Long-Term Survival After Heart Transplantation at Centers Stratified by Short-Term Performance

Cardiac magnetic resonance in advanced heart failure

Heart failure (HF) is a chronic and progressive disease that often progresses to an advanced stage where conventional therapy is insufficient to relieve patients' symptoms. Despite the availability of advanced therapies such as mechanical circulatory support or heart transplantation, the complexity of defining advanced HF, which requires multiple parameters and multimodality assessment, often leads to delays in referral to dedicated specialists with the result of a worsening prognosis. In this review, we aim to explore the role of cardiac magnetic resonance (CMR) in advanced HF by showing how CMR is useful at every step in managing these patients: from diagnosis to prognostic stratification, hemodynamic evaluation, follow-up and advanced therapies such as heart transplantation. The technical challenges of scanning advanced HF patients, which often require troubleshooting of intracardiac devices and dedicated scans, will be also discussed.

Textbook outcome: A novel metric in heart transplantation outcomes

OBJECTIVE

Assessing heart transplant program quality using short-term survival is insufficient. We define and validate the composite metric textbook outcome and examine its association with overall survival.

METHODS

We identified all primary, isolated adult heart transplants in the United Network for Organ Sharing/Organ Procurement and Transplantation Network Standard Transplant Analysis and Research files from May 1, 2005, to December 31, 2017. Textbook outcome was defined as length of stay 30 days or less; ejection fraction greater than 50% during 1-year follow-up; functional status 80% to 100% at 1 year; freedom from acute rejection, dialysis, and stroke during the index hospitalization; and freedom from graft failure, dialysis, rejection, retransplantation, and mortality during the first year post-transplant. Univariate and multivariate analyses were performed. Factors independently associated with textbook outcome were used to create a predictive nomogram. Conditional survival at 1 year was measured.

RESULTS

A total of 24,620 patients were identified with 11,169 (45.4%, 95% confidence interval, 44.7-46.0) experiencing textbook outcome. Patients with textbook outcome were more likely free from preoperative mechanical support (odds ratio, 3.504, 95% confidence interval, 2.766 to 4.439, P < .001), free from preoperative dialysis (odds ratio, 2.295, 95% confidence interval, 1.868-2.819, P < .001), to be not hospitalized (odds ratio, 1.264, 95% confidence interval, 1.183-1.349, P < .001), to be nondiabetic (odds ratio, 1.187, 95% confidence interval, 1.113-1.266, P < .001), and to be nonsmokers (odds ratio, 1.160, 95% confidence interval,1.097-1.228, P < .001). Patients with textbook outcome have improved long-term survival relative to patients without textbook outcome who survive at least 1 year (hazard ratio for death, 0.547, 95% confidence interval, 0.504-0.593, P < .001).

CONCLUSIONS

Textbook outcome is an alternative means of examining heart transplant outcomes and is associated with long-term survival. The use of textbook outcome as an adjunctive metric provides a holistic view of patient and center outcomes.

The current and future role of artificial intelligence in optimizing donor organ utilization and recipient outcomes in heart transplantation

Heart failure (HF) is a leading cause of morbidity and mortality in the United States. While medical management and mechanical circulatory support have undergone significant advancement in recent years, orthotopic heart transplantation (OHT) remains the most definitive therapy for refractory HF. OHT has seen steady improvement in patient survival and quality of life (QoL) since its inception, with one-year mortality now under 8%. However, a significant number of HF patients are unable to receive OHT due to scarcity of donor hearts. The United Network for Organ Sharing has recently revised its organ allocation criteria in an effort to provide more equitable access to OHT. Despite these changes, there are many potential donor hearts that are inevitably rejected. Arbitrary regulations from the centers for Medicare and Medicaid services and fear of repercussions if one-year mortality falls below established values has led to a current state of excessive risk aversion for which organs are accepted for OHT. Furthermore, non-standardized utilization of extended criteria donors and donation after circulatory death, exacerbate the organ shortage. Data-driven systems can improve donor-recipient matching, better predict patient QoL post-OHT, and decrease needless organ waste through more uniform application of acceptance criteria. Thus, we propose a data-driven future for OHT and a move to patient-centric and holistic transplantation care processes.

Utility of the IMPACT score for predicting heart transplant mortality. Analysis on a contemporary cohort of the Spanish Heart Transplant Registry

INTRODUCTION AND OBJECTIVES

The Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score was derived and validated as a predictor of mortality after heart transplantation (HT). The primary objective of this work is to externally validate the IMPACT score in a contemporary Spanish cohort.

METHODS

Spanish Heart Transplant Registry data were used to identify adult (>16 years) HT patients between January 2000 and December 2015. Retransplantation, multiorgan transplantation and patients in whom at least one of the variables required to calculate the IMPACT score was missing were excluded from the analysis (N = 2,810).

RESULTS

Median value of the IMPACT score was 5 points (IQR: 3, 8). Overall 1-year survival rate was 79.1%. Kaplan-Meier 1-year survival rates by IMPACT score categories (0-2, 3-5, 6-9, 10-14, ≥ 15) were 84.4%, 81.5%, 79.3%, 77.3% and 58.5% respectively (Log-Rank test: p<0.001). Performance analysis showed a good calibration (Hosmer-Lemeshow chi-square for one year was 7.56; p = 0.47) and poor discrimination ability (AUC-ROC 0.59) of the IMPACT score as a predictive model.

CONCLUSIONS

In a contemporary Spanish cohort, the IMPACT score failed to accurately predict the risk of death after HT. This article is protected by copyright. All rights reserved.

Cardiovascular Magnetic Resonance for Rejection Surveillance After Cardiac Transplantation

BACKGROUND

Endomyocardial biopsy (EMB) is the gold standard method for surveillance of acute cardiac allograft rejection (ACAR) despite its invasive nature. Cardiovascular magnetic resonance (CMR)-based myocardial tissue characterization allows detection of myocarditis. The feasibility of CMR-based surveillance for ACAR-induced myocarditis in the first year after heart transplantation is currently undescribed.

METHODS

CMR-based multiparametric mapping was initially assessed in a prospective cross-sectional fashion to establish agreement between CMR- and EMB-based ACAR and to determine CMR cutoff values between rejection grades. A prospective randomized noninferiority pilot study was then undertaken in adult orthotopic heart transplant recipients who were randomized at 4 weeks after orthotopic heart transplantation to either CMR- or EMB-based rejection surveillance. Clinical end points were assessed at 52 weeks.

RESULTS

Four hundred one CMR studies and 354 EMB procedures were performed in 106 participants. Forty heart transplant recipients were randomized. CMR-based multiparametric assessment was highly reproducible and reliable at detecting ACAR (area under the curve, 0.92; sensitivity, 93%; specificity, 92%; negative predictive value, 99%) with greater specificity and negative predictive value than either T1 or T2 parametric CMR mapping alone. High-grade rejection occurred in similar numbers of patients in each randomized group (CMR, n=7; EMB, n=8; P=0.74). Despite similarities in immunosuppression requirements, kidney function, and mortality between groups, the rates of hospitalization (9 of 20 [45%] versus 18 of 20 [90%]; odds ratio, 0.091; P=0.006) and infection (7 of 20 [35%] versus 14 of 20 [70%]; odds ratio, 0.192; P=0,019) were lower in the CMR group. On 15 occasions (6%), patients who were randomized to the CMR arm underwent EMB for clarification or logistic reasons, representing a 94% reduction in the requirement for EMB-based surveillance.

CONCLUSIONS

A noninvasive CMR-based surveillance strategy for ACAR in the first year after orthotopic heart transplantation is feasible compared with EMB-based surveillance.

REGISTRATION

HREC/13/SVH/66 and HREC/17/SVH/80.

AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY

ACTRN12618000672257.

Early and Midterm Results of Orthotopic Heart Transplantation in Poland (2015-2019)

Orthotopic heart transplantation (OHT) has become one of the most expensive and resource-consuming treatment options for patients with end-stage heart failure. It is therefore useful to review clinical data, such as treatment duration after surgery and midterm follow-up in this group of patients. Contemporary epidemiologic data on early and midterm OHT follow-ups including patient demographics, hospitalization rates and related post-OHT morbidity, and mortality are scarce in Poland. The aim of the study was to determine early survival, hospitalization rates related to OHT and related morbidity, and mortality in Poland in the recent decade.

The translation and validation of the Organ Transplant Symptom and Well-Being Instrument in China

To translate the Organ Transplant Symptom and Well-Being instrument (OTSWI) into Chinese and test the reliability and validity of the Chinese version. A total of 259 patients with organ transplants were recruited from The First Affiliated Hospital of China Medical University in Shenyang, from November 2020 to January 2021. Construct validity was evaluated using exploratory factor analysis (EFA) and reliability were assessed using test-retest reliability and internal consistency. The Cronbach's α of the Chinese version of the Organ Transplant Symptom and Well-being instrument was 0.93. EFA demonstrated that 80.785% of the total variance was explained by a seven-factor solution. The criterion validity of the SF-36 was -0.460 (p < .01), while the test-retest reliability was 0.710. The Chinese version of the OTSWI questionnaire is a valid and reliable instrument for assessing the quality of life of organ transplant patients for symptoms and well-being in China.

Sleep quality, depressive symptoms, and transplant outcomes: Follow-up analyses from the ADAPT prospective pilot study

BACKGROUND

Previous studies suggested that depressive symptoms and sleep quality may be important for long-term clinical outcomes following cardiothoracic transplant. Few studies, however, have systematically examined objective markers of these behavioral factors among ambulatory transplant recipients, or their association with clinical outcomes.

METHODS

We examined sleep quality and depressive symptoms with subsequent clinical outcomes (hospitalizations and death) in a sample of 66 lung or heart transplant recipients using a single-center, prospective cohort study. Recipients were assessed at approximately 6 months post-transplant and completed one week of actigraphy assessment to examine sleep quality and self-report measures of mood (Centers for Epidemiologic Studies of Depression [CESD]). Recipients were followed for clinical outcomes.

RESULTS

At 6-months following transplantation, recipients spent the majority of daytime activity at a sedentary level (61% of daily activity [SD = 10]) and elevated depressive symptoms were common (subclinical = 17%, mild = 12%, or moderate = 8%). Over a median follow-up of 4.5 years (IQR = 0.9, 5.1), 51 participants (77%) had at least one unplanned hospitalization and 11 (17%) participants died. In addition, sleep efficiency measurements suggested that a subset of participants exhibited suboptimal sleep (mean efficiency = 87% [SD = 7]). Poorer sleep quality, indexed by lower sleep efficiency and greater sleep fragmentation, was associated with greater depressive symptoms (r's = 0.37-0.50, P < .01). Better sleep quality at 6-months (HR = 0.75 [0.60, 0.95], P = .015), including sleep efficiency (HR = 0.74 [0.56, 0.99], P = .041) and sleep fragmentation (HR = 0.71 [0.53, 0.95], P = .020) were associated with lower risk of hospitalization or death. Compared with individuals without elevated depressive symptoms or sleep difficulties, individuals with either factor (HR = 1.72 [1.05, 2.81], P = .031) or both factors (HR = 2.37 [1.35, 4.18], P = .003) exhibited greater risk of clinical events in adjusted analyses.

CONCLUSIONS

Sleep quality is associated with depressive symptoms among cardiothoracic transplant recipients and enhances the prognostic association between biobehavioral risk factors and clinical outcomes.

Resumé of the challenges and burden of living with transplanted hearts for >31 years

Heart transplantation has extended the lives of many patients with end-stage heart failure. Although beset with the arduous aftermaths of immunosuppression, those who survived live meaningful lives similar to that of the general population. In this series, heart transplantation has led to a considerable extension of life span of >31-34 years. Development of cardiac allograft vasculopathy is a major concern in the long-term follow-up of transplant patients. Immunosuppressive drugs have a major impact on the development and progression of cardiac allograft vasculopathy and the main cause of cardiac allograft loss after the first post-transplantation year. Post-transplant neoplasia remains a challenging long-term problem for patients after orthotopic heart transplantation. Post-transplant lymphoproliferative disease appears to be largely the result of the effectiveness of current agents used for long-term immunosuppression, and the neoplasms typically harbor the Epstein Barr virus genome, which is presumed to play a major role in neoplastic transformation. Post-transplantation, new diseases may occur or there may be worsening of pre-existing diseases. By the end of the 5^th year, all suffered from hypertension. Renal insufficiency developed within 5 years after transplantation, and 10% have a creatinine value of >2.5 mg/dL. Hyperlipidemia, mostly hypercholesterolemia occurs especially in patients on tacrolimus or everolimus. Quality of life is not impaired despite somatic problems. In this period >31 years post-post-orthotopic heart transplantation, they even reported a surprising increase in their emotional well-being. The 10 patients are active and satisfied with their daily lives. They regard their own life as meaningful, have good families and active social relations. Nonetheless, it is burdened by chronic allograft vasculopathy and immunosuppression sequelae, the main limiting factors for survival, which needed to be constantly addressed throughout their lifetime. This brief report provides an insight into the challenges and burden patients living >31 years with transplanted hearts are confronted with.

Twenty-year survival following orthotopic heart transplantation in the United States

BACKGROUND

This study evaluated 20-year survival after adult orthotopic heart transplantation (OHT).

METHODS

The United Network of Organ Sharing Registry database was queried to study adult OHT recipients between 1987 and 1998 with over 20-year posttransplant follow-up. The primary and secondary outcomes were 20-year survival and cause of death after OHT, respectively. Multivariable logistic regression was used to identify significant independent predictors of long-term survival, and long-term survival was compared among cohorts stratified by number of predictors using Kaplan Meier survival analysis.

RESULTS

20,658 patients undergoing OHT were included, with a median follow-up of 9.0 (IQR, 3.2-15.4) years. Kaplan-Meier estimates of 10-, 15-, and 20-year survival were 50.2%, 30.1%, and 17.2%, respectively. Median survival was 10.1 (IQR, 3.9-16.9) years. Increasing recipient age (>65 years), increasing donor age (>40 years), increasing recipient body mass index (>30), black race, ischemic cardiomyopathy, and longer cold ischemic time (>4 h) were adversely associated with a 20-year survival. Of these 6 negative predictors, presence of 0 risk factors had the greatest 10-year (59.7%) and 20-year survival (26.2%), with decreasing survival with additional negative predictors. The most common cause of death in 20-year survivors was renal, liver, and/or multisystem organ failure whereas graft failure more greatly impacted earlier mortality.

CONCLUSIONS

This study identifies six negative preoperative predictors of 20-year survival with 20-year survival rates exceeding 25% in the absence of these factors. These data highlight the potential for very long-term survival after OHT in patients with end-stage heart failure and may be useful for patient selection and prognostication.