Inferior Transplant Outcomes of Adolescents and Young Adults Bridged with a Ventricular Assist Device

Use of Organs for Heart Transplantation after Rescue Allocation: Comparison of Outcome with Regular Allocated High Urgent Recipients

BACKGROUND

 The number of patients waiting for heart transplantation (HTx) is exceeding the number of actual transplants. Subsequently, waiting times are increasing. One possible solution may be an increased acceptance of organs after rescue allocation. These organs had been rejected by at least three consecutive transplant centers due to medical reasons.

METHODS

 Between October 2010 and July 2019, a total of 139 patients underwent HTx in our department. Seventy (50.4%) of the 139 patients were transplanted with high urgency (HU) status and regular allocation (HU group); the remaining received organs without HU listing after rescue allocation (elective group, n = 69).

RESULTS

 Donor parameters were comparable between the groups. Thirty-day mortality was comparable between HU patients (11.4%) and rescue allocation (12.1%). Primary graft dysfunction with extracorporeal life support occurred in 26.9% of the elective group with rescue allocated organs, which was not inferior to the regular allocated organs (HU group: 35.7%). No significant differences were observed regarding the incidence of common perioperative complications as well as morbidity and mortality during 1-year follow-up.

CONCLUSIONS

 Our data support the use of hearts after rescue allocation for elective transplantation of patients without HU status. We could show that patients with rescue allocated organs showed no significant disadvantages in the early perioperative morbidity and mortality as well at 1-year follow-up.

Heart transplantation in patients with ventricular assist devices: Impacts of the implantation technique and support duration

BACKGROUND

Orthotopic heart transplantation (HTx) is the gold standard treatment for patients with terminal heart failure. As donor organs are limited, patients are often on ventricular assist device (VAD) support before receiving HTx. We aimed to compare the outcome after HTx in patients with and without preoperative VADs as well as in patients who underwent different VAD implantation techniques.

METHODS

A total of 126 patients underwent HTx at our department between 2010 and 2019 and were retrospectively analyzed. While 47 patients underwent primary transplantation (No VAD), 79 were on VAD support. The preoperative and intraoperative parameters were comparable between the two groups.

RESULTS

VAD support significantly increased the HTx operation time (<0.0001), cardiopulmonary bypass time (P < .01), and warm ischemia time (P = .04). The ventilation time (P = .02), intensive care unit (ICU) stay (P = .01), and hospital stay (P = .02) were also significantly longer in VAD patients than in No VAD patients. Minimally invasive VAD implantation significantly reduced the requirement for perioperative blood transfusion (P = .01) and rethoracotomy (P = .01). Nonetheless, survival analyses did not show significant differences between the groups, but there was a trend of better results for the primary transplantation patients (30-day survival: No VAD = 91.1%, VAD = 86.1%; n.s.).

CONCLUSIONS

We observed significantly worse perioperative parameters in patients who underwent transplantation after the implantation of a VAD compared to those who underwent primary transplantation. Minimally invasive VAD implantation without full sternotomy decreased complications during the subsequent HTx. In patients who are dependent on temporary VAD support as a bridge to transplantation, we believe that minimally invasive implantation should be performed if possible.

Overview of adult congenital heart transplants

Transplantation for adult patients with congenital heart disease (ACHD) is a growing clinical endeavor in the transplant community. Understanding the results and defining potential high-risk patient subsets will allow optimization of patient outcomes. This review summarizes the scope of ACHD transplantation, the mechanisms of late ventricular dysfunction, the ACHD population at risk of developing heart failure, the indications and potential contraindications for transplant, surgical considerations, and post-transplant outcomes. The findings reveal that 3.3% of adult heart transplants occur in ACHD patients. The potential mechanisms for the development of late ventricular dysfunction include a morphologic systemic right ventricle, altered coronary perfusion, and ventricular noncompaction. The indications for transplant in ACHD patients include systemic ventricular failure refractory medical therapy, Fontan patients failing from chronic passive pulmonary circulation, and progressive cyanosis leading to functional decline. Transplantation in ACHD patients can be quite complex and may require extensive reconstruction of the branch pulmonary arteries, systemic veins, or the aorta. Vasoplegia, bleeding, and graft right ventricular dysfunction can complicate the immediate post-transplant period. The post-transplant operative mortality ranges between 14% and 39%. The majority of early mortality occurs in ACHD patients with univentricular congenital heart disease. However, there has been improvement in operative survival in more contemporary studies. In conclusion, the experience with cardiac transplantation for ACHD patients with end-stage heart failure is growing, and high-risk patient subsets have been defined. Significant strides have been made in developing evidence-based guidelines of indications for transplant, and the intraoperative management of complex reconstruction has evolved. With proper patient selection, more aggressive use of mechanical circulatory support, and earlier referral of patients with failing Fontan physiology, outcomes should continue to improve.