Orthotopic heart transplantation with bicaval anastomosis using older donors

Risk factors and survival of patients with permanent pacemaker implantation after heart transplantation

Background

Permanent pacemaker (PPM) implantation after heart transplantation (HTX) may be required due to severe bradycardia. The aim of this study was to investigate the risk factors, indications, perioperative outcomes and complications of PPM implantation after HTX as well as the underlying effect on post-transplant mortality including causes of death.

Methods

This registry study included 621 patients receiving HTX at Heidelberg Heart Center between 1989 and 2018. Patients were stratified by PPM implantation after HTX. Data analysis of risk factors for PPM implantation included donor and recipient demographics, post-transplant medication, mortality, and causes of death.

Results

Thirty-six patients (5.8%) received PPM implantation after HTX, 12 (33.3%) with early PPM and 24 (66.7%) with late PPM. Indications for PPM implantation after HTX included sinus node dysfunction (SND) (n=15; 41.7%) and atrioventricular block (AVB) (n=21; 58.3%). Multivariate analysis revealed recipient body mass index (BMI) [hazard ratio (HR): 1.10; confidence interval (CI): 1.01-1.21; P=0.03], donor age (HR: 1.07; CI: 1.03-1.10; P<0.01), and biatrial HTX (HR: 2.63; CI: 1.22-5.68; P=0.01) as significant risk factors for PPM implantation after HTX. Kaplan-Meier estimator displayed a statistically significant inferior 5-year post-transplant survival among patients with early PPM after HTX in comparison to patients with late PPM or no PPM after HTX (P<0.01) along with a higher percentage of death due to infection (P<0.01).

Conclusions

Multivariate risk factors for PPM implantation after HTX include recipient BMI, donor age, and biatrial HTX. Early PPM implantation after HTX is associated with increased 5-year post-transplant mortality due to infection.

Results with expanded donor acceptance criteria in heart transplantation

OBJECTIVE

Over the past years both donor and recipient profiles have changed in heart transplantation. Satisfactory clinical outcomes of marginal donors in candidates >60 years of age have led us to allocate suboptimal donors to younger recipients as well. Therefore, we retrospectively reviewed our experience.

METHODS

Among 199 patients undergoing heart transplantation from January 2000 to February 2010, there were 83 (41%) aged 61-72 years. The other 116 (59%) ranged in age between 18 and 60 years. According to their clinical conditions as heart transplantation candidates, They were classified into 4 groups: younger recipients (n=116) of either optimal donors (n=72; group 1 [G1]) or marginal donors (n=44; group 2 [G2]) and older recipients (n=83) of either marginal grafts (n=70, group 3 [G3]) or optimal grafts (n=13; group 4 [G4]). The gender distribution, cause of end-stage heart failure, preoperative pulmonary hypertension incidence, pretransplantation clinical status, and mean follow-up were not significantly different among the 4 groups.

RESULTS

Overall 30-day survival was 90 ± 1% and 10-year rate was 78 ± 9%. Among the groups, 30-day and 10-year actuarial survival rates were, respectively: 94 ± 4% and 87 ± 1% for G1; 86 ± 5% and 84 ± 7% for G2; 88 ± 4% and 71 ± 7% for G3 and were 100% and 82 ± 7% for G4 (P=.7). In comparison among the 4 groups, there was no significant difference regarding freedom from graft failure (P=.3), right ventricular failure (P=.3), acute rejection episodes (P = .2), chronic rejection (P=.2), neoplasia (P=.5), or chronic renal failure (P=.1). Older recipients of marginal donors [G3] had a 4% (n=3) prevalence of permanent pacemaker implant, versus G2: 3% (n=2) among (P=.1).

CONCLUSION

Our results suggest that extended donor and recipient criteria do not compromise clinical outcomes after transplantation.

Cardiac pacemakers in the transplanted heart: short term with the biatrial anastomosis and unnecessary with the bicaval anastomosis

Sinus node dysfunction occurs commonly after orthotopic heart transplantation and may be caused by surgical trauma, ischemia to the sinus node, rejection, drug therapy and increasing donor age. In the past, using the standard biatrial technique described originally by Lower and Shumway, many series have reported permanent pacing in more than 10% of patients. Unlike sinus node dysfunction in nontransplanted patients, which typically worsens with time, sinus node dysfunction in the transplanted heart usually improves over a period of weeks to months. Delaying the implantation of a permanent pacemaker may render it unnecessary. The development of the bicaval technique for implantation of the donor heart appears to have decreased even further or even eliminated the need for early permanent pacing. Because sinus node dysfunction in the transplanted heart does not predict subsequent development of atrioventricular (AV) node dysfunction, rate-responsive atrial pacing should be used in the majority of cases. Even after appropriate pacing for sinus node dysfunction, the sinus node may recover and permanent pacing may be discontinued. AV conduction abnormalities are far less common and generally occur late after transplantation. Dual-chamber pacing is required and permanent pacing should be continued indefinitely.