Results of acute heart retransplantation in Eurotransplant

Cardiac retransplantation in children

To discuss the indications for and outcomes of cardiac retransplantation in childhood. The major challenge of pediatric heart transplantation is graft failure. The major causes of graft failure include coronary allograft vasculopathy and chronic rejection. Retransplantation may be considered in children or young adults who develop graft failure following pediatric heart transplantation. Retransplantation now accounts for 7% of all pediatric transplants. Recent studies have demonstrated that cardiac retransplantation has a poorer outcome than primary heart transplantation. However, the interval from primary transplant to retransplantation appears to impact significantly the success of retransplantation. When children undergo retransplantation for early graft failure, the survival is quite poor and the appropriateness of this strategy is questionable. However, children who undergo retransplantation many years after primary transplantation have outcomes that are similar to primary transplantation. The decision to pursue retransplantation depends on the severity of graft failure and recent data suggest that identification of mild graft dysfunction or coronary allograft vasculopathy does not imply impending graft failure. Novel therapies to extend the life of the primary graft and to stratify those at risk of severe graft dysfunction will improve the allocation of scarce organs for pediatric patients who might be candidates for cardiac retransplantation. Retransplantation can extend the lives of children who develop graft failure after primary transplantation. However, not all patients who develop graft dysfunction should necessarily be listed for retransplantation.

A decade experience of cardiac retransplantation in adult recipients

BACKGROUND

Cardiac retransplantation is considered to be the best therapeutic option for a failing cardiac allograft. However, poor outcomes with retransplantation have previously been reported, a factor that raises important ethical, logistic and financial issues given the limited organ donor supply.

METHODS

Seven hundred sixty-six adult patients underwent cardiac transplantation for end-stage heart failure at our institution from 1992 to 2002. Of these, 41 (5.4%) were retransplants. Variables examined included recipient and donor demographics, indications for retransplant, comorbidities, cytomegalovirus (CMV) serology status, left ventricular assist device use before transplant, donor ischemic time, rate of early mortality (within 30 days), and post-transplantation survival rate.

RESULTS

Indications for cardiac retransplant were transplant-related coronary artery disease in 37, acute rejection in 3, and other causes in 1. The mean interval between transplantation and retransplantation was 5.9 +/- 3.4 years. Baseline characteristics such as recipient age, gender, CMV serology status, and donor age were similar in the primary transplant and retransplant groups. Early mortality after transplantation was comparable between the 2 groups, but post-transplant survival was significantly lower in retransplant patients compared with primary transplants with 1-, 3-, 5-, and 7-year actuarial survival rates of 72.2%, 66.3%, 47.5%, and 40.7% vs. 85.1%, 79.2%, 72.9%, and 66.8%, respectively (p < 0.001).

CONCLUSIONS

Cardiac retransplantation offers short-term outcomes similar to primary transplantation but lower long-term survival rates. Non-retransplant surgical options should also be considered in these patients. Careful patient selection and risk-assessment is necessary to govern appropriate allocation of limited donor organs.