 52.4 ± 12.9 years, 76% males, 33% destination therapy). The mean estimated Glomerular Filtration Rate (eGFR) at 1 year was 85, 72, 69, and 49 mL/min per 1.73 m² in the age groups <45(n = 65, 27%), 45-54(n = 52, 22%), 55-64(n = 87, 36%), and ≥65 years (n = 37, 15%) p <0.001)), respectively. Older age and lower eGFR at baseline (p <0.01) were independent predictors of worse renal function at 1 year. The 1-year survival post-implantation was 79%,84%, 68%, and 54% for those in the age group <45, 45-54, 55-64 and ≥65 years (Log-rank p = 0.003). Older age, lower eGFR and, INTERMACS class I were independent predictors of 1-year mortality. Furthermore, older patients (age > 60 years) with an impaired renal function (eGFR <55 mL/min per 1.73 m²) had a 5-fold increased hazard ratio for mortality during the first year after implantation (p <0.001). In conclusion, age >60 years is an independent predictor for an impaired renal function and mortality. Older age combined with reduced renal function pre-implantation had a cumulative adverse effect on survival in patients receiving a LVAD.

Similar Mortality and Morbidity of Orthotopic Heart Transplantation for Patients 70 Years of Age and Older Compared With Younger Patients

BACKGROUND

The upper age limit of heart transplantation remains controversial. The goal of the present study was to investigate the mortality and morbidity of orthotopic heart transplantation (HT) for recipients ≥70 compared with those <70 years of age.

METHODS

Of 704 adults who underwent HT from December 1988 to June 2012 at our institution, 45 were ≥70 years old (older group) and 659 were <70 years old (younger group). Survival, intraoperative blood product usage, intensive care unit (ICU) and hospital stays, and frequency of reoperation for chest bleeding, dialysis, and >48 hours ventilation were examined after HT.

RESULTS

The older group had 100% 30-day and 60-day survival compared with 96.8 ± 0.7% 30-day and 95.9 ± 0.8% 60-day survival rates in the younger group. The older and younger groups had similar 1-year (93.0 ± 3.9% vs 92.1 ± 1.1%; P = .79), 5-year (84.2 ± 6.0% vs 73.4 ± 1.9%; P = .18), and 10-year (51.2 ± 10.7% vs 50.2 ± 2.5%; P = .43) survival rates. Recipients in the older group had higher preoperative creatinine levels, frequency of coronary artery disease, and more United Network for Organ Sharing status 2 and fewer status 1 designations than recipients in the younger group (P < .05 for all). Pump time and intraoperative blood usage were similar between the 2 groups (P = NS); however, donor-heart ischemia time was higher in the older group (P = .002). Older recipients had higher postoperative creatinine levels at peak (P = .003) and at discharge (P = .007). Frequency of postoperative complications, including reoperation for chest bleeding, dialysis, >48 hours ventilation, pneumonia, pneumothorax, sepsis, in-hospital and post-discharge infections, were similar between groups (P = NS for all comparisons). ICU and hospital length of stays were similar between groups (P = .35 and P = .87, respectively). In Cox analysis, recipient age ≥70 years was not identified as a predictor of lower long-term survival after HT.

CONCLUSIONS

HT recipients ≥70 years old had similar 1, 5, and 10-year survival rates compared with younger recipients. Both patient groups had similar intra- and postoperative blood utilization and frequencies of many postoperative complications. Older and younger patients had similar morbidity and mortality rates following HT. Carefully selected older patients (≥70 years) can safely undergo HT and should not be excluded from HT consideration based solely on age.