The impact of frailty on mortality after heart transplantation

Prevention and rehabilitation after heart transplantation: A clinical consensus statement of the European Association of Preventive Cardiology, Heart Failure Association of the ESC, and the European Cardio Thoracic Transplant Association, a section of ESOT

Little is known either about either physical activity patterns, or other lifestyle-related prevention measures in heart transplantation (HTx) recipients. The history of HTx started more than 50 years ago but there are still no guidelines or position papers highlighting the features of prevention and rehabilitation after HTx. The aims of this scientific statement are (i) to explain the importance of prevention and rehabilitation after HTx, and (ii) to promote the factors (modifiable/non-modifiable) that should be addressed after HTx to improve patients' physical capacity, quality of life and survival. All HTx team members have their role to play in the care of these patients and multidisciplinary prevention and rehabilitation programmes designed for transplant recipients. HTx recipients are clearly not healthy disease-free subjects yet they also significantly differ from heart failure patients or those who are supported with mechanical circulatory support. Therefore, prevention and rehabilitation after HTx both need to be specifically tailored to this patient population and be multidisciplinary in nature. Prevention and rehabilitation programmes should be initiated early after HTx and continued during the entire post-transplant journey. This clinical consensus.

Incidence, risk factors and clinical outcome of multidrug-resistant organisms after heart transplantation

BACKGROUND

Transplant recipients commonly harbor multidrug-resistant organisms (MDROs), as a result of frequent hospital admissions and increased exposure to antimicrobials and invasive procedures.

AIM

To investigate the impact of patient demographic and clinical characteristics on MDRO acquisition, as well as the impact of MDRO acquisition on intensive care unit (ICU) and hospital length of stay, and on ICU mortality and 1-year mortality post heart transplantation.

METHODS

This retrospective cohort study analyzed 98 consecutive heart transplant patients over a ten-year period (2013-2022) in a single transplantation center. Data was collected regarding MDROs commonly encountered in critical care.

RESULTS

Among the 98 transplanted patients (70% male), about a third (32%) acquired or already harbored MDROs upon transplantation (MDRO group), while two thirds did not (MDRO-free group). The prevalent MDROs were Acinetobacter baumannii (14%), Pseudomonas aeruginosa (12%) and Klebsiella pneumoniae (11%). Compared to MDRO-free patients, the MDRO group was characterized by higher body mass index (P = 0.002), higher rates of renal failure (P = 0.017), primary graft dysfunction (10% vs 4.5%, P = 0.001), surgical re-exploration (34% vs 14%, P = 0.017), mechanical circulatory support (47% vs 26% P = 0.037) and renal replacement therapy (28% vs 9%, P = 0.014), as well as longer extracorporeal circulation time (median 210 vs 161 min, P = 0.003). The median length of stay was longer in the MDRO group, namely ICU stay was 16 vs 9 d in the MDRO-free group (P = 0.001), and hospital stay was 38 vs 28 d (P = 0.006), while 1-year mortality was higher (28% vs 7.6%, log-rank-χ 2: 7.34).

CONCLUSION

Following heart transplantation, a predominance of Gram-negative MDROs was noted. MDRO acquisition was associated with higher complication rates, prolonged ICU and total hospital stay, and higher post-transplantation mortality.

Impact of pre-existing frailty on survival outcomes in solid-organ transplant candidates and recipients: A meta-analysis

BACKGROUND

There is controversy surrounding the association between preexisting frailty and increased mortality in candidates and recipients of solid-organ transplants. This meta-analysis aimed to evaluate the impact of preexisting frailty on survival outcomes in solid-organ transplant candidates and recipients.

METHODS

A systematic search was conducted in the PubMed, Web of Sciences, and Embase databases until October 2, 2023. Two reviewers independently selected the eligible studies according to the PECOS criteria: Participants (candidates and recipients of solid-organ transplants), Exposure (frailty), Comparison (no-frailty), Outcomes (waitlist or posttransplant mortality), and Study design (retrospective or prospective cohort studies). The pooled effects were summarized by pooling the adjusted hazard ratio (HR) with 95 % confidence intervals (CI) for the frail patients than those without frailty.

RESULTS

Sixteen studies with 10091 patients met the eligibility criteria. Depending on the frailty tools used, the prevalence of frailty in solid-organ transplant candidates/recipients ranged from 4.6 % to 45.1 %. Frailty was significantly associated with an increased risk of waitlist mortality (HR 2.44; 95 % CI 1.84-3.24) and posttransplant mortality (HR 2.23; 95 % CI 1.61-3.09) in solid-organ transplant candidates and recipients, respectively. Subgroup analyses showed that the association of preexisting frailty with waitlist mortality and posttransplant mortality appeared to stronger in kidney transplant candidates (HR 2.70; 95 % CI 1.93-3.78) and lung transplantation recipients (HR 2.52; 95 % CI 1.23-5.15).

CONCLUSION

Frailty is a significant predictor of reduced survival in solid-organ transplant candidates and recipients. Assessment of frailty has the potential to identify patients who are suitable for transplantation.

The Impact of Frailty Components and Preoperative Mechanical Cardiac Support Changes with Time after Heart Transplantation

BACKGROUND

Frailty has been proven to be associated with mortality after orthotopic heart transplantation (OHT). The aim of our study was to determine the impact of frailty on mortality in the current era using pretransplant mechanical cardiac support (MCS).

METHODS

We retrospectively calculated the frailty scores of 471 patients undergoing OHT in a single institution between January 2012 and August 2022. The outcome was all-cause mortality.

RESULTS

The median survival time was 1987 days (IQR: 1487 days) for all patients. In total, 266 (56.5%) patients were categorized as nonfrail, 179 (38.0%) as prefrail, and 26 (5.5%) as frail. The survival rates were 0.73, 0.54, and 0.28 for nonfrail, prefrail, and frail patients, respectively. The frailty score was associated with mortality [HR: 1.34 (95% CI: 1.22-1.47, p < 0.001)]. Among the components of the frailty score, age above 50 years, creatinine ≥ 3.0 mg/dL or prior dialysis, and hospitalization before OHT were independently associated with mortality. Continuous-flow left ventricular assist devices (CF-LVAD) were associated with an increased risk for all-cause mortality [AHR: 1.80 (95% CI: 1.01-3.24, p = 0.047)].

CONCLUSIONS

The components of the frailty score were not equally associated with mortality. Frailty and pretransplant MCS should be included in the risk estimation.

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.

The Association Between Preoperative Pectoralis Muscle Quantity and Outcomes After Cardiac Transplantation

BACKGROUND

Sarcopenia is underappreciated in advanced heart failure and is not routinely assessed. In patients receiving a left ventricular assist device, preoperative sarcopenia, defined by using computed-tomography (CT)-derived pectoralis muscle-area index (muscle area indexed to body-surface area), is an independent predictor of postoperative mortality. The association between preoperative sarcopenia and outcomes after heart transplant (HT) is unknown.

OBJECTIVES

The primary aim of this study was to determine whether preoperative sarcopenia, diagnosed using the pectoralis muscle-area index, is an independent predictor of days alive and out of the hospital (DAOHs) post-transplant.

METHODS

Patients who underwent HT between January, 2018, and June, 2022, with available preoperative chest CT scans were included. Sarcopenia was diagnosed as pectoralis muscle-area index in the lowest sex-specific tertile. The primary endpoint was DAOHs at 1 year post-transplant.

RESULTS

The study included 169 patients. Patients with sarcopenia (n = 55) had fewer DAOHs compared to those without sarcopenia, with a median difference of 17 days (320 vs 337 days; P = 0.004). Patients with sarcopenia had longer index hospitalizations and were also more likely to be discharged to a facility other than home. In a Poisson regression model, sarcopenia was a significant univariable and the strongest multivariable predictor of DAOHs at 1 year (parameter estimate = -0.17, 95% CI -0.19 to -14; P = < 0.0001).

CONCLUSIONS

Preoperative sarcopenia, diagnosed using the pectoralis muscle-area index, is an independent predictor of poor outcomes after HT. This parameter is easily measurable from commonly obtained preoperative CT scans and may be considered in transplant evaluations.

The Relationship Between Rehabilitation and Frailty in Advanced Heart or Lung Disease

Background

Frailty increases morbidity and mortality in patients with advanced heart and lung disease. Emerging evidence shows that postoperative cardiac or pulmonary rehabilitation can improve the frailty status of these patients. The aim of this hypothesis-generating study was to test the relationship between prehabilitation and frailty in patients with advanced heart or lung disease referred for heart and lung transplantation.

Methods

The study was a retrospective audit of consecutive patients with advanced heart or lung disease referred for transplant assessment between January 2021 and December 2022. Frailty scores were recorded using Fried's frailty phenotype (range, 0-5), and rehabilitation status of patients at the time of frailty assessment was recorded.

Results

Of 286 patients, 124 patients had advanced heart disease (mean age 53 ± 12 y; 82% men) and 162 patients had advanced lung disease (mean age 55 ± 12 y; 43% men). Sixty-nine (24%) patients were robust (score 0), 156 (55%) were prefrail (score, 1-2), and 61 (21%) were frail (score, 3-5). Eighty-two (29%) patients participated in hospital-based rehabilitation, 72 (25%) in home-based rehabilitation, and 132 (46%) in no rehabilitation. Frailty scores were significantly lower in patients participating in hospital-based or home-based rehabilitation compared with patients not participating in rehabilitation (0.8 ± 1.0 versus 0.8 ± 0.9 versus 2.3±1.2, P < 0.0001).

Conclusions

This study shows that patients participating in cardiac or pulmonary rehabilitation are less frail compared with patients not participating in rehabilitation. These findings suggest that prehabilitation could be beneficial for patients awaiting heart or lung transplantation.

What motivates heart transplantation patients to exercise and engage in physical activity? A network analysis

AIMS

After heart transplantation (HTx), increments in physical activity (PA) are strongly recommended. However, participation rates in exercise-based cardiac rehabilitation and engagement in PA are insufficient in many patients. Hence, this study aimed to explore the central factors and the interconnections among distinct types of motivation to exercise, PA, sedentary time, psychosomatic, diet, and activity limitation characteristics in post-HTx patients.

METHODS AND RESULTS

This is a cross-sectional study involving 133 post-HTx patients (79 men, mean age 57 ± 13 years, mean time from transplantation 55 ± 42 months) recruited from an outpatient clinic in Spain. The patients were asked to fill in questionnaires measuring self-reported PA, motivation to exercise, kinesiophobia, musculoskeletal pain, quality of sleep, depression, functional capacity, frailty, sarcopenia risk, and diet quality. Two network structures were estimated: one network including PA and one network including sedentary time as nodes. The relative importance of each node in the network structures was determined using centrality analyses. According to the strength centrality index, functional capacity and identified regulation (subtypes of motivation to exercise) are the two most central nodes of the network (strength: z-score = 1.35-1.51). Strong and direct connections emerged between frailty and PA and between sarcopenia risk and sedentary time.

CONCLUSION

Functional capacity and autonomous motivation to exercise are the most promising targets of interventions to improve PA levels and sedentary time in post-HTx patients. Furthermore, frailty and sarcopenia risk were found to mediate the effects of several other factors on PA and sedentary time.

Moving towards the detection of frailty with biomarkers: A population health study

Aging adults experience increased health vulnerability and compromised abilities to cope with stressors, which are the clinical manifestations of frailty. Frailty is complex, and efforts to identify biomarkers to detect frailty and pre-frailty in the clinical setting are rarely reproduced across cohorts. We developed a predictive model incorporating biological and clinical frailty measures to identify robust biomarkers across data sets. Data were from two large cohorts of older adults: "Invecchiare in Chianti (Aging in Chianti, InCHIANTI Study") (n = 1453) from two small towns in Tuscany, Italy, and replicated in the Atherosclerosis Risk in Communities Study (ARIC) (n = 6508) from four U.S. communities. A complex systems approach to biomarker selection with a tree-boosting machine learning (ML) technique for supervised learning analysis was used to examine biomarker population differences across both datasets. Our approach compared predictors with robust, pre-frail, and frail participants and examined the ability to detect frailty status by race. Unique biomarker features identified in the InCHIANTI study allowed us to predict frailty with a model accuracy of 0.72 (95% confidence interval (CI) 0.66-0.80). Replication models in ARIC maintained a model accuracy of 0.64 (95% CI 0.66-0.72). Frail and pre-frail Black participant models maintained a lower model accuracy. The predictive panel of biomarkers identified in this study may improve the ability to detect frailty as a complex aging syndrome in the clinical setting. We propose several concrete next steps to keep research moving toward detecting frailty with biomarker-based detection methods.

Assessing nutrition status, sarcopenia, and frailty in adult transplant recipients

The assessment of nutrition status, sarcopenia, and frailty holds significant relevance in the context of adult transplantation, as these factors are associated with an unfavorable prognosis; thus, transplant candidates must undergo a full nutrition assessment. Screening tools may be used to prioritize patients, this can be done using the Nutrition Risk Screening 2002 or Royal Free Hospital-Nutritional Prioritizing Tool. Subsequently, a thorough nutrition-focused physical examination should be conducted to evaluate clinical signs of nutrition deficiencies, fat and muscle loss, and fluid overload; dietary history and current intake must also be assessed. Apart from physical examination, specific testing for sarcopenia and frailty are recommended. For sarcopenia assessment, specifically for muscle quantification, the gold standard is the cross-sectional measurement of the muscle at L3 obtained from a computed tomography scan or magnetic resonance imaging; dual-energy x-ray absorptiometry is also a good tool especially when appendicular skeletal muscle index is calculated. Other more readily available options include phase angle from bioelectrical impedance or bioimpedance spectroscopy. In the sarcopenia assessment, muscle function evaluation is required, handgrip strength stands as the primary test for this purpose; this test is also part of the subjective global assessment and is included in some frailty scores. Finally, for frailty assessment, the Short Physical Performance Battery is useful for evaluating physical frailty, and for a multidimensional evaluation, the Fried frailty phenotype can be used. Specifically for liver transplant candidates, the use of Liver Frailty Index is recommended.

Association of frailty with postoperative outcomes following thoracic transplantation: A national analysis

Objective

Frailty has been repeatedly associated with inferior outcomes after surgical hospitalizations. However, a thorough evaluation of the impact of frailty on the clinical and financial outcomes of patients undergoing solid-organ thoracic transplantation is sparse in the literature. We evaluated the association of frailty, as determined by an administrative tool, with postoperative outcomes and healthcare resource use after heart or lung transplantation.

Methods

The Nationwide Readmissions Database was used to identify all adult hospitalizations for heart or lung transplant from 2014 to 2020. Patients were grouped as frail or nonfrail using International Classification of Diseases codes associated with conditions in the Johns Hopkins Adjusted Clinical Groups cluster. Multivariable regression models were developed to evaluate the association of frailty status on in-hospital mortality, complications, length of stay, costs, and unplanned readmissions.

Results

Of an estimated 35,862 heart or lung transplant recipients, 7316 (20.4%) were considered frail. After multivariable adjustment, frailty in heart transplantation was associated with greater odds of in-hospital mortality (adjusted odds ratio, 1.54; 95% CI, 1.19-1.99) and infectious complications (adjusted odds ratio, 1.77; 95% CI, 1.45-2.15; P < .001). Frailty in lung transplantation was also associated with higher odds of in-hospital mortality (adjusted odds ratio, 1.38; 95% CI, 1.11-1.69) and infectious complications (adjusted odds ratio, 1.93; 95% CI, 1.60-2.31). In addition, frailty in both heart transplantation and lung transplantation was associated with increased postoperative length of stay and greater costs.

Conclusions

Among transplant recipients, those classified as frail were associated with increased in-hospital mortality, perioperative complications, and resource use.

Bioimpedance Spectroscopy in Heart Transplantation: Posttransplant Changes in Body Composition and Effects in Outcomes

BACKGROUND

Bioimpedance spectroscopy yields measurements of fat-free mass, fat mass, phase angle, and other measures. Bioimpedance spectroscopy has been validated as a preoperative assessment tool in cardiac surgical studies, in which low phase angle predicted morbidity and mortality. No studies have evaluated bioimpedance spectroscopy following heart transplantation.

METHODS

We evaluated body composition, nutrition status (Subjective Global Assessment, body mass index, midarm muscle circumference, and triceps skinfolds), and functional status (handgrip strength and 6-min walk test) in 60 adults. Body composition measurements via a 256-frequency bioimpedance spectroscopy device included fat and fat-free mass as well as phase angle calculated at 50 kHz. Testing was completed at baseline and 1, 3, 6, and 12 mo following heart transplantation. Mortality and hospital readmissions were analyzed.

RESULTS

Phase angle and fat mass increased while fat-free mass decreased; grip strength and 6-min walk test improved after transplantation (all P <  0.001). Improvement in phase angle in the first month postoperatively was associated with reduced risk of readmission. Low perioperative and 1-mo phase angles were associated with prolonged posttransplant length of stay (median: 13 versus 10 d, P =  0.03), increased infection-related readmissions (40% versus 5%, P =  0.001), and increased 4-y mortality (30% versus 5%, P =  0.01).

CONCLUSIONS

Phase angle, grip strength, and 6-min walk test distance improved after heart transplantation. Low phase angle appears to be associated with suboptimal outcomes and may be a feasible and affordable method to predict outcomes. Further research should ascertain whether preoperative phase angle can predict outcomes.

Frailty Is Common in Heart Transplant Candidates But Is Not Associated With Clinical Events and Is Reversible After Heart Transplantation

Assessment of frailty before heart transplant (HT) is recommended but is not standard in most HT protocols. Our objective was to evaluate frailty at inclusion in HT list and during follow-up and to assess the influence of baseline frailty on prognosis. A prospective multicenter study in all adults included in the nonurgent HT waiting list. Frailty was defined as Fried's frailty phenotype score ≥3. Mean follow-up was 25.9 ± 1.2 months. Of 99 patients (mean age 54.8 [43.1 to 62.5] years, 70 men [70.7%]), 28 were frail (28.3%). A total of 85 patients received HT after 0.5 ± 0.01 years. Waiting time was shorter in frail patients (0.6 years [0.3 to 0.8] vs 0.2 years [0.1 to 0.4], p = 0.001) because of an increase in priority. Baseline frailty was not associated with overall mortality, (hazard ratio 0.99 [95% confidence interval 0.41 to 2.37, p = 0.98]). A total of 16 transplant recipients died (18.8%). Of the remaining 69 HT recipients, 65 underwent frailty evaluation during follow-up. Patients without baseline frailty (n = 49) did not develop it after HT. Of 16 patients with baseline frailty, only 2 were still frail at the end of follow-up. Frailty is common in HT candidates but is reversible in most cases after HT and is not associated with post-transplant mortality. Our results suggest that frailty should not be considered an exclusion criterion for HT.

Frailty in the Advanced Heart Failure Patient: A Challenging, Neglected, Yet Potentially Modifiable Risk Factor

Purpose of review

There is an increasing push for frailty assessment to become a routine part of the evaluation of potential candidates for advanced heart failure (AHF) therapies. The aim of this review is to highlight the importance of frailty in the care of the AHF patient.

Recent findings

This review focuses on some of the available data for the assessment of frailty specifically in the AHF, durable mechanical circulatory support (MCS), and heart transplant (HT) patients, and explores some of the challenges in assessing frailty in these patient populations.

Summary

As the presence of frailty can significantly impact outcomes after HT and durable MCS implantation, there should be an increased recognition of this entity during routine evaluation and management of the AHF patient.

Functional status predicts pediatric heart transplant outcomes: A united network for organ sharing (UNOS) database study

BACKGROUND

Functional status predicts waitlist survival in adult heart transplantation and is an independent predictor of outcomes in pediatric liver transplantation. This has not been studied in pediatric heart transplantation. Study aims were to determine the association of: (1) functional status at listing with waitlist and post-transplant outcomes, and (2) functional status at transplant with post-transplant outcomes in pediatric heart transplantation.

METHODS

Retrospective United Network of Organ Sharing database study of pediatric patients listed for heart transplant between 2005 and 2019 with Lansky Play Performance Scale (LPPS) scores at listing. Standard statistical methods were used to assess relationships between LPPS and outcomes (waitlist and post-transplant). Negative waitlist outcome was defined as death or removal from waitlist due to clinical deterioration.

RESULTS

There were 4,169 patients identified, including 1,080 with LPPS 80-100 (normal activity), 1,603 with LPPS 50-70 (mild limitations), and 1,486 with LPPS 10-40 (severe limitations). LPPS 10-40 correlated with negative waitlist outcomes (HR 1.69, CI 1.59-1.80, p < 0.0001). While LLPS at listing had no association with post-transplant survival, those with LPPS 10-40 at transplant had inferior 1-year post-transplant survival compared to those with LPPS ≥50 (92% vs 95%-96%, p = 0.0011). Functional status was an independent predictor of post-transplant outcomes in patients with cardiomyopathy. A functional improvement of ≥20 points between listing and transplant (N = 770, 24%) was associated with higher 1-year post-transplant survival (HR 1.63, 95% CI: 1.10-2.41, p = 0.018).

CONCLUSIONS

Functional status is associated with waitlist and post-transplant outcomes. Interventions targeting functional impairment may improve pediatric heart transplantation outcomes.

Cellular Senescence and Frailty in Transplantation

Purpose of review

To summarizes the literature on cellular senescence and frailty in solid-organ transplantation and highlight the emerging role of senotherapeutics as a treatment for cellular senescence.

Recent findings

Solid-organ transplant patients are aging. Many factors contribute to aging acceleration in this population, including cellular senescence. Senescent cells accumulate in tissues and secrete proinflammatory and profibrotic proteins which result in tissue damage. Cellular senescence contributes to age-related diseases and frailty. Our understanding of the role cellular senescence plays in transplant-specific complications such as allograft immunogenicity and infections is expanding. Promising treatments, including senolytics, senomorphics, cell-based regenerative therapies, and behavioral interventions, may reduce cellular senescence abundance and frailty in patients with solid-organ transplants.

Summary

Cellular senescence and frailty contribute to adverse outcomes in solid-organ transplantation. Continued pursuit of understanding the role cellular senescence plays in transplantation may lead to improved senotherapeutic approaches and better graft and patient outcomes.

Multidisciplinary Care in Heart Failure Services

The American College of Cardiology/American Heart Association/Heart Failure Society of American 2022 guidelines for heart failure (HF) recommend a multidisciplinary team approach for patients with HF. The multidisciplinary HF team-based approach decreases the hospitalization rate for HF and health care costs and improves adherence to self-care and the use of guideline-directed medical therapy. This article proposes the optimal multidisciplinary team structure and each team member's delineated role to achieve institutional goals and metrics for HF care. The proposed HF-specific multidisciplinary team comprises cardiologists, surgeons, advanced practice providers, clinical pharmacists, specialty nurses, dieticians, physical therapists, psychologists, social workers, immunologists, and palliative care clinicians. A standardized multidisciplinary HF team-based approach should be incorporated to optimize the structure, minimize the redundancy of clinical responsibilities among team members, and improve clinical outcomes and patient satisfaction in their HF care.

The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2021 Part II: Cardiac Transplantation

This article spotlights the research highlights of this year that specifically pertain to the specialty of anesthesia for heart transplantation. This includes the research on recent developments in the selection and optimization of donors and recipients, including the use of donation after cardiorespiratory death and extended criteria donors, the use of mechanical circulatory support and nonmechanical circulatory support as bridges to transplantation, the effect of COVID-19 on heart transplantation candidates and recipients, and new advances in the perioperative management of these patients, including the use of echocardiography and postoperative outcomes, focusing on renal and cerebral outcomes.

The role of frailty in advanced HF and cardiac transplantation

Frailty is a complex, multi-system condition often associated with multimorbidity. It has become an important prognostic maker across a range of conditions and is particularly relevant in patients with cardiovascular disease. Frailty encompasses a range of domains including, physical, psychological, and social. There are currently a range of validated tools available to measure frailty. It is an especially important measurement in advanced HF, because frailty occurs in up to 50% of HF patients and is potentially reversible with therapies such as mechanical circulatory support and transplantation. Moreover, frailty is dynamic, and therefore serial measurements are important. This review delves into the measurement of frailty, mechanisms, and its role in different cardiovascular cohorts. Understanding frailty will help determine patients that will benefit from therapies, as well as prognosticate outcomes.

Addressing sex-based disparities in solid organ transplantation in the United States - a conference report

Solid organ transplantation provides the best treatment for end-stage organ failure, but significant sex-based disparities in transplant access exist. On June 25, 2021, a virtual multidisciplinary conference was convened to address sex-based disparities in transplantation. Common themes contributing to sex-based disparities were noted across kidney, liver, heart, and lung transplantation, specifically the existence of barriers to referral and wait listing for women, the pitfalls of using serum creatinine, the issue of donor/recipient size mismatch, approaches to frailty and a higher prevalence of allosensitization among women. In addition, actionable solutions to improve access to transplantation were identified, including alterations to the current allocation system, surgical interventions on donor organs, and the incorporation of objective frailty metrics into the evaluation process. Key knowledge gaps and high-priority areas for future investigation were also discussed.

Virtual cardiac fitness training in pediatric heart transplant patients: A pilot study

BACKGROUND

Cardiac fitness training in pediatric heart transplant recipients can improve functional capacity. Widespread implementation has been limited mostly due to logistical constraints, specifically related to travel. The aim of this study was to implement and assess a virtual cardiac fitness program for pediatric heart transplant patients.

METHODS

Participants were between the age of 10 and 20 years old. All subjects completed an initial 6MWT, strength/flexibility assessment, and QOL assessment with the PROMIS measurement. Participants then underwent a 16-week intervention with exercise sessions twice weekly for 30 min with a trained exercise physiologist over a virtual platform. At the end of the intervention period, participants repeated a 6MWT, strength/flexibility assessment, and PROMIS measurement. Throughout the study, patients wore a FitBit accelerometer to monitor daily activity levels.

RESULTS

Thirteen individuals were enrolled. Mean age was 15.4 years (SD =3.4) with a mean post-transplant period of 9.7 years (SD = 4.3). Session attendance was 83%. Post-intervention measurements showed improvements in 6MWT (median, +21 m, p = .02), push-up repetitions (median, +5 rep, p = .0005), wall-sit duration (median, +10 s, p = .001), plank duration (median, +9 s, p = .03), sit-up repetitions (median, +7 rep, p = .002), and sit and reach distance (median, +5 cm, p = .04). PROMIS measurement showed significant improvements in self-reported fatigue (Δz-score, -7.7, p = .008) and sleep impairment (Δz-score, -5.9, p = .002). Average daily step count increased 1464 steps per day per patient (p = .008).

CONCLUSION

We have demonstrated the successful implementation of a virtual cardiac fitness with excellent adherence and improvement in physical fitness and QOL metrics.

Physical Frailty is Modifiable in Young Cardiac Rehabilitation Patients

Frailty is a standardized, quantitative metric used to assess multisystem physiologic reserve and vulnerability to poor health outcomes. Cardiac rehabilitation (CR) positively impacts patient outcomes, including frailty, in adult cardiovascular disease (CVD); however, both the frailty paradigm and CR are understudied in pediatric CVD. This retrospective, single-center cohort study aimed to determine baseline composite frailty for pediatric-onset CVD patients and examine its change throughout CR using a proposed frailty assessment tool. Youth with pediatric-onset CVD participating in CR were stratified into five CVD diagnostic groups: post-heart transplant (HTx) (n = 34), post-ventricular assist device (VAD) (n = 12), single ventricle (n = 20) and biventricular (n = 29) congenital heart disease, and cardiomyopathy (n = 25), and frailty was assessed at baseline and every 30 days during CR. Post-HTx and post-VAD groups had significantly higher median frailty scores at baseline (6/10 and 5.75/10, respectively) driven by reduced strength, gait speed, and functional status. All groups except post-VAD displayed a significant absolute reduction in frailty from baseline to 120 days (HTx: - 3.5; VAD: - 3; SV CHD: - 1; BV CHD: - 1; CM: - 1.5), with similar median post-CR scores (1-3/10 in all groups). These improvements did not significantly correlate with number of CR sessions attended. This study established that frailty exhibits discriminatory utility across pediatric-onset CVD groups at baseline and is significantly modifiable over time. Improvements in frailty and other fitness metrics are likely due to a combination of post-operative recovery, post-diagnosis pharmacological and lifestyle changes, and CR. Further study of this frailty tool is needed to explore its prognostic utility.

Current recommendations regarding evaluation of cognitive functioning in organ transplant candidates

PURPOSE OF REVIEW

Cognitive impairment is associated with negative effects on solid organ transplant candidates, recipients, and their care partners. However, because of the heterogeneity of mechanisms, presentations, and assessment measures, research suggests a wide array of impairments, patterns of impairments, and unclear trajectories posttransplant. This review provides an abbreviated synthesis of recent research on cognitive impairments observed in organ-eligible candidates and potential trajectories through posttransplant, current clinical recommendations regarding integration of assessment into routine clinical transplant practice, as well as recommendations for future research.

RECENT FINDINGS

Transplantation may resolve certain disease-contributing factors to cognitive impairments but also introduces new potential neurocognitive assaults. Recent studies in kidney and lung recipients document continued impairments in subsets of patients, particularly those identified as frail. For liver candidates, new assessment measures of hepatic encephalopathy have been developed and preliminarily tested with potential for translation into routine clinical care. Clinical implications, as well as ethical considerations are discussed.

SUMMARY

Although guidelines agree that cognitive assessment is an important part of the organ transplantation process, many questions remain of how to best assess cognition and intervene when cognitive impairment is identified in transplant populations. Further research should focus on prospective, longitudinal assessments in transplant-eligible populations through posttransplant.

Outcomes of Cardiac Transplantation in Western Australia - A Contemporary Single Centre Experience

BACKGROUND

Cardiac transplantation remains the gold standard therapy for select patients with end-stage heart failure and outcomes have improved significantly over the past few decades. We report the 5-year contemporary experience of cardiac transplantation in Western Australia, one of the most remote transplant centres worldwide.

METHODS

Patients undergoing isolated cardiac transplant at Fiona Stanley Hospital (FSH) from February 2015 until April 2021 were included. Donor details were collected using donor electronic records (Donate Life, Australia). Recipient data was collated from electronic medical records at FSH and the Australia and New Zealand Society of Cardiothoracic Surgery database. The primary outcome measure was all-cause mortality. Secondary outcome measures included postoperative intensive care and total hospital length of stay and rates of acute kidney injury, rejection, serious infections, and cardiac allograft vasculopathy. Frailty indices were also assessed.

RESULTS

A total of 60 patients were included (mean age 53±14 yrs, 66.7% male). The commonest indication for transplant was a non-ischaemic cardiomyopathy (46.7%). Mean donor age was 35±12 years and median donor ischaemia time was 171 minutes (IQR=138-240). After median follow-up of 3.7 years, there were no mortalities. Postoperative renal failure occurred in 21 (35.0%) patients, pneumonia in four (6.7%), deep sternal wound infection in three (5.1%), acute rejection in 17 (28.3%) and cardiac allograft vasculopathy (CAV) in 23 (38.3%).

CONCLUSION

With recipient and donor criteria comparable to national and international standards, compounded by the challenges of geographic isolation, we report the first published data on contemporary outcomes post isolated cardiac transplantation in Western Australia.

Frailty and solid-organ transplant candidates: a scoping review

Background

There is currently no consensus as to a standardized tool for frailty measurement in any patient population. In the solid-organ transplantation population, routinely identifying and quantifying frailty in potential transplant candidates would support patients and the multidisciplinary team to make well-informed, individualized, management decisions. The aim of this scoping review was to synthesise the literature regarding frailty measurement in solid-organ transplant (SOT) candidates.

Methods

A search of four databases (Cochrane, Pubmed, EMBASE and CINAHL) yielded 3124 studies. 101 studies (including heart, kidney, liver, and lung transplant candidate populations) met the inclusion criteria.

Results

We found that studies used a wide range of frailty tools (N = 22), including four ‘established’ frailty tools. The most commonly used tools were the Fried Frailty Phenotype and the Liver Frailty Index. Frailty prevalence estimates for this middle-aged, predominantly male, population varied between 2.7% and 100%. In the SOT candidate population, frailty was found to be associated with a range of adverse outcomes, with most evidence for increased mortality (including post-transplant and wait-list mortality), post-operative complications and prolonged hospitalisation. There is currently insufficient data to compare the predictive validity of frailty tools in the SOT population.

Conclusion

Overall, there is great variability in the approach to frailty measurement in this population. Preferably, a validated frailty measurement tool would be incorporated into SOT eligibility assessments internationally with a view to facilitating comparisons between patient sub-groups and national and international transplant services with the ultimate goal of improved patient care.

Characteristics and Outcomes of Left Ventricular Assist Device Recipients Transplanted Before and After the New Donor Heart Allocation System

BACKGROUND

Concerns about the impact of the new donor heart allocation system on post-transplant outcomes have emerged after its implementation. We sought to evaluate the characteristics and outcomes of left ventricular assist device (LVAD) recipients transplanted before and after the implantation of the new policy on October 18, 2018.

METHODS

Data on bridge to transplantation adult LVAD patients January 2015 and October 2021, with durable LVAD as a (BTT), was queried from the United Network of Organ Sharing (UNOS) registry. The main outcomes were 30-day all-cause mortality, 30-day fatal graft failure, 1-year all-cause mortality, treated acute rejection at one year and renal replacement therapy (RRT) for acute renal failure.

RESULTS

In our study, 7096 patients met the inclusion criteria including 2,435 in the new allocation system. The transplanted patients in the new allocation system era had older donor age, longer ischemic time and higher proportion of newer generation LVADs. Adjusted 30-day all-cause mortality was significantly lower for LVAD recipients in the new allocation system era (2.5% vs 3.6%; sub-hazard ratio [SHR] 0.36, 95% Confidence intervals [CI] 0.27-0.48, p<0.001) without differences in the risk of fatal graft failure and one-year mortality (7.8% vs 9.6%). Significantly lower adjusted 30-day mortality with HVAD and HM3 devices than HM2 in the new allocation system era was found, without differences in one-year mortality. Acute allograft rejection requiring treatment was significantly lower (Odds Ratio 0.78, 95% CI 0.65-0.94, p=0.01) whereas a trend towards higher risk of renal failure requiring RRT was identified.

CONCLUSIONS

Despite changing donor characteristics and longer ischemic times, post-transplant outcomes in LVAD recipients have not worsened with the implementation of the new allocation system and this finding is related to the use of newer generation continuous flow LVADs.

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.

Sarcopenia and risk of infection in adult heart transplant recipients in Japan

AIMS

Heart transplantation (HT) is an effective therapeutic option for end-stage heart failure. Infection is a major cause of morbidity and mortality after HT. Sarcopenia, defined as the loss of muscle mass and strength, is a common comorbidity in HT candidates with end-stage heart failure. However, the effects of sarcopenia on the occurrence of post-HT infections are not well understood. Therefore, we explored the association between the skeletal muscle mass and post-transplant infections in adult HT recipients.

METHODS AND RESULTS

We retrospectively examined the records of 135 patients who underwent HT between August 2007 and November 2019 at our institution. Pre-transplant computed tomography was used to calculate the skeletal muscle index (SMI) at the level of the third lumbar vertebra. Muscle wasting was defined as the SMI of the lowest sex-based tertiles. The primary endpoint was infections within 6 months of HT. The study included 109 patients (80 men, mean age: 41.6 ± 12.0 years): 37 patients in the muscle wasting group and 72 patients in the non-muscle wasting group. The mean SMI values in the muscle wasting and non-muscle wasting groups were 29.9 ± 4.8 cm² /m² and 40.7 ± 6.7 cm² /m² , respectively. Prior to HT, 108 (99.1%) patients were on left ventricular assist device support, and during that support, the rate of late right heart failure was significantly higher in the muscle wasting group than non-muscle wasting group (P = 0.012). Sixteen infections occurred within 6 months of HT. The most common infection sites included the respiratory tract (n = 5) and the upper gastrointestinal tract (n = 5), followed by the urinary tract (n = 4). Overall, 10 patients experienced infections in the muscle wasting group (27.0%) and 6 in the non-muscle wasting group (8.3%) (P = 0.009). Two patients in the muscle wasting group required intensive care unit admission, compared to none in the non-muscle wasting group. Low skeletal muscle mass was associated with infections in the univariate and multivariate logistic regression models (hazard ratio: 3.68, 95% confidence interval: 1.19-11.3; P = 0.023). However, the duration of all-cause mortality within 3 years did not differ between the groups (P = 0.56).

CONCLUSIONS

Low skeletal muscle mass is a predictor of post-HT infections within 6 months of HT.

Association between frailty and clinical outcomes in surgical patients admitted to intensive care units: a systematic review and meta-analysis

BACKGROUND

Preoperative frailty may be a strong predictor of adverse postoperative outcomes. We investigated the association between frailty and clinical outcomes in surgical patients admitted to the ICU.

METHODS

PubMed, Embase, and Ovid MEDLINE were searched for relevant articles. We included full-text original English articles that used any frailty measure, reporting results of surgical adult patients (≥18 yr old) admitted to ICUs with mortality as the main outcome. Data on mortality, duration of mechanical ventilation, ICU and hospital length of stay, and discharge destination were extracted. The quality of included studies and risk of bias were assessed using the Newcastle Ottawa Scale. Data were synthesised according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

RESULTS

Thirteen observational studies met inclusion criteria. In total, 58 757 patients were included; 22 793 (39.4%) were frail. Frailty was associated with an increased risk of short-term (risk ratio [RR]=2.66; 95% confidence interval [CI]: 1.99-3.56) and long-term mortality (RR=2.66; 95% CI: 1.32-5.37). Frail patients had longer ICU length of stay (mean difference [MD]=1.5 days; 95% CI: 0.8-2.2) and hospital length of stay (MD=3.9 days; 95% CI: 1.4-6.5). Duration of mechanical ventilation was longer in frail patients (MD=22 h; 95% CI: 1.7-42.3) and they were more likely to be discharged to a healthcare facility (RR=2.34; 95% CI: 1.36-4.01).

CONCLUSION

Patients with frailty requiring postoperative ICU admission for elective and non-elective surgeries had increased risk of mortality, lengthier admissions, and increased likelihood of non-home discharge. Preoperative frailty assessments and risk stratification are essential in patient and clinician planning, and critical care resource utilisation.

CLINICAL TRIAL REGISTRATION

PROSPERO CRD42020210121.

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.

Cardiac Allograft Injuries: A Review of Approaches to a Common Dilemma, With Emphasis on Emerging Techniques

Clinical features of allograft injury are often unreliable, and context within the transplant journey is key. In the setting of post-transplant allograft dysfunction, the choice of initial investigation depends on clinical assessment and history. One of the major considerations is the time post transplantation in helping to decide a likely cause for allograft injury. Immediately post transplantation, it is important to consider donor factors (including donor demographics as well as immunological match), ischaemic times, surgical issues as well as early rejection. Clinical suspicion needs to remain high with variable presentations, including haemodynamic instability, arrhythmia, as well as left ventricular dysfunction. Symptoms of allograft dysfunction may include dyspnoea, exertional intolerance, dizziness / lightheadedness, palpitations, as well as right or left heart failure. In the coming weeks and months, endomyocardial biopsy and blood-based biomarkers may be helpful including high sensitivity troponin and donor-derived cell-free DNA. Molecular markers for rejection are hopeful, and may also be useful in non-ischaemic causes of allograft dysfunction. Screening remains important late post heart transplant due to variety of signs associated with rejection (early) and lack of typical anginal symptoms (later). New imaging modalities - especially cardiac magnetic resonance imaging, have been shown to be useful for assessing cause of allograft dysfunction including ischemia, infarction and rejection.

Frailty Measures of Patient-reported Activity and Fatigue May Predict 1-year Outcomes in Ambulatory Advanced Heart Failure: A Report From the REVIVAL Registry

BACKGROUND

The Fried Frailty Phenotype predicts adverse outcomes in geriatric populations, but has not been well-studied in advanced heart failure (HF). The Registry Evaluation of Vital Information for Ventricular Assist Devices (VADs) in Ambulatory Life (REVIVAL) study prospectively collected frailty measures in patients with advanced HF to determine relevant assessments and their impact on clinical outcomes.

METHODS AND RESULTS

HF-Fried Frailty was defined by 5 baseline components (1 point each): (1) weakness: hand grip strength less than 25% of body weight; (2) slowness based on time to walk 15 feet; (3) weight loss of more than 10 lbs in the past year; (4) inactivity; and (5) exhaustion, both assessed by the Kansas City Cardiomyopathy Questionnaire. A score of 0 or 1 was deemed nonfrail, 2 prefrail, and 3 or greater was considered frail. The primary composite outcome was durable mechanical circulatory support implantation, cardiac transplant or death at 1 year. Event-free survival for each group was determined by the Kaplan-Meier method and the hazard of prefrailty and frailty were compared with nonfrailty with proportional hazards modeling. Among 345 patients with all 5 frailty domains assessed, frailty was present in 17%, prefrailty in 40%, and 43% were nonfrail, with 67% (n = 232) meeting the criteria based on inactivity and 54% (n = 186) for exhaustion. Frail patients had an increased risk of the primary composite outcome (unadjusted hazard ratio [HR] 2.82, 95% confidence interval [CI] 1.52-5.24; adjusted HR 3.41, 95% CI 1.79-6.52), as did prefrail patients (unadjusted HR 1.97, 95% CI 1.14-3.41; adjusted HR 2.11, 95% CI 1.21-3.66) compared with nonfrail patients, however, the predictive value of HF-Fried Frailty criteria was modest (Harrel's C-statistic of 0.603, P = .004).

CONCLUSIONS

The HF-Fried Frailty criteria had only modest predictive power in identifying ambulatory patients with advanced HF at high risk for durable mechanical circulatory support, transplant, or death within 1 year, driven primarily by assessments of inactivity and exhaustion. Focus on these patient-reported measures may better inform clinical trajectories in this population.

Body composition and maximal exercise capacity after heart transplantation

Aims

Maximal exercise capacity as measured by peak oxygen consumption (pVO₂) in cardiopulmonary exercise testing (CPET) of heart transplant recipients (HTR) is limited to a 50–70% level of healthy age‐matched controls. This study investigated the relationship between body composition and pVO₂ during the first decade post‐transplant.

Methods and results

Body composition was determined by dual‐energy X‐ray absorptiometry (DXA) and pVO₂ by CPET in 48 HTR (n = 38 males; mean age 51 ± 12 years). A total of 95 assessments were acquired 1–9 years post‐transplant, and the results of four consecutive periods were compared [Period 1: 1–2 years (n = 25); 2: 3–4 years (n = 23); 3: 5–6 years (n = 23); 4: 7–9 years (n = 24)]. Linear regression analysis analysed the correlation between pVO₂ and pairs of appendicular lean mass (ALM) and fat mass (FM). The relation between ALM and daily dose of calcineurin inhibitor (CNI) was explored using partial correlation controlling for age, gender, and height. pVO₂ increased from 0.98 (0.34) to 1.35 (0.35) L/min (P < 0.01) between Periods 1 and 4 corresponding to 54.5–63.3% of predicted value. Peak heart rate (HR) raised from 115 ± 19 to 131 ± 23 b.p.m. (P = 0.05), and anaerobic threshold (AT = VO₂ achieved at AT) increased from 0.57 (0.18) to 0.83 (0.35) L/min (P < 0.01) between Periods 1 and 3. Median FM normalized to height² (FMI) always remained elevated (>8.8 kg/m²). ALM normalized to body mass index increased from 0.690 (0.188) to 0.848 (0.204) m² (P = 0.02) between Periods 1 and 4, explaining 45% of the variance of pVO₂ (R² = 0.455; P < 0.001). Eighty‐one per cent of the variance of pVO₂ (R² = 0.817; P < 0.001) in multiple regression was explained by AT (β = 0.488), ALM (β = 0.396), peak HR (β = 0.366), and FMI (β = −0.181). ALM was negatively correlated with daily CNI dose (partial R = −0.258; P = 0.01).

Conclusions

After heart transplantation, the beneficial effect of peripheral skeletal muscle gain on pVO₂ is opposed by increased FM. Our findings support lifestyle efforts to fight adiposity and CNI dose reduction in the chronic stable phase to favour positive adaptation of peripheral muscle mass.

Prevention and Reversal of Frailty in Heart Failure - A Systematic Review

BACKGROUND

Frailty is prevalent in patients with heart failure (HF) and associated with increased morbidity and mortality. Hence, there has been increased interest in the reversibility of frailty following treatment with medication or surgery. This systematic review aimed to assess the reversibility of frailty in patients with HF before and after surgical interventions aimed at treating the underlying cause of HF. It also aimed to assess the efficacy of cardiac rehabilitation and prehabilitation in reversing or preventing frailty in patients with HF.Methods and Results:Searches of PubMed, MEDLINE and Academic Search Ultimate identified studies with HF patients undergoing interventions to reverse frailty. Titles, abstracts and full texts were screened for eligibility based on the PRISMA guidelines and using predefined inclusion/exclusion criteria in relation to participants, intervention, control, outcome and study design. In total, 14 studies were included: 3 assessed the effect of surgery, 7 assessed the effect of rehabilitation programs, 2 assessed the effect of a prehabilitation program and 2 assessed the effect of program interruptions on HF patients.

CONCLUSIONS

Overall, it was found that frailty is at least partially reversible and potentially preventable in patients with HF. Interruption of rehabilitation programs resulted in deterioration of the frailty status. Future research should focus on the role of prehabilitation in mitigating frailty prior to surgical intervention.

Frailty of the Heart Recipient

Frailty has been defined as a state of increased vulnerability due to a decline in the reserve and function of multiple physiological systems. Initially conceived as a geriatric syndrome indicative of physiological aging, it is now apparent that frailty can also be observed as a manifestation of chronic disease states including heart failure. Estimates of the prevalence of frailty in heart failure vary according to the age of the study population and the frailty instrument used, however multiple studies have identified frailty to be prevalent in patients with advanced heart failure including those who are referred for heart transplantation. Frailty is emerging as an independent predictor of mortality both before and after bridge-to-transplant ventricular assist device (BTT VAD) implantation and heart transplantation. Frailty is also predictive of prolonged hospitalization following these procedures. Heart failure-associated frailty is a dynamic state. While reversibility of frailty can be anticipated in younger heart failure patients, predicting the reversibility of frailty is more challenging in older patients who often have multiple comorbidities that may contribute to the frailty syndrome. Prehabilitation is a promising approach to both preventing and reversing frailty however more research is urgently needed to establish its effectiveness in mitigating the adverse impacts of frailty on post-VAD and posttransplant morbidity and mortality.