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The advent of direct acting antivirals has allowed for utilization of HCV NAT+ donors with good short-term outcomes. The goal of this study was to compare clinical outcomes among heart transplant recipients who received hearts from HCV NAT+ donors to those from NAT- donors. We examined the UNOS registry of all primary orthotopic adult heart transplants from March 15, 2015 to August 31, 2021 and identified their donors as HCV NAT+ or NAT-. Those with multiorgan transplants or waitlisted for other organs were excluded. Baseline characteristics, three-year survival, and treatment for rejection at one year were compared between the two groups. Of 16,491 heart transplants meeting study criteria, 729(4%) hearts came from HCV NAT+ donors. HCV NAT+ donors were older (34±8 vs 32±11 years, p<0.01), more likely males(75% vs 70%, p<0.01), white race(83% vs 63%, p<0.01), and blood group O(60% vs 50%, p<0.01). They were more likely to have drug use as cause of death(59% vs 18%, p<0.01) and classified as CDC high risk (87% vs 29%, p<0.01). Recipients were more likely blood group O(48% vs 39%, p<0.01) and have positive hepatitis C serologies(5% vs 2%, p<0.01). They were less likely Status 1A (58% vs 67%, p<0.01) or Status 1 (4% vs 9%, p<0.01) or 2 (36% vs 48%, p<0.01). Distance traveled (241 vs 139 nautical miles, p<0.01) and ischemia times (3.48 vs 3.23 hours, p<0.01) were greater in the HCV NAT+ group, while wait list duration was similar (69 vs 69 days, p=0.20). Three-year survival (87% vs 85%,Figure; log-rank p=0.26) and treatment for rejection in first year post transplant (19% vs 18%, p=0.72) were not significantly different between the two groups. HCV NAT+ donors are being increasingly used for heart transplantation, particularly for lower status recipients with otherwise longer wait times. Three-year survival and treatment for rejection at one year are comparable to those from HCV NAT- donors. Therefore, HCV NAT+ donor hearts should continue to be utilized with monitoring of long-term outcomes. [ABSTRACT FROM AUTHOR]

Despite the increasing number of heart-kidney transplants being performed in recent years, renal failure after heart transplantation remains a pervasive recipient complication. The purpose of this study was to determine the predictors and outcomes of renal failure after heart transplantation in a contemporary cohort. This was a retrospective cohort study of all adults undergoing isolated heart transplantation in the 2018-2022 United Network for Organ Sharing database. Heart recipients were stratified into those experiencing postoperative renal failure requiring dialysis prior to discharge and those without renal failure. We used multivariable logistic regression to determine factors associated with postoperative renal failure and compared postoperative outcomes between groups. Of 10,545 patients undergoing heart transplantation, 1,485 (14%) experienced postoperative renal failure. Factors associated with increased odds of renal failure included: increasing creatinine (odds ratio, OR 2.09/mg/dL 95% CI 1.85-2.35), pretransplant dialysis (OR 4.83, 95% CI 3.46-6.74), ventilation (OR 1.86, 95% CI 1.28-2.69) or extracorporeal membrane oxygenation (OR 1.78, 95% CI 1.38-2.29) prior to transplant, and prior cardiac surgery (OR 1.41, 95% CI 1.25-1.59). Patients with renal failure following heart transplantation experienced markedly higher rates of primary graft dysfunction (5% vs 1%, P<0.001) and 30-day mortality as well as lower 1- and 3-year survival compared to those without renal failure (Figure). Renal failure occurred frequently in a contemporary cohort of isolated heart transplant patients, with limited modifiable risk factors for its development. Renal-sparing strategies need to be considered in the care of heart transplant recipients with these known risk factors. Despite the increasing number of heart-kidney transplants being performed, these data suggest that additional patients may benefit from dual organ transplantation. [ABSTRACT FROM AUTHOR]

With the advent of direct acting antivirals, hepatitis C viremic donors are being increasingly used for heart transplantation. Single institutions have reported increased incidence of acute rejection when utilizing these hearts. The goal of this study was to evaluate one-year acute rejection following heart transplant from HCV viremic donors. We conducted retrospective review of UNOS of all primary adult heart transplants conducted between March 31, 2015 and June 30, 2020, excluding recipients with prior transplants, multiorgan transplants, or those waitlisted for other organs. Donors were dichotomized as being HCV NAT+ or HCV NAT-. One-year acute rejection requiring treatment was compared and evaluated by univariable and multivariable logistic regression. Of 11,058 heart transplant recipients in our cohort during the study period, 432 (3.9%) came from HCV NAT+ donors. HCV NAT+ donors were significantly older (34±8 vs 32±11 years, p<0.01), more likely to be white (82% vs 64%, p<0.01), blood group O (61% vs 49%, p<0.01), CDC high risk (88% vs 30%, p<0.01), and have drug use as cause of death (61% vs 17%, p<0.01). Recipients in the HCV NAT+ group were older [58(49-64) vs 56 (46-63) years, p<0.01), had higher ischemic times (3.5±1.0 vs 3.1±1.1 hours, p<0.01) and were more likely to be blood group O (49% vs 39%, p<0.01) and HCV antibody positive (5% vs 2%, p<0.01). They were less likely to be on inotropes (31% vs 37%, p<0.01) or any life support (81% vs 86%, p<0.01) at the time of transplant. Incidence of acute rejection requiring treatment within one year was not significantly different between the two groups (21% HCV NAT+ vs 19% HCV NAT-, p = 0.31). Donor HCV NAT+ was not associated with one-year acute rejection on either univariable (OR 1.13, 95% CI 0.89-1.43) or multivariable (aOR 1.08, 95% CI 0.84-1.41) logistic regression. Despite single center studies reporting potential increases in acute rejection when utilizing HCV-viremic donor hearts for transplantation, our UNOS registry analysis did not demonstrate increased treatment for acute rejection after one year. We should continue to utilize these donor hearts with careful surveillance and monitoring of long-term outcomes. [ABSTRACT FROM AUTHOR]

The new UNOS heart allocation policy prioritizes patients with percutaneous ventricular support devices over durable LVADs. We examined one-year survival of heart transplant recipients successfully bridged with Impella versus durable LVADs in the most recent era. We retrospectively reviewed all primary adult orthotopic heart transplant recipients in the UNOS registry between Jan 1, 2016 to June 12, 2020. Recipients were identified as having an isolated durable LVAD or Impella device at the time of transplant. Those bridged with ECMO, RVAD, BIVAD, or TAH were excluded. One-year survival was examined with the Kaplan Meier method and multivariable Cox proportional hazards regression. Of 10,492 heart transplant recipients in the study period, 4610(44%) were bridged with a durable LVAD and 158(2%) with Impella. Impella use increased following the UNOS allocation policy change (3% vs 1% of transplants, p<0.01) and a higher proportion were status 1 or 2 compared to those bridged with durable LVADs (96% vs 26%, p<0.01). Median days between listing and transplant were 40, 218, and 13 days for no MCS, durable LVAD, and Impella, respectively (p<0.01). Impella-bridged recipients were less likely to be obese (26% vs 41%, p<0.01), have diabetes (24% vs 31%, p<0.01), ischemic cardiomyopathy (28% vs 35%, p<0.01), prior cardiac surgery (27% vs 73%, p<0.01), and were more likely to be on inotropes at the time of transplant (65% vs 6%, p<0.01). On multivariate analysis, neither bridge with durable LVAD (aHR 1.25, 95% CI 0.97-1.62, p = 0.08) nor Impella (aHR 1.07, 95% CI 0.55-2.08, p=0.84) was associated with a difference in one-year survival following heart transplantation. Impella utilization as bridge to transplant has tripled in the current era of heart transplantation with no significant difference in one-year survival compared to those bridged with durable LVADs. Percutaneous LVAD platforms can be cautiously considered in the sickest patients requiring LVAD bridge to transplantation. [ABSTRACT FROM AUTHOR]

The United Network for Organ Sharing instituted a new allocation policy on October 18, 2018 to better risk-stratify heart transplant recipients. We sought to evaluate changes in transplant characteristics and mid-term outcomes following this change. We conducted retrospective review of all orthotopic adult heart transplants in the UNOS registry between January 1, 2010 and March 31, 2019. Transplants were dichotomized as occurring before or after October 18, 2018. Baseline characteristics were compared, 6-month survival was assessed by the Kaplan Meier method, and a multivariate Cox proportional hazards model was used to evaluate factors associated with survival. Of 21838 heart transplants performed during the study period, 1263 (5.8%) were performed following the policy change. Distribution of recipients included 108 (9%) Status 1, 526 (42%) Status 2, 327 (26%) Status 3, 231 (19%) Status 4, 4 (0.3%) Status 5, and 45(4%) Status 6. Recipients following the policy change were more likely to be supported with a ventilator (3% vs 1%, p<0.01), IABP (23% vs 7%, p<0.01), ECMO (5% vs 1%, p<0.01) and less likely to be supported with an LVAD (36% vs 42%, p<0.01) at the time of transplant. Ischemic times were also significantly longer (3.4±1.0 vs 3.1±1.0 hrs, p<0.01). On Kaplan Meier analysis, 6-month survival was significantly worse following the change in policy (HR 1.48, 95% CI 1.16-1.88, Fig 1). On multivariate analysis, factors associated with poor survival included recipient BMI≥30 (HR1.24, 95% CI 1.11-1.39), ventilator support (HR 3.22, 95% CI 2.41-4.33), ECMO (HR 2.55, 95% CI 1.81-3.59), and increased ischemic time (HR 1.18, 95% CI 1.13-1.23). The change in UNOS allocation policy has led to decreased mid-term survival, likely as a result of increasing number of heart transplant recipients supported with a ventilator, IABP, or ECMO at the time of transplant and a decreasing number of recipients supported with an LVAD. [ABSTRACT FROM AUTHOR]

Heart transplantation from Hepatitis C (HCV) viremic donors is an increasingly utilized strategy, though long-term outcomes with respect to cardiac allograft vasculopathy (CAV) are unknown. HCV is implicated as a potent trigger of the inflammatory cascade and may be associated with CAV. We report the incidence of CAV and subclinical disease in recipients of HCV-viremic donors (nucleic amplification test positive: NAT+) vs non-viremic donors (nucleic amplification test negative: NAT-) We retrospectively reviewed coronary angiograms with intravascular ultrasound (IVUS) of patients who received NAT+ and NAT- hearts between January 2014 and July 2020 at two large academic institutions. Donor-derived acute HCV infection was treated with a direct-acting antiviral agent per site protocol. CAV was graded according to ISHLT guidelines. Maximal intimal thickness (MIT) of the left main and left anterior descending artery was measured by IVUS. MIT ≥ 0.5mm was considered significant subclinical disease. Two-sample t tests were performed for continuous variables. Chi-square or Fisher's exact test were used for categorical variables. Among 178 patients, 65 received NAT+ donor hearts. Average recipient age was 58 and 55 years in the NAT+ and NAT- groups respectively and 15% vs 27% were female. NAT- donors were older (42 vs 36 years), but with no significant difference in cardiac risk factors including tobacco use, hypertension, and diabetes. CAV ≥ grade 1 was present in 9.1% of the NAT+ vs 18.8% of the NAT- group at 1 year (p=0.16), and 19.4% vs 21.0% at 2 years (p=1). Rates of significant IVUS disease were 53.7% in NAT+ vs 70.5% in NAT- at 1 year (p=0.068), and 72.2% vs 78.3% at 2 years (p=0.3). Among heart transplant recipients from HCV viremic donors our data show no difference in rates of angiographic CAV or subclinical disease by IVUS at 1 or 2 years. While these results are encouraging, longer follow up is needed to assess CAV risk in this population. [ABSTRACT FROM AUTHOR]