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Peled Y, Ducharme A, Kittleson M, Bansal N, Stehlik J, Amdani S, Saeed D, Cheng R, Clarke B, Dobbels F, Farr M, Lindenfeld J, Nikolaidis L, Patel J, Acharya D, Albert D, Aslam S, Bertolotti A, Chan M, Chih S, Colvin M, Crespo-Leiro M, D'Alessandro D, Daly K, Diez-Lopez C, Dipchand A, Ensminger S, Everitt M, Fardman A, Farrero M, Feldman D, Gjelaj C, Goodwin M, Harrison K, Hsich E, Joyce E, Kato T, Kim D, Luong ML, Lyster H, Masetti M, Matos LN, Nilsson J, Noly PE, Rao V, Rolid K, Schlendorf K, Schweiger M, Spinner J, Townsend M, Tremblay-Gravel M, Urschel S, Vachiery JL, Velleca A, Waldman G, Walsh J. International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024. J Heart Lung Transplant 2024:S1053-2498(24)01679-6. [PMID: 39115488 DOI: 10.1016/j.healun.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 08/18/2024] Open
Abstract
The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.
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Affiliation(s)
- Yael Peled
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel.
| | - Anique Ducharme
- Deparment of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Michelle Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Neha Bansal
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Diyar Saeed
- Heart Center Niederrhein, Helios Hospital Krefeld, Krefeld, Germany
| | - Richard Cheng
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Brian Clarke
- Division of Cardiology, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Fabienne Dobbels
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Maryjane Farr
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX; Parkland Health System, Dallas, TX, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, TN, USA
| | | | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Deepak Acharya
- Division of Cardiovascular Diseases, University of Arizona Sarver Heart Center, Tucson, Arizona, USA
| | - Dimpna Albert
- Department of Paediatric Cardiology, Paediatric Heart Failure and Cardiac Transplant, Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Alejandro Bertolotti
- Heart and Lung Transplant Service, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Michael Chan
- University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Sharon Chih
- Heart Failure and Transplantation, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Monica Colvin
- Department of Cardiology, University of Michigan, Ann Arbor, MI; Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Maria Crespo-Leiro
- Cardiology Department Complexo Hospitalario Universitario A Coruna (CHUAC), CIBERCV, INIBIC, UDC, La Coruna, Spain
| | - David D'Alessandro
- Massachusetts General Hospital, Boston; Harvard School of Medicine, Boston, MA, USA
| | - Kevin Daly
- Boston Children's Hospital & Harvard Medical School, Boston, MA, USA
| | - Carles Diez-Lopez
- Advanced Heart Failure and Heart Transplant Unit, Department of Cardiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Anne Dipchand
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Melanie Everitt
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alexander Fardman
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Marta Farrero
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - David Feldman
- Newark Beth Israel Hospital & Rutgers University, Newark, NJ, USA
| | - Christiana Gjelaj
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew Goodwin
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Kimberly Harrison
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eileen Hsich
- Cleveland Clinic Foundation, Division of Cardiovascular Medicine, Cleveland, OH, USA
| | - Emer Joyce
- Department of Cardiology, Mater University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| | - Tomoko Kato
- Department of Cardiology, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan
| | - Daniel Kim
- University of Alberta & Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Me-Linh Luong
- Division of Infectious Disease, Department of Medicine, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Haifa Lyster
- Department of Heart and Lung Transplantation, The Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Marco Masetti
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Johan Nilsson
- Department of Cardiothoracic and Vascular Surgery, Skane University Hospital, Lund, Sweden
| | | | - Vivek Rao
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Katrine Rolid
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kelly Schlendorf
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Joseph Spinner
- Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Madeleine Townsend
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Maxime Tremblay-Gravel
- Deparment of Medicine, Montreal Heart Institute, Université?de Montréal, Montreal, Quebec, Canada
| | - Simon Urschel
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Jean-Luc Vachiery
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Angela Velleca
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Georgina Waldman
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - James Walsh
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane; Heart Lung Institute, The Prince Charles Hospital, Brisbane, Australia
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Henricksen EJ, Wayda B, Teuteberg JJ, Luikart H, Njoroge J, Guenthart BA, Khush KK. 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. J Heart Lung Transplant 2024:S1053-2498(24)01784-4. [PMID: 39122221 DOI: 10.1016/j.healun.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 07/26/2024] [Accepted: 08/01/2024] [Indexed: 08/12/2024] Open
Abstract
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.
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Affiliation(s)
| | - Brian Wayda
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Jeffrey J Teuteberg
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Helen Luikart
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Joyce Njoroge
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Brandon A Guenthart
- Cardiothoracic Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Kiran K Khush
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
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3
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Jaiswal A, Kittleson M, Pillai A, Baran D, Baker WL. Usage of older donors is associated with higher mortality after heart transplantation: A UNOS observational study. J Heart Lung Transplant 2024; 43:806-815. [PMID: 38232792 DOI: 10.1016/j.healun.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/12/2023] [Accepted: 01/02/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Utilization of heart from older donors is variable across centers with uncertain outcomes of recipients. We sought to utilize a national registry to examine the usage and outcomes of heart transplant (HT) recipients from older donors. We also explored the impact of current donor heart allocation scheme on the outcomes of hearts from older donors. METHODS This observational study utilized the United Network for Organ Sharing database between 2015 and 2023 with donors categorized into age <45 years or ≥45 years and evaluated organ disposition and geographical variation. Thirty-day, 1-, and 3-year mortality, and graft failure rates were compared among recipients as per donor age group. We also evaluated annual trends in HT for each group over the follow-up period. RESULTS A total of 24,966 adult donors were recovered: 3,742 (15.0%) were ≥45 years; 3,349 (15.6%) adults received heart from such donors with significant geographical variation, and a declining utilization in the transplantation rate in current donor allocation system. Donors with age ≥45 years had higher comorbidities and were allotted with a significantly shorter ischemic time to recipients who were significantly less likely to receive temporary mechanical circulatory support and more likely female. Unadjusted and adjusted, 30-day mortality were similar but 1- and 3-year mortality and graft failure rates were significantly higher in recipients of such donors. Spline analysis suggested a higher 1-year mortality risk at older donor age with risk increasing after age 40 years. CONCLUSIONS Older donor age was associated with worsened 1- and 3-year mortality and graft failure for heart transplant recipients.
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Affiliation(s)
- Abhishek Jaiswal
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut.
| | - Michelle Kittleson
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ashwin Pillai
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - David Baran
- Cleveland Clinic Florida, Heart, Vascular and Thoracic Institute, Advanced Heart Failure Program, Weston, Florida
| | - William L Baker
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut; University of Connecticut School of Pharmacy, Department of Pharmacy Practice, Storrs, Connecticut
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Akbar AF, Zhou AL, Wang A, Feng ASN, Rizaldi AA, Ruck JM, Kilic A. Special Considerations for Advanced Heart Failure Surgeries: Durable Left Ventricular Devices and Heart Transplantation. J Cardiovasc Dev Dis 2024; 11:119. [PMID: 38667737 PMCID: PMC11050210 DOI: 10.3390/jcdd11040119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 04/08/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, 1800 Orleans Street, Zayed 7107, Baltimore, MD 21287, USA; (A.F.A.); (A.L.Z.); (A.W.); (A.S.N.F.); (A.A.R.); (J.M.R.)
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5
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Sollie ZW, Kwon JH, Usry B, Shorbaji K, Welch BA, Hashmi ZA, Witer L, Pope N, Tedford RJ, Kilic A. Changes in heart transplant outcomes of elderly patients in the new allocation era. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00269-1. [PMID: 38519014 DOI: 10.1016/j.jtcvs.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 02/16/2024] [Accepted: 03/08/2024] [Indexed: 03/24/2024]
Abstract
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.
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Affiliation(s)
- Zachary W Sollie
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Jennie H Kwon
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Benjamin Usry
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Brett A Welch
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Zubair A Hashmi
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Va
| | - Lucas Witer
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Nicolas Pope
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Ryan J Tedford
- Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC.
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Holzhauser L, Reza N, Edwards JJ, Birati EY, Owens AT, McLean R, Maeda K, O'Connor MJ, Rossano JW, Mondal A, Katcoff H, Edelson JB. Emergency Department Use and Hospital Mortality Among Heart Transplant Recipients in the United States. J Am Heart Assoc 2024; 13:e032676. [PMID: 38420765 PMCID: PMC10944034 DOI: 10.1161/jaha.123.032676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/19/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND Annual heart transplant (HT) volumes have increased, as have post-HT outpatient care needs. Data on HT-related emergency department (ED) visits are limited. METHODS AND RESULTS A retrospective analysis of 177 450 HT patient ED visits from the 2009 to 2018 Nationwide Emergency Department Sample was conducted. HT recipients, primary diagnoses, and comorbidities associated with ED visits were identified via International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, Tenth Revision (ICD-10) codes. Multivariable logistic regression was used to predict outcomes of hospital admission and death. HT volumes and HT-related ED visits increased from 2009 to 2018. Infection was the most common primary diagnosis (24%), and cardiac primary diagnoses represented 10% of encounters. Hospital admissions occurred in 48% of visits, but overall mortality was low (1.6%). Length of stay was 3.1 days (interquartile range, 1.6-5.9 days), and comorbidity burden was high: 42% had hypertension, 38% had diabetes, and 31% had ≥2 comorbidities. Those aged ≥65 years had significantly higher odds of admission (odds ratio [OR], 2.14 [95% CI, 1.97-2.33]) and death (OR, 2.06 [95% CI, 1.61-2.62]). Comorbidities increased odds of admission (OR, 1.62 [95% CI, 1.51-1.75]) but not death. Renal primary diagnosis had the highest risk of admission (OR, 4.1 [95% CI, 3.6-4.6]), but cardiac primary diagnosis had the highest odds of death (OR, 11.6 [95% CI, 9.1-14.8]). CONCLUSIONS HT-related ED visits increased from 2009 to 2018 with high admission rates but low in-hospital mortality, suggesting an opportunity to improve prehospital care. Older patients and those with cardiac primary diagnoses had the highest risk of death. The observed contrast between predictors of admission and mortality signals a need for further study to improve risk stratification and outpatient care strategies.
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Affiliation(s)
- Luise Holzhauser
- Division of Cardiovascular Medicine, Department of MedicinePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Nosheen Reza
- Division of Cardiovascular Medicine, Department of MedicinePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Jonathan J. Edwards
- Division of Cardiology, Cardiac Center, the Childrens Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Edo Y. Birati
- The Lydia and Carol Kittner, Lea and Benjamin Davidai Division of Cardiovascular Medicine and Surgery, Tzafon (Poriya) Medical Center, and Azrieli Faculty of MedicineBar‐Ilan UniversityRamat GanIsrael
| | - Anjali T. Owens
- Division of Cardiovascular Medicine, Department of MedicinePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Rhondalyn McLean
- Division of Cardiovascular Medicine, Department of MedicinePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Katsuhide Maeda
- Division of Cardiothoracic Surgery, Cardiac Center, the Children’s Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Matthew J. O'Connor
- Division of Cardiology, Cardiac Center, the Childrens Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Joseph W. Rossano
- Division of Cardiology, Cardiac Center, the Childrens Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
- Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Healthcare EconomicsUniversity of PennsylvaniaPhiladelphiaPA
| | - Antara Mondal
- Leonard Davis Institute for Healthcare EconomicsUniversity of PennsylvaniaPhiladelphiaPA
| | - Hannah Katcoff
- Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
| | - Jonathan B. Edelson
- Division of Cardiology, Cardiac Center, the Childrens Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
- Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Healthcare EconomicsUniversity of PennsylvaniaPhiladelphiaPA
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7
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Yuzefpolskaya M, Fiedler AG, Katz JN, Houston BA. Is it time to stop living in a HeartMate II world? J Heart Lung Transplant 2023; 42:1621-1626. [PMID: 37536469 DOI: 10.1016/j.healun.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/30/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023] Open
Abstract
Despite improving outcomes with modern pump technology, left ventricular assist device (LVAD) utilization for patients with end-stage heart failure (HF) has declined significantly in the preceding half-decade. Here, we examine this trend, noting an inherent contradiction in the declining utilization of an improving therapeutic option. We propose a series of provocative questions as a "call to action" for the field of advanced HF to consider both scientifically and clinically, focusing on our evaluation parameters for LVAD candidacy, our approach to dichotomous LVAD vs transplant decisions, and our current management paradigms. We conclude that modernization in these areas to match the advantages of modern pump technology is required to best serve patients with advanced HF.
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Affiliation(s)
- Melana Yuzefpolskaya
- Division of Cardiovascular Medicine, Columbia University Irving Medical Center, New York, New York
| | - Amy G Fiedler
- Department of Cardiac Surgery, University of California San Francisco, San Francisco, California
| | - Jason N Katz
- Division of Cardiology, Duke University, Durham, North Carolina
| | - Brian A Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.
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8
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Ohira S, Okumura K, Hirani R, Martinez S, Ichikawa H, Isath A, Lanier GM, De La Pena C, Spielvogel D, Kai M. Use of Donor Hearts ≥50 Years Old for Septuagenarians in Heart Transplantation. Ann Thorac Surg 2023; 116:580-586. [PMID: 37146787 DOI: 10.1016/j.athoracsur.2023.04.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/04/2023] [Accepted: 04/24/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND The impact of using donors ≥50 years old on heart transplantation outcomes of septuagenarians is unknown, which may have a potential to expand the donor pool. METHODS From January 2011 to December 2021, 817 septuagenarians received donor hearts <50 years old (DON<50) and 172 septuagenarians received donor hearts ≥50 years old (DON≥50) in the United Network for Organ Sharing database. Propensity score matching was performed using recipient characteristics (167 pairs). The Kaplan-Meier method and Cox proportional hazards model were used to analyze death and graft failure. RESULTS The number of heart transplants in septuagenarians has been increasing (54 per year in 2011 to 137 per year in 2021). In a matched cohort, the donor age was 30 years in DON<50 and 54 years in DON≥50. In DON≥50, cerebrovascular disease was the main cause of death (43%), whereas head trauma (38%) and anoxia (37%) were the causes in DON<50 (P < .001). The median heart ischemia time was comparable (DON<50, 3.3 hours; DON≥50, 3.2 hours; P = .54). In matched patients, 1- and 5-year survival rates were 88.0% (DON<50) vs 87.2% (DON≥50) and 79.2% (DON<50) vs 72.3% (DON≥50), respectively (log-rank, P = .41). In the multivariable Cox proportional hazards models, donors ≥50 years old were not associated with death in matched (hazard ratio, 1.05; 95% CI, 0.67-1.65; P = .83) and nonmatched groups (hazard ratio, 1.11; 95% CI, 0.82-1.50; P = .49). CONCLUSIONS The use of donor hearts older than 50 years can be an effective option for septuagenarians, thereby potentially increasing organ availability without compromising outcomes.
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Affiliation(s)
- Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York; New York Medical College, Valhalla, New York.
| | - Kenji Okumura
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York
| | | | | | - Hajime Ichikawa
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Ameesh Isath
- Department of Cardiology, Westchester Medical Center, Valhalla, New York
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center, Valhalla, New York
| | - Corazon De La Pena
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York; New York Medical College, Valhalla, New York
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York; New York Medical College, Valhalla, New York
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9
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Masarone D, Kittleson MM, Falco L, Martucci ML, Catapano D, Brescia B, Petraio A, De Feo M, Pacileo G. The ABC of Heart Transplantation-Part 1: Indication, Eligibility, Donor Selection, and Surgical Technique. J Clin Med 2023; 12:5217. [PMID: 37629260 PMCID: PMC10455167 DOI: 10.3390/jcm12165217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/04/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
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.
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Affiliation(s)
- Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Michelle M. Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Hospital, Los Angeles, CA 90048, USA
| | - Luigi Falco
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Maria L. Martucci
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Dario Catapano
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Benedetta Brescia
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
| | - Andrea Petraio
- Heart Transplant Unit, Department of Cardiac Surgery and Transplants, AORN dei Colli Monaldi Hospital, 80131 Naples, Italy
| | - Marisa De Feo
- Cardiac Surgery Unit, Department of Cardiac Surgery and Transplants, AORN dei Colli Monaldi Hospital, 80131 Naples, Italy
| | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
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10
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Sherard C, Sama V, Kwon JH, Shorbaji K, Huckaby LV, Welch BA, Inampudi C, Tedford RJ, Kilic A. Outcomes of Combined Heart-Kidney Transplantation in Older Recipients. Cardiol Res Pract 2023; 2023:4528828. [PMID: 37396466 PMCID: PMC10314816 DOI: 10.1155/2023/4528828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 02/22/2023] [Accepted: 06/05/2023] [Indexed: 07/04/2023] Open
Abstract
Objectives The upper limit of recipient age for combined heart-kidney transplantation (HKT) remains controversial. This study evaluated the outcomes of HKT in patients aged ≥65 years. Methods The United Network of Organ Sharing (UNOS) was used to identify patients undergoing HKT from 2005 to 2021. Patients were stratified by age at transplantation: <65 and ≥ 65 years. The primary outcome was one-year mortality. Secondary outcomes included 90-day and 5-year mortality, postoperative new-onset dialysis, postoperative stroke, acute rejection prior to discharge, and rejection within one-year of HKT. Survival was compared using Kaplan-Meier analysis, and risk adjustment for mortality was performed using Cox proportional hazards modeling. Results HKT in recipients aged ≥65 significantly increased from 5.6% of all recipients in 2005 to 23.7% in 2021 (p=0.002). Of 2,022 HKT patients in the study period, 372 (18.40%) were aged ≥65. Older recipients were more likely to be male and white, and fewer required dialysis prior to HKT. There were no differences between cohorts in unadjusted 90-day, 1-year, or 5-year survival in Kaplan-Meier analysis. These findings persisted after risk-adjustment, with an adjusted hazard for one-year mortality for age ≥65 of 0.91 (95% CI (0.63-1.29), p=0.572). As a continuous variable, increasing age was not associated with one-year mortality (HR 1.01 (95% CI (1.00-1.02), p=0.236) per year). Patients aged ≥65 more frequently required new-onset dialysis prior to discharge (11.56% vs. 7.82%, p=0.051). Stroke and rejection rates were comparable. Conclusion Combined HKT is increasing in older recipients, and advanced age ≥65 should not preclude HKT.
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Affiliation(s)
- Curry Sherard
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Vineeth Sama
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Jennie H. Kwon
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Lauren V. Huckaby
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Brett A. Welch
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Chakradhari Inampudi
- Department of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Ryan J. Tedford
- Department of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, USA
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11
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Gelzinis TA, Ungerman E, Jayaraman AL, Bartels S, Bond JA, Hayanga HK, Patel B, Khoche S, Subramanian H, Ball R, Knight J, Choi C, Ellis S. The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2021 Part II: Cardiac Transplantation. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00339-7. [PMID: 37353423 DOI: 10.1053/j.jvca.2023.05.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 05/17/2023] [Indexed: 06/25/2023]
Abstract
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.
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Affiliation(s)
| | - Elizabeth Ungerman
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Arun L Jayaraman
- Department of Anesthesiology and Perioperative Medicine, Department of Critical Care Medicine, Mayo Clinic, Pheonix, AZ
| | - Steven Bartels
- Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, Maywood, IL
| | - Jonathan A Bond
- Division of Adult Cardiothoracic Anesthesiology, University of Kentucky, Lexington, KY
| | - Heather K Hayanga
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology, West Virginia University, WV
| | - Bhoumesh Patel
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT
| | - Swapnil Khoche
- Department of Anesthesiology, University of California, San Diego, CA
| | - Harikesh Subramanian
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Ryan Ball
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Joshua Knight
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Christine Choi
- Department of Anesthesiology, University of California, San Diego, CA
| | - Sarah Ellis
- Department of Anesthesiology, University of California, San Diego, CA
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12
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Chen Q, Malas J, Chan J, Esmailian G, Emerson D, Megna D, Catarino P, Bowdish ME, Kittleson M, Patel J, Chikwe J, Kobashigawa J, Esmailian F. Evaluating age-based eligibility thresholds for heart re-transplantation - an analysis of the united network for organ sharing database. J Heart Lung Transplant 2023; 42:593-602. [PMID: 36535808 PMCID: PMC10121767 DOI: 10.1016/j.healun.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/20/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Risk-adjusted survival after late heart re-transplantation may be comparable to primary transplant, but the efficacy of re-transplantation in older candidates is not established. We evaluated outcomes after heart re-transplantation in recipients > 60 years. METHODS We identified 1026 adult patients undergoing isolated heart re-transplantation between 2003 and 2020 from the United Network for Organ Sharing database. Older recipients (> 60 years, n=177) were compared to younger recipients (≤ 60 years, n=849). Five and ten-year post-transplant survival was estimated using the Kalpan-Meier method and adjusted with multivariable Cox models. RESULTS Older recipients were more likely to be male and have diabetes or previous malignancies with higher baseline creatinine. They also more frequently required pre-transplant ECMO (11.9% vs. 6.8%, p=0.02) and received re-transplantation due to primary graft failure (13.6% vs. 8.5%, p=0.03). After the transplant, older recipients had a higher incidence of stroke (6.8% vs. 2.6%, p=0.01) and dialysis requirements (20.3% vs. 13.2%) before discharge (both p<0.05), and more frequently died from malignancy-related causes (16.3% vs. 3.9%, p<0.001). After adjustment, recipient age >60 was associated with an increased risk of both 5-year (HR 1.42, 95% CI 1.02-2.01, p=0.04) and 10-year mortality (HR 1.72, 95% CI 1.20-2.45, p=0.003). Restricted cubic spline showed a non-linear relationship between recipient age and 10-year mortality. CONCLUSIONS Heart re-transplantation in recipients > 60 years has inferior outcomes compared to younger recipients. Strict patient selection and close follow-up are warranted to ensure the appropriate utilization of donor hearts and to improve long-term outcomes.
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Affiliation(s)
- Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Jad Malas
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Joshua Chan
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Gabriel Esmailian
- The George Washington School of Medicine and Health Sciences, Washington, District of Columbia
| | - Dominic Emerson
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Dominick Megna
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Pedro Catarino
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Michael E Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Michelle Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Jignesh Patel
- Department of Cardiology, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Jon Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Fardad Esmailian
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California.
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13
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DeFilippis EM, Khush KK, Farr MA, Fiedler A, Kilic A, Givertz MM. Evolving Characteristics of Heart Transplantation Donors and Recipients: JACC Focus Seminar. J Am Coll Cardiol 2022; 79:1108-1123. [PMID: 35300823 DOI: 10.1016/j.jacc.2021.11.064] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/08/2021] [Accepted: 11/22/2021] [Indexed: 12/22/2022]
Abstract
Although the burden of end-stage heart failure continues to increase, the number of available organs for heart transplantation (HT) remains inadequate. The HT community has been challenged to find ways to expand the number of donor hearts available. Recent advances include use of hearts from donors infected with hepatitis C virus as well as other previously underutilized donors, including those with left ventricular dysfunction, of older age, and with a history of cocaine use. Concurrently, emerging trends in HT surgery include donation after circulatory death, ex vivo normothermic heart perfusion, and controlled hypothermic preservation, which may enable procurement of organs from farther distances and prevent early allograft dysfunction. Contemporary HT recipients have also evolved in light of the 2018 revision to the U.S. heart allocation policy. This focus seminar discusses recent trends in donor and recipient phenotypes and management strategies for successful HT, as well as evolving areas and future directions.
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Affiliation(s)
| | - Kiran K Khush
- Stanford University Medical Center, Stanford, California, USA
| | | | - Amy Fiedler
- University of Wisconsin Hospitals, Madison, Wisconsin, USA
| | - Arman Kilic
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael M Givertz
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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14
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Heart Transplant in Older Adults. CURRENT TRANSPLANTATION REPORTS 2022; 9:48-54. [PMID: 35039790 PMCID: PMC8755401 DOI: 10.1007/s40472-022-00358-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 11/22/2022]
Abstract
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.
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